Second Edition

DIABETES ATLAS

SecondSecond edition

The mission of the International Diabetes Federation is to work with our member associations to enhance the lives of people with diabetes. Diabetes Atlas committee Bjørnar Allgot (co-chair) Delice Gan (co-chair) Hilary King Pierre Lefèbvre Jean-Claude Mbanya Martin Silink Linda Siminerio Rhys Williams Paul Zimmet

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

Diabetes Atlas, second edition, and other IDF publications are available from: International Diabetes Federation Executive Office 19 Avenue Emile de Mot B-1000 Brussels Belgium Tel +32-2-5385511 Fax +32-2-5385114 [email protected] www.idf.org

Electronic version of Diabetes Atlas: www.idf.org/e-atlas

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

First published, 2000 Second edition, 2003

Permission has been obtained to use material from the following organizations: (1) United Nations (2) World Bank (3) World Health Organization

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

ISBN 2-930229-27-6

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

Diabetes Atlas Second Edition Diabetes Atlas Second Edition Acknowledgements

The International Diabetes Federation (IDF) Chapter 1 would like to express its thanks to the World 1.1 R Sicree, J Shaw, P Zimmet Diabetes Foundation for its generous support 1.2 R Tapp, J Shaw, P Zimmet in making the Diabetes Atlas, second edition, Chapter 2 possible. 2.1 G Soltèsz, C Patterson, G Dahlquist 2.2 R Singh, J Shaw, P Zimmet IDF would also like to thank Novo Nordisk A/S for its generous support. Chapter 3 Introduction P Zimmet IDF would like to thank Novartis Pharma AG 3.1 N Rigby, RJ Leach, WPT James for its generous support in making possible 3.2 CS Cockram, K Hynes the report on impaired glucose tolerance in Chapter 4 Chapter 1. R Williams

IDF would also like to thank Johnson and Chapter 5 Johnson for its generous support in making J-C Mbanya, L Fezeu possible the report on type 2 diabetes in the Chapter 6 young in Chapter 2. 6.1 J Piette 6.2 L Siminerio A publication such as this would not have 6.3 T Songer been possible without the commitment and contribution of many people around the Chapter 7 world. IDF would like to thank and gratefully 7.1 K Ramaiya, R Sicree, C Patterson acknowledges the contributions of the 7.2 M Arab, AS Shera, R Sicree, C Patterson following authors: 7.3 M Massi-Benedetti, L Etu-Seppälä, R Sicree, C Patterson 7.4 Y Vovides, B Wentzell, R Sicree, C Patterson 7.5 A Pérez-Comas, R Sicree, C Patterson 7.6 H Mahtab, MA Sayeed, R Sicree, C Patterson 7.7 G Bunyan, R Sicree, C Patterson

Chapter 8 8.1 M Massi-Benedetti, J Akwe Akwi, P Ferolla, MO Federici 8.2 Y Vovides, B Wentzell 8.3 CS Cockram

Chapter 9 C Regniers, D Gan, B Allgot

Chapter 10 P Lefèbvre

Profiles J Colquhoun, D Lukoseviciene, N Ojha, G Rafique, M Silink

Appendix 2 A Hornsby

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

Diabetes Atlas Second Edition Diabetes Atlas Second Edition IDF also gratefully acknowledges the help of the following people in making this publication possible:

N Abdella, K Ajlouni, C Alexander, AS Alkuwari, MC Almaraz, A Al-Nuaim, FI Al-Zurba, T Aspray, V Augustiniene, B Balkau, TK Banerjee, A Barceló, T Beljic, P Bennett, O Bernard, C Berne, PR Betts, G Booth, E Briganti, C Castell, A Chan, S-Y Chen, B Choi, P Chou, LM Chuang, SS Chung, R Colagiuri, S Colagiuri, M Comaschi, D Dabelea, M Dagmar, R Dankner, H Dean, D De Bacquer, B Detournay, CL de Visser, M Dragan, R Duarte, T Dwyer, R Dyck, M Elbagir, M Eliasson, M Engelau, J Eriksson, E Eskelinen, J Feinglass, E Ford, MC Foss, M M-T Fuh, MM Garcia de Belaunde, C Giorda, RT Go, A Goday, R Gupta, CH Han, N Hancu, M Harris, J Harvey, L de Hassine, GE Holder-Nelson, G Hu, C Invitti, ED Janus, J Jervell, F Johansen, AJ Karter, S Kiauka, T Kitagawa, D Koev, M Korecova, CF Kwok, L Lavery, A Lerario, N Levitt, S Likitmaskul, B McBride, M McGill, SM Makled, K Midthjell, J Mohith, Z Naeemullah, P Nilsson, W Nitiyanant, F Nobels, H-H Parving, J Perusicova, G Piatt, E Placzkiewicz, D Ragoobirsingh, A Ramachandran, U Ramdanee, H Rashidi, W Rathmann, I Raz, G Rennert, G Roglic, A Rotchford, E Rudinskiene, M Sadikot, I Satman, MA Sayeed, A Schranz, D Simon, A Sinha, J Skrha, E Spichler, E Stern, S Tandhanand, W Thefeld, R Toomath, J Tuomilehto, G Uwaifo, K Van Acker, D Webb, S Wild, P Wilson, JP Yeo

IDF gratefully acknowledges the support and help given by its member associations, task forces and consultative sections.

Special thanks to L Al Obaidi, S Ash, V Campanella de Lemes, L Cann, E Ng, N Ohja, P Onraed, L Rabemananjara and Y Vovides for their invaluable contribution in the regions.

Diabetes Atlas Second Edition Contents

Contents

Foreword 7 Introduction 9 Executive Summary 11

1. The Global Burden of Diabetes 15 1.1 Diabetes and Impaired Glucose Tolerance: Prevalence and Projections 17 1.2 Complications of Diabetes 72

2. Diabetes in the Young: a Global Perspective 113 2.1 Global Trends in Childhood Type 1 Diabetes 114 2.2 Type 2 Diabetes in the Young 135

3. The Widening Circle 157 3.1 Obesity 159 3.2 Cardiovascular Disease and Diabetes: Double Jeopardy 167

4. The Economic Impact of Diabetes 175

5. Access to Insulin and Diabetes Supplies 193

6. Diabetes Education 207 6.1 Effectiveness of Self-management Education 208 6.2 Educational Practices: a Global View 216 6.3 Cost-Effectiveness of Diabetes Education 221

7. Meeting the Challenges 225 7.1 Africa 226 7.2 Eastern Mediterranean and Middle East 231 7.3 Europe 237 7.4 North America 244 7.5 South and Central America 250 7.6 South-East Asia 255 7.7 Western Pacific 260

8. Reducing the Burden 267 8.1 The St Vincent Declaration 268 8.2 Declaration of the Americas on Diabetes 276 8.3 Western Pacific Declaration on Diabetes 278 8.4 Declaration of the Eastern Mediterranean and Middle East Region 280

Diabetes Atlas Second Edition Contents

9. Diabetes Associations: from Patients to Partners 283

10. Prevention and Strategic Action 301

Appendices Appendix 1 Methodology 305 Appendix 2 Socio-economic Indicators 316 Appendix 3 IDF Member Associations Address List 329

Glossary 345 Acronyms 349 World Diabetes Foundation 352 Index 354 Index of Countries 357

Diabetes Atlas Second Edition Foreword

Foreword

everal years ago it was proposed by my predecessors that it would be helpful to bring together relevant data about diabetes and diabetes associations around Sthe world. This culminated in the publication of the first edition of the Diabetes Atlas at the 17th IDF Congress in Mexico. It was beautifully produced and instantly popular. It went to Ministers of Health in IDF member countries, WHO offices, diabetes associations and many others.

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

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

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

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

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

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

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

Diabetes Atlas Second Edition Foreword

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

Sir George Alberti IDF President, 2000 - 2003

Diabetes Atlas Second Edition Introduction

Introduction

ince the publication of the first edition of theDiabetes Atlas in 2000, a number of things have changed. Our appreciation of the extent of the burden of diabetes Sin the world has been refined, our knowledge of the risks to health as a whole and to diabetes in particular has increased and our conviction that type 2 diabetes is potentially preventable has been confirmed with solid evidence about the steps we need to make that potential a reality.

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

In terms of the worldwide burden, the WHO Global Burden of Disease estimated that around 177 million people in the world had diabetes in the year 2000. This second edition of the Diabetes Atlas estimates 194 million in the year 2003, and around two-thirds of these people live in developing countries. The projections for the future provide no comfort at all. If current trends prevail, the above figure may well more than double by the year 2025. We also know that already as much as a quarter or even a third of acute sector health expenditures in some communities has to be devoted to diabetes and its long-term complications.

The World Health Report 2002 quantifies the impact of several major risk factors on current mortality and overall burden of disease. It brings into focus the importance of overweight and low levels of physical activity in increasing the risks of developing type 2 diabetes as well as a number of other conditions of enormous public health importance. In that Report it is estimated that 58% of the global burden of diabetes, 21% of ischaemic heart disease and 8-42% of certain cancers are attributable to BMI (body mass index) above 21 kg/m2.

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

The Report also quantifies the potential for future reduction of the burden of disease. A relatively modest 25% reduction of current and future obesity and physical inactivity could avoid at least one-half and one-third of the burden attributed to these respective risk factors in the year 2020. Several risk factors can be addressed in synergy with policies that promote a healthy diet and encourage physical activity.

Diabetes Atlas Second Edition Introduction

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

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

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

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

Diabetes Atlas Second Edition Executive Summary

Executive Summary

any new topics have been included dominate the health economies of many It is estimated that Min the second edition of the Diabetes countries by the end of the first quarter currently some Atlas to reflect the growing need to tackle of the current century. 194 million people the diabetes pandemic on all fronts. worldwide, or 5.1% in These topics emphasize the importance The decision to include data on IGT was the adult population, of looking not just at the epidemiology based on two major factors associated have diabetes and of diabetes but also at its risk factors, with its presence: a high sensitivity that this will jump to the management of the disease to for future diabetes incidence and its 333 million, or 6.3%, prevent or delay complications and association with future cardiovascular by 2025. primary prevention of diabetes in high disease occurrence. IGT is now risk groups. This edition of the Atlas also recognized as being a stage in the shows the immense costs of diabetes, in transition from normality to diabetes. financial and human terms, to both the Thus, individuals with IGT are at high individual and society as a whole. risk of progressing to type 2 diabetes, although such progression is not The Diabetes Atlas therefore aims to inevitable. Some 70% of these individuals, communicate the global impact of however, are expected to develop the diabetes and to underline the need for disease. intervention now. In spite of the number of studies describing the epidemiology The reports in this edition of the Diabetes of diabetes, many governments and Atlas reconfirm that diabetes is now one public health planners still remain largely of the most common non-communicable unaware of the current magnitude, or, diseases globally. It is the fourth or fifth more importantly, the future potential leading cause of death in most developed for increases in diabetes and its serious countries and there is substantial complications in their own countries. evidence that it is epidemic in many developing and newly industrialized The second edition of the Diabetes Atlas nations. extends coverage to 212 countries and territories around the world. It provides It is estimated that currently some current estimates of the prevalence of 194 million people worldwide, or 5.1% diabetes and impaired glucose tolerance in the adult population, have diabetes (IGT) as well as forecasts the estimates and that this will jump to 333 million, or for 2025, forewarning of the enormous 6.3%, by 2025. burden to come. The future predictions of cost are as alarming as the future This situation is exacerbated by the predictions of prevalence. They suggest estimated number of people with IGT that unless effective prevention measures – currently at 314 million, or 8.2% in are introduced, expenditure devoted the adult population, and expected to to diabetes and its complications will increase to 472 million, or 9.0%, by 2025.

Diabetes Atlas Second Edition Executive Summary Executive Summary

Type 2 diabetes constitutes about 85% The studies on type 2 diabetes in children to 95% of all diabetes in developed have important implications in that countries, and accounts for an even they highlight the risk of complications higher percentage in developing occurring at a relatively young age, countries. It is now a serious global which will place a significant burden on health problem, which, for most health budgets as well as society as a countries, has evolved in association whole. Early detection and intervention is with rapid cultural and social changes, therefore essential to reduce the risk of ageing populations, increasing future complications. urbanization, dietary changes, reduced physical activity, and other unhealthy Governments will be forced to deal with lifestyle and behavioural patterns. the problem of type 2 diabetes in children The change in lifestyle is a worldwide in time to come. As such, it would be phenomenon, occurring in both better to address the problem as a public developed and emerging nations, where health issue under the heading of primary it is most prevalent in urban areas. care and prevention, rather than dealing with the consequences of an entrenched The risk of developing type 2 diabetes is condition and its complications in a clearly linked to an increasing prevalence young population. of obesity. Reports from the World Health Organization (WHO) and the International Although type 1 diabetes usually Obesity Task Force (IOTF) indicate that accounts for only a minority of the total approximately 58% of diabetes mellitus burden of diabetes in a population it is globally can be attributed to body mass the predominant form of the disease in index above 21 kg/m2. However, there younger age groups in most developed are indications that in western countries, countries. The incidence of childhood around 90% of type 2 diabetes cases are onset diabetes is increasing in many attributable to weight gain. countries in the world with an estimated overall annual increase of around 3%. Whereas previously type 2 diabetes affected only individuals in the older age It is estimated that on an annual basis groups, there are now ever increasing some 65,000 children worldwide under reports of type 2 diabetes in children the age of 15 years develop type 1 worldwide, with some as young as eight diabetes. Of the estimated total of years of age being affected. There is now about 400,000 prevalent cases of type growing recognition that type 2 diabetes 1 diabetes in childhood, more than a in children is becoming a global public quarter come from the South-East Asian health issue with potentially serious Region, and more than a fifth from the health outcomes. European Region where reliable, up- to-date estimates of incidence were The purpose of the report on type 2 available for the majority of countries. diabetes in the young is to call attention to this emergent problem by bringing The continued mapping of global trends together for the first time, the available in incidence of type 1 diabetes in all age epidemiological data on type 2 diabetes groups is important, and in conjunction incidence and prevalence in the young with other scientific research may provide from around the world. By the inclusion a logical basis for intervention studies of such data it is hoped to highlight and future primary prevention strategies deficiencies in the knowledge of the which must be the ultimate goal. disease and also to promote strategies to deal with it.

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Diabetes Atlas Second Edition Diabetes Atlas Second Edition Executive Summary Executive Summary

The new section on diabetic healthcare costs of diabetes worldwide, complications, which brings together for people in the 20-79 age group, available studies on the prevalence of is currently estimated to be at least the major complications, is a reminder 153 billion international dollars and may of the urgent need for effective diabetes be as much as 286 billion. care. The main relevance of diabetes complications in a public health If predictions of diabetes prevalence for perspective is the relationship to human 2025 are fulfilled, total direct healthcare suffering and disability, and the huge expenditure on diabetes worldwide for socio-economic costs through premature that year will be between 213 billion and morbidity and mortality. Indeed, diabetic 396 billion international dollars. In some complications are those aspects of the countries this will be as much as 40% of disease that are most feared such as their total healthcare budget. If predictions of blindness and amputation, and account diabetes prevalence for much of the social and financial Even while sophisticated medical for 2025 are fulfilled, burden of diabetes. technology and new medications are total direct healthcare being developed in one part of the expenditure on diabetes In virtually every developed society, world, one cannot ignore the fact that worldwide for that year diabetes is ranked among the leading there are people dying from the simple will be between 213 causes of blindness, renal failure and lack of access to insulin in another part. billion and 396 billion lower limb amputation. Through its Continuous accessibility to insulin is still international dollars. effects on cardiovascular disease a major problem in many developing In some countries this (50-80% of people with diabetes die of countries especially those in sub-Saharan will be as much as 40% cardiovascular disease), it is also now Africa such that there are reports of of their total healthcare one of the leading causes of death. premature deaths due to the chronic budget. lack of access to insulin in some of these Cardiovascular death rates on the whole countries. are either high or appear to be climbing in countries where diabetes is prevalent. At the same time, although the medical The outlook for cardiovascular disease aspects of diabetes care such as eye (CVD) is alarming when one considers exams and blood glucose monitoring the number of people with diabetes have improved in recent years, outcomes worldwide and that this is set to more for many people with diabetes remain than double by 2025. poor. While many factors contribute to poor outcome, this apparent The recent decline in cardiovascular contradiction also reflects the central disease in the USA, Australasia and role that people with diabetes themselves western Europe may be compromised play in determining their health status, significantly by this upsurge in and the challenges associated with diabetes. In other parts of the world supporting their efforts to manage their where CVD have been proliferating in self-care. recent years, the additional impact of diabetes threatens to have devastating The expanded section on diabetes consequences. education clearly shows that diabetes education is now considered an integral The heavy financial burden is shown part of diabetes care. Diabetes self- clearly in the chapter on the economic management education assists people impact of diabetes in which estimates in coping with the mental and physical are made on the direct healthcare demands of their illness, given their expenditure in countries covered by unique economic, cultural and social the Diabetes Atlas. The annual direct circumstances.

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Diabetes Atlas Second Edition Diabetes Atlas Second Edition Executive Summary

Diabetes self-management education The ultimate goal of a publication is therefore a multi-faceted process such as the Diabetes Atlas would be to involving much more than helping stimulate research and concrete action people with diabetes monitor their blood by governments and all those concerned glucose, or take their medication as with health and wellbeing to stem the prescribed. Diabetes education must be rising tide of diabetes in order to bring an ongoing process rather than a one- about better lives for all. time event because a person’s health status and need for support changes over time. More importantly, self-management education is most likely to be successful when it is part of a comprehensive and coordinated approach to diabetes care.

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

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

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

Diabetes Atlas Second Edition The Global Burden of Diabetes Chapter 1

The Global Burden of Diabetes Chapter 1

iabetes is now one of the most Dcommon non-communicable diseases globally. It is the fourth or fifth leading cause of death in most developed countries and there is substantial evidence that it is epidemic in many developing and newly industrialized nations. Complications from diabetes, such as coronary artery and peripheral vascular disease, stroke, diabetic neuropathy, amputations, renal failure and blindness are resulting in increasing disability, reduced life expectancy and enormous health costs for virtually every society. Diabetes is certain to be one of the most challenging health problems in the 21st century. 1.1 Diabetes and Impaired Glucose Tolerance: The number of studies describing the Prevalence and Projections epidemiology of diabetes over the last 1.2 Complications of Diabetes 20 years has been extraordinary, but many governments and public health planners still remain largely unaware of the current magnitude, or, more importantly, the future potential for increases in diabetes and its serious complications in their own countries.

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

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

15 Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

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

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

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

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1.1 Diabetes and Impaired Glucose Tolerance: Prevalence and Projections

Introduction At a glance

Diabetes mellitus and lesser forms of glucose intolerance, particularly impaired All diabetes and IGT 2003 2025 glucose tolerance, can now be found in almost every population in the world and Total world population (billions) 6.3 8.0 epidemiological evidence suggests that, Adult population (billions) without effective prevention and control (20-79 years) 3.8 5.3 programmes, diabetes will likely continue Number of people with diabetes (millions) to increase globally (1). (20-79 years) 194 333 World diabetes prevalence (%) Major categories of glucose (20-79 years) 5.1 6.3 intolerance Number of people with IGT (millions) Diabetes is recognized as a group (20-79 years) 314 472 of heterogeneous disorders with the IGT prevalence (%) common elements of hyperglycaemia (20-79 years) 8.2 9.0 and glucose intolerance due to insulin deficiency, impaired effectiveness of insulin action, or both (2).

Diabetes mellitus is classified on the basis of aetiology and clinical presentation of the disorder into four types: The diagnosis of type 2 diabetes usually • type 1 diabetes occurs after the age of 40 years although • type 2 diabetes the age of onset is often a decade earlier • gestational diabetes in populations with a high diabetes • other specific types prevalence (10). Type 2 diabetes can remain asymptomatic for many years Type 1 diabetes and the diagnosis is often made from Type 1 diabetes results from cellular- associated complications or incidentally mediated autoimmune destruction of through an abnormal blood or urine pancreatic islet beta cells causing the loss glucose test. of insulin production (3). It ranks as the most common chronic childhood disease Type 2 diabetes is often, but not always, in developed nations (4), but occurs at all associated with obesity, which itself ages (5) and the clinical presentation can can cause insulin resistance and lead vary with age (6, 7). to elevated blood sugar levels. It is strongly familial, but major susceptibility Type 2 diabetes genes have not yet been identified. In Type 2 diabetes is characterized by contrast to type 1 diabetes, persons with insulin resistance and relative insulin type 2 diabetes are not dependent on deficiency, either of which may be exogenous insulin and are not ketosis- present at the time that diabetes becomes prone, but may require insulin for clinically manifest (8, 9). The specific control of hyperglycaemia if this is not reasons for the development of these achieved with diet alone or with oral abnormalities are not yet known. hypoglycaemic agents.

16 17 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

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

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a. Rates are age-standardized to Segi’s World Population for ages 30 to 64 years

Type 2 diabetes constitutes about 85 or urbanized populations that may have to 95% of all diabetes in developed experienced a greater degree of lifestyle countries (1), and accounts for an change. The lowest rates are generally even higher percentage in developing found in rural communities where people countries. Type 2 diabetes is now a are living lifestyles incorporating high common and serious global health levels of physical activity. problem, which, for most countries, has evolved in association with rapid cultural The incidence and prevalence of type 2 and social changes, ageing populations, diabetes is also reported to be increasing increasing urbanization, dietary changes, in children. Studies from America and reduced physical activity and other Japan have demonstrated an increasing unhealthy lifestyle and behavioural incidence (12, 13). Other ethnic groups patterns (1). with high adult diabetes prevalence such as the Pima Indians (14) are also reporting Figure 1.1 highlights the large range of increasing adolescent prevalences. The type 2 diabetes prevalence even within importance of this problem and the need the same or similar ethnic groups, when for further research are emphasized by living under different conditions. Clearly, the authors of this chapter. A section many of the differences between these collating studies on type 2 diabetes rates reflect underlying behavioural, in children and adolescents has been environmental and social risk factors, included in Chapter 2. such as diet, level of obesity and physical activity. Impaired glucose tolerance (IGT) is an asymptomatic condition defined by Within ethnic groups, high rates of type elevated (though not diabetic) levels of 2 diabetes are usually found in migrant blood glucose two hours after a 75g oral

18 19 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

glucose challenge. Along with impaired appropriate strategies for the detection of fasting glucose (IFG), it is now recognized GDM can be developed. as being a stage in the transition from normality to diabetes. Classification criteria and reporting standards Thus, individuals with IGT are at high Standardization of methods and risk of progressing to type 2 diabetes, reporting in diabetes epidemiology although such progression is not promotes comparison between studies inevitable, and probably over 30% of and may permit the pooling of results individuals with IGT will return to normal from different investigations (22, 23). glucose tolerance over a period of Standardized criteria for detecting and several years (15). Not surprisingly, IGT reporting glucose intolerance have shares many characteristics with type 2 evolved greatly since the 1960s (24). diabetes, being associated with obesity, advancing age, insulin resistance and an In the late 1970s both the US National insulin secretory defect (16). Diabetes Data Group (NDDG) and the World Health Organization (WHO) produced new In addition to estimating the prevalence criteria on which to diagnose diabetes of diabetes for the years 2003 and 2025, mellitus. In 1985, WHO modified their data on case numbers and national criteria to be more consistent with NDDG prevalence of IGT are presented for values. More recently, the American both years in this section. The decision Diabetes Association (ADA) (25) and WHO to include data on IGT was based on (26) have produced new recommendations two major factors associated with for the diagnosis of diabetes. The major its presence: a higher sensitivity for change recommended is the lowering of future diabetes incidence (17), and its the diagnostic value of the fasting plasma association with future occurrence of glucose concentration to 7.0 mmol/l. For cardiovascular disease (18, 19). glucose tested in whole blood, the new recommended threshold is 6.1 mmol/l (26). Gestational diabetes The most widely accepted definition of In many population studies, individuals gestational diabetes mellitus (GDM) is have been categorized as having diabetes “carbohydrate intolerance of varying mellitus based on blood glucose values degrees of severity with onset or first measured after an overnight fast and/or recognition during pregnancy” (20, 21). two hours after a 75g oral glucose load. This definition applies regardless of Whilst WHO still recommends the oral whether insulin is used for treatment or glucose tolerance test (OGTT) as being the condition persists after pregnancy. the single best choice, they also state It does not exclude the possibility that that “if it is not possible to perform the unrecognized glucose intolerance may OGTT (eg for logistical or economic have antedated the pregnancy. reasons), the fasting plasma glucose alone may be used for epidemiological It is widely believed that differences in purposes” (26). reported prevalence of GDM parallel the differences that have been found in the It is important to realize that different frequency of type 2 diabetes among screening and diagnostic criteria may different populations. Nonetheless GDM have been used for different studies in is increasing in prevalence in concert with this report. The impact that the recent the worldwide rise in type 2 diabetes. diagnostic cut-off level changes have on Studies currently in progress hold much prevalence estimates seems to vary from hope of providing the data from which country to country (27). In this section, ‘outcome based’ diagnostic criteria and

18 19 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

the criteria used will be reported when curves for prevalence (with respect they are known. to age). 3 Applying the prevalence rates to Global estimates of diabetes the population distribution of that The global burden of diabetes has been country, and where no data for estimated several times (28-31). In 1994, countries were available, to those the International Diabetes Federation other countries of similar ethnicity Directory (28) contained type 1 and and economic circumstances. type 2 diabetes estimates supplied 4 Assuming an urban:rural prevalence by member nations. Using these data ratio of 2:1 for diabetes (but not IGT), the International Diabetes Federation except in those countries classified (IDF) estimated that over 100 million by WHO (30) as market economies, people worldwide had diabetes. Also in or former socialist economies. The 1994, McCarty et al (29) used data from urban proportion of the population population-based epidemiological studies was derived from UN estimates (32). and estimated that the global burden of The only other exception to this diabetes was 110 million in 1994 and 2:1 urban:rural prevalence ratio was that it would likely more than double to for India (and Nepal, for which data 239 million by 2010. were derived from India), for which the cited data indicated that the WHO (30) also produced a report using urban:rural ratio was nearer to 4:1 for epidemiological information and diabetes prevalence (33, 34). estimated the global burden at 5 The data for diabetes rates include 135 million in 1995, with the number both type 1 and type 2 diabetes, reaching 299 million by the year 2025. with a separate chapter providing In 1997, Amos et al (31) estimated the estimates on type 1 diabetes in global burden of diabetes to be 124 children and adolescents (see million people, and projected that this Chapter 2). would increase to 221 million people by 6 The prevalence of diabetes the year 2010. Despite using different throughout the Diabetes Atlas methodologies, and at times showing includes both undiagnosed and large differences in country-specific previously diagnosed diabetes. estimates, these reports have arrived at remarkably similar global figures of This section contains prevalence diabetes. estimates of diabetes and IGT for the years 2003 and 2025, and although the Methodology Tables contain data listed to one decimal point, it should not be inferred that this The principal details of the methodology indicates the degree of precision, but are provided in Appendix 1.1, where details rather to facilitate calculations and the of the rationale and process of obtaining appearance of the tables. In general, no age-specific prevalences for those countries predictions of diabetes or IGT numbers with adequate data are given. should be taken as having reliability of more than one significant figure. The principal aspects of the determination of prevalence were: The consequence of applying current age and gender specific prevalence rates to 1 Identification of studies through a estimate 2025 prevalences and number detailed literature search, and contact of cases is that only changes in the with IDF member organizations. age and urban/rural distribution of the 2 Employing the methodology indicated population will affect the estimates. Since in Appendix 1.1 to create smoothed it is likely that the age specific prevalence

20 21 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

rates (the prevalence at any given age) Figure 1.2 will rise due to increasing obesity, the World population (20-79 age group) by region figures are probably underestimates. �� Results

�� The main aim of this section is to estimate the prevalence of diabetes mellitus and IGT for each country for the ��

years 2003 and 2025. Data are provided � � � � �

for 212 countries and territories, � � which have been allocated mostly on �� a geographical basis into one of the seven IDF regions: Africa (AFR), Eastern

Mediterranean and Middle East (EMME), �� Europe (EUR), North America (NA), South and Central America (SACA), South-East Asia (SEA) and Western Pacific (WP). � ��

Rates for each country have not been ��

age-standardized, but are presented as �� the crude rates for the specific country and region according to the number of persons aged 20-79 years for that Figure 1.3 national and geographical entity. Prevalence of diabetes (20-79 age group) by region

�� The data presented are for all diabetes and IGT for adults from 20 to 79 years, and relate only to individuals 20 years

of age or older because the majority of �� people who have type 2 diabetes and IGT

are adults. Type 2 diabetes in children � � �

and adolescents is acknowledged as a � � �

� �

very important and growing problem � � �

(see Chapter 2). � � �

Furthermore as the emphasis is on �� numbers of persons with diabetes and IGT for each country, prevalence rates are markedly affected by the population age distribution so that those countries with � older age distributions will inevitably ��

have higher crude prevalences for the �� 20-79 year age group. It should be noted �� that column numbers in the Tables may not always exactly be the sum of the components because of rounding effects.

Demography Pacific Region, which has China as The total populations and the population a member, and the South-East Asian aged from 20-79 years are shown in Region, which has India as a member, Figure 1.2. It is clear that the Western have the greatest numbers in people.

20 21 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Figure 1.4 Diabetes Number of people with diabetes (20-79 age group) by region Prevalence In 2003, it is estimated that �� approximately 194 million people worldwide, or 5.1% in the age group 20-79, have diabetes. This estimate is �� expected to increase to some 333 million, or 6.3% in the adult population, by 2025.

�� The European Region with 48 million and � � �

� Western Pacific Region with 43 million � � �

� currently have the highest number of �� people with diabetes. However the prevalence rate of 3.1% for the Western Pacific Region is significantly lower than �� 7.9% in the North American Region and 7.8% in the European Region as seen in Figure 1.3. � �� By 2025, the region with the greatest �� number of persons with diabetes is �� expected to change to the South-East Asian Region with about 82 million as shown in Figure 1.4. The region’s Figure 1.5 prevalence of 7.5% will however continue Prevalence of impaired glucose tolerance (20-79 age group) to be lower than that of North America, by region estimated at 9.7%, and Europe at 9.1%.

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

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

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

22 23 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

182 million urban and 61 million rural Figure 1.6 persons with diabetes. Number of people with impaired glucose tolerance (20-79 age group) by region Impaired Glucose Tolerance �� Prevalence In 2003, it is estimated that approximately 314 million people

worldwide, or 8.2% in the age group �� 20 – 79, have IGT. By 2025, the number of people with IGT is projected to �

increase to 472 million, or 9.0% in the � � � �

� ��

adult population. � �

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

in Figure 1.5. ��

By 2025, the trend is expected to continue with the South-East Asian Figure 1.7 Region leading in prevalence with Estimated prevalence of diabetes and impaired glucose 13.5% and in number with some 146 tolerance (20-79 age group) by region million people as seen in Figure 1.6. The �� prevalence of IGT in the European Region will remain the next highest with 10.9%.

�� As can be seen in Figure 1.7, the prevalence of IGT is more than twice that of diabetes in the African and South-East ��

Asian Regions, whereas in the Eastern � � �

Mediterranean and Middle East, and North � � � �

American Regions the prevalence of IGT �

� ��

is slightly lower than that of diabetes. � � �

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

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

22 23 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Figure 1.8 a random blood glucose (RBG), and Estimated number of people with diabetes and impaired some based their data on self-report glucose tolerance (20-79 age group) by region (SR). It is difficult to control for this unless, for example, only those studies �� that used an OGTT were included. This would also have the effect of excluding studies lacking OGTT data, which �� would have increased the number of countries for which data were extrapolated from another country. ��

� • There were some inconsistencies in the � �� technique used for a particular test (eg for the Argentinian data, diabetes was measured according to a 50g two-hour

�� post-glucose load test, and not a 75g load as recommended by WHO), and persons with previously diagnosed � diabetes were excluded from the �� analysis. ��

�� • There were inconsistencies in the diagnostic criteria adopted, resulting �� from the updating of the diagnostic criteria in 1997 (25). The use of a lower fasting diagnostic criterion for diabetes will tend to result in a higher Regional estimates for diabetes and IGT prevalence of diabetes and lower for 2003 and 2025 are shown in Table prevalence of IGT. The diagnostic 1.1, and highlight the large increases criteria used for each country are in absolute numbers of both conditions indicated in the data source tables. over the 22-year period as also shown in Figure 1.8. • Three of the datasets reported only previously diagnosed diabetes – New Discussion Zealand (35), Canada (36) and Germany (37). In order to account for those with In order to make national, regional and undiagnosed diabetes, the figures global predictions for the prevalence from New Zealand were doubled based of diabetes, a number of assumptions on Australian data showing that the needed to be made, and therefore ratio of known:unknown persons with the results are subject to a number diabetes is 1:1 (38, 39), as was data of limitations. In addition to those from Germany (40) while data from highlighted in the Methodology section in the USA (41) indicated that Canadian Appendix 1.1, some of these are that: figures should be increased by 50%.

• The studies included in this section • If a country lacked data, it was often used differing screening assumed that their age and sex- techniques. The majority of studies specific prevalence rates of diabetes used an OGTT to screen for diabetes, mellitus were the same as those however, some studies used a fasting rates in another socio-economically, blood glucose test (FBG), some a ethnically and geographically similar two-hour blood glucose (2BG), some country.

24 25 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

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

2003 2025 No. of No. of No. of No. of Population people with Diabetes people IGT Population people with Diabetes people IGT (20-79) diabetes prevalence with IGT prevalence (20-79) diabetes prevalence with IGT prevalence Region (millions) (millions) (%) (millions) (%) (millions) (millions) (%) (millions) (%) AFR 295 7.1 2.4 21.4 7.3 541 15.0 2.8 39.4 7.3 EMME 276 19.2 7.0 18.7 6.8 494 39.4 8.0 36.5 7.4 EUR 621 48.4 7.8 63.2 10.2 646 58.6 9.1 70.6 10.9 NA 290 23.0 7.9 20.3 7.0 374 36.2 9.7 29.6 7.9 SACA 252 14.2 5.6 18.5 7.3 364 26.2 7.2 29.5 8.1 SEA 705 39.3 5.6 93.4 13.2 1,081 81.6 7.5 146.3 13.5 WP 1,384 43.0 3.1 78.5 5.7 1,751 75.8 4.3 120.2 6.9 Total 3,823 194 5.1 314 8.2 5,251 333 6.3 472 9.0

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

It is hoped that this report will assist in monitoring the trends of diabetes prevalence over time, by adopting the same methodology for future reports. A report such as this should also be an indicator of a country’s and region’s ‘database’ of research. It should stimulate research in those countries lacking data, as well as encourage further and improved research in those countries where available data may not be representative of national rates.

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

24 25 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Map 1.1 Prevalence estimates of diabetes, 2003

�� Map 1.2 �� Prevalence estimates of diabetes, 2025 ��

�� 26 �� 27 Diabetes Atlas Second Edition ��Diabetes�� Atlas Second Edition�� The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Map 1.3 Prevalence estimates of impaired glucose tolerance, 2003

�� Map 1.4 �� Prevalence estimates of impaired glucose tolerance, 2025 ��

�� 26 27 �� Diabetes Atlas Second Edition Diabetes Atlas Second Edition �� The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Top ten

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

��

� � ��

��

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

2003 2025 Country Prevalence (%) Country Prevalence (%) 1 Nauru 30.2 1 Nauru 33.0 2 United Arab Emirates 20.1 2 United Arab Emirates 24.5 3 Bahrain 14.9 3 Singapore, Republic of 19.5 4 Kuwait 12.8 4 Bahrain 18.3 5 Tonga 12.4 5 Kuwait 16.4 6 Singapore, Republic of 12.3 6 Tonga 15.9 7 Oman 11.4 7 Mauritius 14.7 8 Mauritius 10.7 8 Barbados 12.8 9 Germany 10.2 9 Hong Kong 12.8 10 Spain 9.9 10 Suriname 12.3

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

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

2003 2025 Country Persons (millions) Country Persons (millions) 1 India 35.5 1 India 73.5 2 China, People’s Republic of 23.8 2 China, People’s Republic of 46.1 3 USA 16.0 3 USA 23.1 4 Russia 9.7 4 Pakistan 11.6 5 Japan 6.7 5 Russia 10.7 6 Germany 6.3 6 Brazil 10.7 7 Pakistan 6.2 7 Mexico 9.0 8 Brazil 5.7 8 Egypt 7.8 9 Mexico 4.4 9 Japan 7.1 10 Egypt 3.9 10 Germany 7.1

28 29 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Top ten

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

��

� � ��

��

Table 1.4 Estimated top 10: Prevalence of impaired glucose tolerance (20-79 age group), 2003 and 2025

2003 2025 Country Prevalence (%) Country Prevalence (%) 1 Nauru 20.4 1 Nauru 21.2 2 Bahrain 17.2 2 United Arab Emirates 20.8 3 United Arab Emirates 17.2 3 Bahrain 20.7 4 Kiribati 17.2 4 Kuwait 19.6 5 Kuwait 16.8 5 Poland 18.5 6 Singapore, Republic of 16.6 6 Kiribati 18.1 7 Poland 16.6 7 Mauritius 17.7 8 Mauritius 16.2 8 Singapore, Republic of 17.5 9 India 14.2 9 Hong Kong 14.6 10 Japan 13.0 10 India 14.5

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

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

2003 2025 Country Persons (millions) Country Persons (millions) 1 India 85.6 1 India 132.0 2 China, People’s Republic of 33.2 2 China, People’s Republic of 54.3 3 Russia 17.8 3 Indonesia 20.9 4 USA 13.9 4 USA 19.3 5 Indonesia 12.9 5 Russia 18.3 6 Japan 12.6 6 Japan 12.7 7 Brazil 7.5 7 Brazil 11.7 8 Ukraine 6.2 8 Pakistan 10.9 9 Pakistan 5.7 9 Bangladesh 10.1 10 Bangladesh 5.3 10 Nigeria 7.4

28 29 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

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

Country Data used Screening method Diagnostic criteria Sample size Age (yrs) Angolaa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43 OGTT/FBG WHO – 1985, 1999 7,781 15+ Beninb Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45 OGTT WHO – 1985, 1999 6,500 24+ Botswanac South Africa (Omar et al, 1993 and Levitt et al, 1993)46,47 OGTT WHO – 1985 1,208 15+ Burkina Fasob Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45 OGTT WHO – 1985, 1999 6,500 24+ Burundia Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43 OGTT/FBG WHO – 1985, 1999 7,781 15+ Cameroon Cameroon (Mbanya et al, 1997)44 OGTT WHO – 1985 1,767 24-74 Cape Verdeb Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45 OGTT WHO – 1985, 1999 6,500 24+ Central African Republicb Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45 OGTT WHO – 1985, 1999 6,500 24+ Chad Sudan (Elbagir et al, 1996)48 2BG WHO – 1985 1,284 25-84 Comorosa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43 OGTT/FBG WHO – 1985, 1999 7,781 15+ Congo, Democratic Republic of a Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43 OGTT/FBG WHO – 1985, 1999 7,781 15+ Congo, Republic ofb Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45 OGTT WHO – 1985, 1999 6,500 24+ Côte d’Ivoireb Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45 OGTT WHO – 1985, 1999 6,500 24+ Djibouti Sudan (Elbagir et al, 1996)48 2BG WHO – 1985 1,284 25-84 Equatorial Guineab Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45 OGTT WHO – 1985, 1999 6,500 24+ Eritreaa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43 OGTT/FBG WHO – 1985, 1999 7,781 15+ Ethiopiaa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43 OGTT/FBG WHO – 1985, 1999 7,781 15+ Gabonb Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45 OGTT WHO – 1985, 1999 6,500 24+ Gambiab Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45 OGTT WHO – 1985, 1999 6,500 24+ Ghana Ghana (Amoah et al, 2002)45 OGTT WHO – 1999 4,733 25+ Guineab Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45 OGTT WHO – 1985, 1999 6,500 24+ Guinea-Bissaub Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45 OGTT WHO – 1985, 1999 6,500 24+ Kenyaa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43 OGTT/FBG WHO – 1985, 1999 7,781 15+ Lesothoc South Africa (Omar et al, 1993 and Levitt et al, 1993)46,47 OGTT WHO – 1985 1,208 15+ Liberiab Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45 OGTT WHO – 1985, 1999 6,500 24+ Madagascara Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43 OGTT/FBG WHO – 1985, 1999 7,781 15+ Malawia Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43 OGTT/FBG WHO – 1985, 1999 7,781 15+ Malib Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45 OGTT WHO – 1985, 1999 6,500 24+ Mauritania Sudan (Elbagir et al, 1996)48 2BG WHO – 1985 1,284 25-84 Mozambiquea Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43 OGTT/FBG WHO – 1985, 1999 7,781 15+ Namibiac South Africa (Omar et al, 1993 and Levitt et al, 1993)46,47 OGTT WHO – 1985 1,208 15+ Nigerb Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45 OGTT WHO – 1985, 1999 6,500 24+ Nigeriab Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45 OGTT WHO – 1985, 1999 6,500 24+ Reunion Mauritius (Dowse et al, 1990)49 OGTT WHO – 1985 4,929 25-74 Rwandaa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43 OGTT/FBG WHO – 1985, 1999 7,781 15+ Sao Tome and Principeb Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45 OGTT WHO – 1985, 1999 6,500 24+ Senegalb Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45 OGTT WHO – 1985, 1999 6,500 24+ Seychelles Mauritius (Dowse et al, 1990)49 OGTT WHO – 1985 5,080 25-74 Sierra Leoneb Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45 OGTT WHO – 1985, 1999 6,500 24+ Somaliaa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43 OGTT/FBG WHO – 1985, 1999 7,781 15+ South Africac South Africa (Omar et al, 1993 and Levitt et al, 1993)46,47 OGTT WHO – 1985 1,208 15+ Swazilandc South Africa (Omar et al, 1993 and Levitt et al, 1993)46,47 OGTT WHO – 1985 1,208 15+ Tanzaniaa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43 OGTT/FBG WHO – 1985, 1999 7,781 15+ Togob Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45 OGTT WHO – 1985, 1999 6,500 24+ Ugandaa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43 OGTT/FBG WHO – 1985, 1999 7,781 15+ Western Sahara Sudan (Elbagir et al, 1996)48 2BG WHO – 1985 1,284 25-84 Zambiaa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43 OGTT/FBG WHO – 1985, 1999 7,781 15+ Zimbabwea South Africa (Omar et al, 1993 and Levitt et al, 1993)46,47 OGTT WHO – 1985 1,208 15+

a. The prevalence was calculated after the combination of the data of the two studies, notwithstanding the different criteria. IGT figures were calculated from the McLarty data, as the Aspray study only used FBG criteria. b. The prevalence was calculated as the average of the two studies as their sample sizes differed considerably. c. The prevalence was calculated after the combination of the data of the two studies. IGT figures were based only on the study of Omar et al.

30 31 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

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

Population DM Number of people with DM (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Rural Urban Male Female 20-39 40-59 60-79 Total Angola 5,846 2.7 33.1 123.7 84.0 72.8 51.6 69.5 35.8 156.8 Benin 2,911 2.1 23.6 38.9 32.7 29.8 19.0 28.1 15.5 62.5 Botswana 716 3.6 3.2 22.3 8.8 16.7 4.1 13.9 7.5 25.5 Burkina Faso 4,969 2.7 90.4 44.8 67.8 67.4 40.1 55.2 40.0 135.3 Burundi 2,860 1.3 22.0 16.0 19.4 18.6 12.6 15.6 9.8 38.0 Cameroon 7,278 0.8 19.5 38.9 23.9 34.5 9.4 42.3 6.7 58.4 Cape Verde 228 2.3 1.1 4.2 2.2 3.1 2.0 1.7 1.7 5.3 Central African Republic 1,780 2.3 16.3 25.0 21.1 20.2 10.7 17.6 13.0 41.3 Chad 3,674 2.7 60.7 39.9 39.1 61.5 12.2 54.5 33.9 100.6 Comoros 355 2.5 1.9 7.0 4.8 4.1 3.2 3.9 1.8 8.9 Congo, Democratic Republic of 22,436 2.5 136.6 415.4 294.7 257.3 182.3 237.4 132.3 552.0 Congo, Republic of 1,403 2.6 7.6 28.3 18.4 17.6 10.5 15.2 10.3 35.9 Côte d’Ivoire 7,959 2.3 63.9 121.9 107.3 78.6 51.4 83.0 51.5 185.8 Djibouti 300 4.9 1.3 13.5 4.8 9.9 1.3 8.3 5.2 14.8 Equatorial Guinea 226 2.5 1.8 3.8 2.9 2.7 1.5 2.5 1.7 5.6 Eritrea 1,906 1.9 13.6 22.7 19.7 16.6 11.8 15.6 8.8 36.2 Ethiopia 29,562 1.9 214.6 335.8 299.4 250.9 176.6 234.9 138.8 550.4 Gabon 647 2.9 5.0 13.9 9.9 9.0 4.0 8.1 6.8 18.9 Gambia 703 2.2 7.4 8.0 8.3 7.0 4.1 7.2 4.0 15.4 Ghana 9,986 3.3 143.8 190.2 185.0 149.0 93.4 152.8 87.8 334.0 Guinea 3,855 2.0 37.6 41.2 42.8 36.0 23.3 35.5 20.1 78.9 Guinea-Bissau 588 2.0 7.0 4.8 6.3 5.5 3.1 5.2 3.5 11.8 Kenya 14,604 2.5 78.1 281.5 193.6 166.0 133.7 152.3 73.5 359.6 Lesotho 1,040 3.1 17.3 14.8 12.3 19.8 4.2 17.6 10.4 32.1 Liberia 1,573 2.0 10.5 21.3 17.0 14.8 11.6 11.6 8.6 31.8 Madagascar 7,782 2.5 47.3 144.6 104.3 87.5 63.2 85.5 43.2 191.9 Malawi 5,131 1.7 38.0 49.3 46.6 40.6 28.8 35.5 23.0 87.2 Mali 5,231 2.0 54.4 52.5 55.8 51.1 30.7 42.6 33.6 106.9 Mauritania 1,309 3.5 11.4 34.6 18.0 28.0 5.6 26.1 14.3 46.0 Mozambique 8,681 3.1 44.9 221.6 142.4 124.1 86.0 118.8 61.6 266.5 Namibia 831 3.1 10.1 15.4 9.5 16.0 3.9 13.6 8.0 25.5 Niger 4,728 3.1 36.4 110.3 57.7 89.0 20.8 83.9 41.9 146.7 Nigeria 54,248 2.2 439.3 779.4 655.4 563.3 354.5 528.9 335.3 1,218.7 Reuniona 474 13.1 10.0 51.9 29.1 32.8 11.2 29.7 21.0 61.9 Rwanda 3,645 1.1 28.3 13.1 22.7 18.7 15.2 14.7 11.4 41.4 Sao Tome and Principeb 107 2.8 1.0 1.9 1.6 1.4 0.6 1.3 1.0 2.9 Senegal 4,607 2.3 34.9 68.9 54.7 49.0 31.3 46.8 25.6 103.7 Seychellesa,b 49 12.3 1.5 4.5 2.9 3.0 1.0 2.9 2.0 6.0 Sierra Leone 2,268 2.2 21.3 27.6 25.7 23.2 14.0 21.8 13.1 48.9 Somalia 4,086 2.3 24.5 67.5 49.6 42.4 32.2 40.5 19.3 92.0 South Africa 24,741 3.4 272.1 569.1 322.7 518.5 127.1 489.6 224.5 841.2 Swaziland 450 3.0 6.0 7.4 5.2 8.2 2.0 7.4 3.9 13.4 Tanzania 16,616 2.3 98.1 281.0 203.4 175.7 134.9 163.9 80.3 379.1 Togo 2,196 2.1 21.4 23.7 23.9 21.2 13.2 19.4 12.5 45.1 Uganda 10,018 1.5 71.0 83.9 84.9 70.0 56.7 60.7 37.5 154.9 Western Sahara 149 4.9 0.1 7.1 2.9 4.4 0.7 3.6 2.9 7.3 Zambia 4,625 3.0 21.8 118.2 76.1 64.0 49.2 59.1 31.8 140.1 Zimbabwe 5,686 2.6 68.2 80.5 59.0 89.7 24.7 79.7 44.3 148.7

AFR Total * 295,065 2.4 2,380 4,692 3,580 3,491 1,985 3,265 1,821 7,072

* The totals may not be the exact sum of the column due to rounding. a. Reunion and the Seychelles were deemed as having the same ethnicity distribution as Mauritius. b. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that of world population 2003.

32 33 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

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

Population DM Number of people with DM (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Rural Urban Male Female 20-39 40-59 60-79 Total Angola 11,873 3.2 48.5 334.5 206.0 176.9 142.3 167.3 73.4 382.9 Benin 5,851 2.4 36.1 107.0 74.4 68.7 43.4 60.8 39.0 143.1 Botswana 1,011 3.5 1.8 33.6 14.6 20.9 7.3 17.6 10.7 35.5 Burkina Faso 10,920 1.9 99.2 105.7 106.3 98.6 69.6 89.4 46.0 204.9 Burundi 5,534 1.8 37.6 60.6 53.1 45.1 36.2 39.0 23.0 98.2 Cameroon 12,625 1.2 28.3 119.5 64.5 83.3 49.9 52.7 45.2 147.8 Cape Verde 412 3.2 1.6 11.4 6.4 6.6 3.0 6.5 3.6 13.0 Central African Republic 2,988 2.4 19.7 51.8 36.5 35.0 22.0 29.0 20.6 71.6 Chad 7,349 2.8 94.7 113.5 82.2 126.1 27.7 116.6 63.9 208.2 Comoros 715 3.5 3.3 21.9 13.9 11.4 7.7 12.6 5.0 25.2 Congo, Democratic Republic of 49,259 3.0 220.5 1,251.8 799.2 673.2 556.3 625.2 290.9 1,472.4 Congo, Republic of 2,823 2.6 10.6 62.9 37.7 35.8 23.3 30.9 19.4 73.5 Côte d’Ivoire 13,673 2.3 76.0 244.3 182.3 138.0 90.5 140.4 89.4 320.3 Djibouti 378 3.5 0.8 12.3 3.6 9.5 2.0 5.2 5.9 13.1 Equatorial Guinea 430 2.7 2.2 9.2 6.0 5.5 3.2 5.0 3.3 11.4 Eritrea 3,628 2.6 22.3 71.5 51.2 42.6 30.4 41.1 22.3 93.8 Ethiopia 52,442 2.4 307.4 952.9 692.5 567.8 457.0 510.8 292.5 1,260.3 Gabon 1,095 2.8 5.2 25.7 16.2 14.7 8.4 12.3 10.2 30.9 Gambia 1,167 2.6 10.0 19.9 15.9 14.1 7.3 13.2 9.4 29.9 Ghana 17,839 4.1 216.6 507.7 408.3 315.9 178.0 345.2 201.0 724.2 Guinea 7,131 2.4 56.5 114.1 93.0 77.5 47.2 77.6 45.8 170.6 Guinea-Bissau 1,036 2.2 9.8 12.6 11.9 10.5 6.4 9.6 6.3 22.3 Kenya 25,033 3.4 107.3 753.5 472.7 388.2 300.0 386.7 174.1 860.8 Lesotho 1,195 2.9 13.0 21.7 14.2 20.5 5.9 15.8 13.0 34.6 Liberia 3,300 2.4 18.0 61.6 43.5 36.0 22.4 42.5 14.7 79.5 Madagascar 15,397 3.3 75.4 431.5 276.5 230.4 161.4 233.2 112.4 507.0 Malawi 8,961 2.2 53.7 142.7 109.3 87.1 74.6 78.3 43.5 196.4 Mali 10,339 2.2 82.2 149.0 124.0 107.2 69.2 99.4 62.6 231.2 Mauritania 2,590 3.9 16.1 85.3 40.5 60.9 11.8 56.6 33.0 101.4 Mozambique 13,773 3.6 49.8 447.1 270.3 226.6 183.7 212.7 100.4 496.9 Namibia 1,463 3.2 12.2 35.1 19.4 28.0 8.4 25.5 13.4 47.4 Niger 10,662 2.6 133.9 148.2 115.4 166.8 39.3 162.8 80.0 282.2 Nigeria 103,872 2.5 615.3 1,987.4 1,411.5 1,191.2 777.5 1,118.4 706.9 2,602.7 Reuniona 640 16.4 11.5 93.1 49.3 55.3 12.8 49.8 42.1 104.7 Rwanda 6,305 1.4 46.3 44.9 50.4 40.8 32.1 38.7 20.4 91.2 Sao Tome and Principeb 146 3.4 1.2 3.8 2.7 2.3 0.8 2.1 2.0 5.0 Senegal 8,798 2.6 52.0 176.1 120.0 108.1 64.6 104.3 59.2 228.1 Seychellesa,b 67 14.9 1.7 8.3 4.9 5.1 1.4 4.7 3.9 10.0 Sierra Leone 4,181 2.3 29.3 68.7 51.5 46.5 29.1 43.2 25.7 98.0 Somalia 9,053 2.9 43.7 220.5 142.5 121.7 92.7 119.3 52.3 264.2 South Africa 26,816 3.9 249.3 805.7 416.8 638.2 130.2 536.3 388.5 1,055.0 Swaziland 589 2.9 5.1 11.8 6.8 10.1 3.3 8.1 5.5 16.9 Tanzania 31,855 3.1 152.2 849.6 544.6 457.2 343.5 460.8 197.6 1,001.8 Togo 4,178 2.3 32.6 65.0 52.3 45.3 28.5 42.7 26.4 97.6 Uganda 22,514 2.0 132.4 327.4 252.9 206.9 175.6 197.7 86.5 459.8 Western Sahara 269 5.2 0.1 13.9 5.8 8.3 1.3 8.6 4.2 14.0 Zambia 8,922 3.6 31.1 286.1 177.0 140.1 121.1 141.3 54.7 317.1 Zimbabwe 10,041 2.8 89.3 194.7 119.5 164.5 56.6 152.6 74.8 284.0

AFR Total * 541,140 2.8 3,364 11,677 7,870 7,171 4,566 6,750 3,724 15,041

* The totals may not be the exact sum of the column due to rounding.

a. Reunion and the Seychelles were deemed as having the same ethnicity distribution as Mauritius. b. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that of world population growth from 2003 to 2025.

32 33 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.9 Prevalence estimates of impaired glucose tolerance (IGT), 2003 – African Region

Population IGT Number of people with IGT (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Male Female 20-39 40-59 60-79 Total Angola 5,846 7.5 190.2 251.0 193.9 152.4 95.0 441.2 Benin 2,911 6.9 99.3 102.7 82.9 77.5 41.5 202.0 Botswana 716 7.0 31.4 18.9 15.3 12.3 22.7 50.3 Burkina Faso 4,969 7.0 156.8 189.3 144.6 113.2 88.3 346.1 Burundi 2,860 7.5 86.2 127.0 94.4 76.5 42.4 213.2 Cameroon 7,278 2.2 104.5 56.4 23.9 86.4 50.6 161.0 Cape Verde 228 6.8 6.2 9.2 7.2 4.2 4.0 15.4 Central African Republic 1,780 7.4 63.0 69.2 47.3 49.2 35.7 132.3 Chad 3,674 2.3 29.9 53.5 21.0 38.5 23.9 83.4 Comoros 355 7.3 11.3 14.7 12.4 8.7 4.9 26.0 Congo, Democratic Republic of 22,436 7.6 729.1 966.7 746.0 572.8 377.0 1,695.8 Congo, Republic of 1,403 7.2 48.7 51.7 39.5 36.5 24.4 100.4 Côte d’Ivoire 7,959 7.2 308.9 262.6 219.2 219.5 132.8 571.5 Djibouti 300 2.6 2.3 5.6 1.5 3.9 2.5 7.9 Equatorial Guinea 226 7.5 8.3 8.6 6.0 6.4 4.4 16.8 Eritrea 1,906 7.6 62.6 82.0 62.7 51.5 30.3 144.6 Ethiopia 29,562 7.6 978.6 1,270.7 966.5 796.1 486.7 2,249.3 Gabon 647 8.1 25.7 26.7 15.5 20.1 16.8 52.5 Gambia 703 7.4 26.0 25.8 18.9 21.5 11.5 51.9 Ghana 9,986 12.0 564.8 636.3 529.4 409.1 262.6 1,201.1 Guinea 3,855 7.0 137.9 133.9 109.0 104.9 57.8 271.7 Guinea-Bissau 588 7.4 21.4 22.0 15.9 16.7 10.8 43.4 Kenya 14,604 7.2 461.0 592.7 514.6 338.9 200.2 1,053.7 Lesotho 1,040 8.5 58.7 30.1 19.7 22.5 46.5 88.8 Liberia 1,573 6.5 52.0 50.6 49.8 30.4 22.4 102.7 Madagascar 7,782 7.5 256.3 331.0 257.2 207.1 122.9 587.3 Malawi 5,131 7.5 166.1 221.0 170.5 131.6 85.0 387.2 Mali 5,231 7.2 183.2 193.8 148.2 129.0 99.9 377.1 Mauritania 1,309 2.3 10.8 18.9 7.5 14.3 7.9 29.7 Mozambique 8,681 7.6 286.0 376.5 284.6 228.3 149.6 662.5 Namibia 831 8.0 43.3 22.9 17.0 15.4 33.7 66.1 Niger 4,728 6.7 160.8 157.1 140.8 117.7 59.4 318.0 Nigeria 54,248 7.1 1,947.9 1,900.5 1,527.5 1,432.8 888.1 3,848.4 Reuniona 474 16.2 29.2 47.6 29.2 31.0 16.6 76.8 Rwanda 3,645 7.2 114.7 149.5 128.5 83.3 52.4 264.2 Sao Tome and Principeb 107 8.1 4.3 4.3 2.6 3.5 2.6 8.7 Senegal 4,607 7.0 160.5 162.2 131.1 124.7 66.9 322.7 Seychellesa,b 49 16.1 3.2 4.7 2.9 3.2 1.7 7.9 Sierra Leone 2,268 7.2 79.8 82.8 63.2 62.5 36.9 162.6 Somalia 4,086 7.4 129.9 171.1 139.6 104.5 56.9 301.0 South Africa 24,741 7.2 1,201.8 573.4 498.6 553.8 722.8 1,775.2 Swaziland 450 7.8 23.4 11.7 9.1 8.9 17.0 35.1 Tanzania 16,616 7.3 525.5 694.8 574.2 413.1 233.1 1,220.3 Togo 2,196 7.1 77.1 78.5 62.1 57.4 36.1 155.6 Uganda 10,018 7.3 319.3 407.9 351.2 233.9 142.1 727.2 Western Sahara 149 2.5 1.3 2.4 0.8 1.6 1.3 3.7 Zambia 4,625 7.4 151.4 189.5 158.8 107.2 74.9 340.9 Zimbabwe 5,686 7.2 285.0 124.2 126.9 99.6 182.6 409.2

AFR Total * 295,065 7.3 10,426 10,984 8,789 7,434 5,186 21,410

34 35 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

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

Population IGT Number of people with IGT (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Male Female 20-39 40-59 60-79 Total Angola 11,873 7.2 374.9 484.9 418.6 279.6 161.6 859.8 Benin 5,851 7.1 204.9 210.0 167.6 151.6 95.7 414.9 Botswana 1,011 7.2 47.0 26.0 22.8 16.7 33.6 73.0 Burkina Faso 10,920 6.7 357.3 373.7 327.9 268.4 134.8 731.0 Burundi 5,534 7.3 175.3 230.5 193.6 131.2 80.9 405.7 Cameroon 12,625 2.2 188.1 93.6 45.2 156.8 79.7 281.7 Cape Verde 412 7.8 15.1 17.1 10.0 14.4 7.9 32.2 Central African Republic 2,988 7.1 102.7 109.6 86.7 73.7 51.8 212.3 Chad 7,349 2.2 58.5 100.6 43.3 75.1 40.7 159.1 Comoros 715 7.7 24.2 30.7 22.5 21.4 11.0 54.9 Congo, Democratic Republic of 49,259 7.2 1,568.1 1,991.9 1,753.6 1,125.6 680.7 3,559.9 Congo, Republic of 2,823 6.9 96.2 99.7 82.6 69.9 43.4 195.9 Côte d’Ivoire 13,673 7.3 522.6 471.2 382.0 371.8 240.0 993.8 Djibouti 378 2.1 2.3 5.7 2.4 2.5 3.0 7.9 Equatorial Guinea 430 7.3 15.5 15.7 11.9 11.7 7.6 31.2 Eritrea 3,628 7.7 122.2 155.8 119.2 96.2 62.5 277.9 Ethiopia 52,442 7.4 1,718.8 2,144.7 1,834.1 1,200.7 828.8 3,863.5 Gabon 1,095 7.5 40.7 41.1 30.0 28.4 23.3 81.7 Gambia 1,167 7.7 44.5 45.2 30.2 34.9 24.5 89.6 Ghana 17,839 12.7 1,070.9 1,188.0 874.2 837.3 547.5 2,258.9 Guinea 7,131 7.3 265.8 252.5 194.7 205.4 118.1 518.3 Guinea-Bissau 1,036 7.2 36.9 37.5 29.1 27.6 17.7 74.4 Kenya 25,033 7.5 827.7 1,041.4 847.0 636.2 385.9 1,869.1 Lesotho 1,195 8.6 66.5 36.7 26.2 19.8 57.1 103.1 Liberia 3,300 6.9 117.5 109.0 88.2 103.3 35.0 226.5 Madagascar 15,397 7.7 518.3 661.4 500.5 419.9 259.3 1,179.6 Malawi 8,961 7.2 292.2 355.9 319.2 198.2 130.6 648.0 Mali 10,339 7.1 368.5 361.3 295.8 268.0 166.0 729.8 Mauritania 2,590 2.3 22.2 38.0 14.6 28.9 16.7 60.2 Mozambique 13,773 7.3 444.6 563.9 484.7 316.8 207.0 1,008.5 Namibia 1,463 7.5 73.3 36.5 30.9 28.2 50.7 109.9 Niger 10,662 6.8 370.9 348.9 315.6 270.0 134.2 719.7 Nigeria 103,872 7.1 3,807.8 3,593.1 2,962.3 2,738.5 1,700.1 7,400.9 Reuniona 640 17.4 44.3 67.2 31.6 47.9 31.9 111.4 Rwanda 6,305 7.3 202.2 260.6 214.1 167.1 81.7 462.9 Sao Tome and Principeb 146 8.9 6.5 6.5 3.1 5.2 4.8 13.0 Senegal 8,798 7.3 318.4 319.9 242.3 254.1 141.8 638.3 Seychellesa,b 67 17.0 4.7 6.7 3.5 4.8 3.1 11.4 Sierra Leone 4,181 7.1 146.5 148.8 118.5 111.6 65.3 295.4 Somalia 9,053 7.3 289.0 375.6 309.6 229.0 126.0 664.6 South Africa 26,816 8.8 1,585.0 766.0 523.5 597.6 1,229.9 2,350.9 Swaziland 589 7.6 29.2 15.6 13.3 9.4 22.1 44.8 Tanzania 31,855 7.5 1,041.2 1,341.5 1,072.5 844.0 466.2 2,382.7 Togo 4,178 7.2 151.1 148.8 117.7 113.3 68.9 299.9 Uganda 22,514 7.1 706.8 896.0 801.7 535.8 265.3 1,602.8 Western Sahara 269 2.6 2.6 4.4 1.4 3.8 1.9 7.0 Zambia 8,922 7.2 289.5 349.5 317.7 208.8 112.6 639.1 Zimbabwe 10,041 6.8 478.0 202.2 228.6 181.4 270.3 680.3

AFR Total * 541,140 7.3 19,257 20,181 16,566 13,543 9,329 39,438

* The totals may not be the exact sum of the column due to rounding.

34 35 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.11 Data sources: prevalence estimates of diabetes mellitus (DM) and impaired glucose tolerance (IGT) – Eastern Mediterranean and Middle East Region

Country Data used Screening method Diagnostic criteria Sample size Age (yrs) Afghanistana Pakistan (Shera et al, 1995, 1999a, 1999b)50,51,52 OGTT WHO – 1985 3,409 25+ Algeriab,c Tunisia (Papoz et al, 1988 and Ghannem et al, 1997)53,54 FBG/SR WHO – 1980 6,570 20+ Armenia Turkey (Satman et al, 2002)55 2BG WHO – 1999 24,788 20+ Bahraind Bahrain (Al-Mahroos et al, 1998)56 OGTT WHO – 1985 2,128 40-69 Egyptb Egypt (Herman et al, 1995 and Arab, 1997)57,58 OGTT/Post-prandial GT WHO – 1985 5,251 20+ Irane Iran (Amini et al, 1997)59 OGTT WHO – 1985 3,910 40+ Iraq Jordan (Ajlouni et al, 1998)60 OGTT WHO – 1985 2,776 25-79 Jordan Jordan (Ajlouni et al, 1998)60 OGTT WHO – 1985 2,776 25-79 Kuwaitd Kuwait (Abdella et al, 1998)61 OGTT WHO – 1985 3,003 20+ Lebanon Lebanon (Salti et al, 1997)62 OGTT WHO – 1985 2,518 30+ Libyac Libya (Kadiki et al, 1999)63 Registration N/A 15,912 20+ Moroccob,c Tunisia (Papoz et al, 1988 and Ghannem et al, 1997)53,54 FBG/SR WHO – 1980 6,570 20+ Occupied Palestinian Territories Jordan (Ajlouni et al, 1998)60 OGTT WHO – 1985 2,776 25-79 Omanf Oman (Al-Lawati et al, 2002)64 OGTT WHO – 1999 5,731 20-79 Pakistana Pakistan (Shera et al, 1995, 1999a, 1999b)50,51,52 OGTT WHO – 1985 3,409 25+ Qatard Bahrain (Al-Mahroos et al, 1998)56 OGTT WHO – 1985 2,128 40-69 Saudi Arabia Saudi Arabia (El-Hazmi et al, 1998)66 OGTT WHO – 1985 15,420 14+ Sudan Sudan (Elbagir et al, 1996)48 2BG WHO – 1985 1,284 25-84 Syria Jordan (Ajlouni et al, 1998)60 OGTT WHO – 1985 2,776 25-79 Tunisiab,c Tunisia (Papoz et al, 1988 and Ghannem et al, 1997)53,54 FBG/SR WHO – 1980 6,570 20+ United Arab Emirates UAE (Malik et al, 2002 )67 OGTT WHO – 1999 6,612 19+ Yemenf Oman (Al-Lawati et al, 2002)64 OGTT WHO – 1999 5,731 20-79

a. The prevalence was obtained by combining the data from the three studies. b. The prevalences were calculated as the average of the two cited studies as their sample sizes differed considerably. c. Because of the absence of data for IGT in the studies used for diabetes, IGT figures were calculated from Jordanian data. d. Because of the absence of data for IGT in the study used for diabetes, IGT figures were calculated from UAE data. e. Because of the absence of data for IGT in the studies used for diabetes, IGT figures were calculated from Pakistani 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)65.

N/A not available

36 37 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.12 Prevalence estimates of diabetes mellitus (DM), 2003 – Eastern Mediterranean and Middle East Region

Population DM Number of people with DM (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Rural Urban Male Female 20-39 40-59 60-79 Total Afghanistan 11,130 8.2 718.0 199.4 501.5 415.8 231.5 487.1 198.7 917.3 Algeria 17,737 4.1 176.0 551.8 321.0 406.8 205.8 344.9 177.1 727.8 Armenia 2,607 8.1 48.6 162.4 81.6 129.3 20.1 96.9 94.0 211.0 Bahrain 439 14.9 2.4 63.1 42.1 23.4 11.4 44.8 9.3 65.5 Egypt 39,299 9.8 1,326.8 2,542.5 1,729.5 2,139.8 1,007.7 1,931.5 930.1 3,869.3 Iran 38,506 3.6 317.0 1,073.7 705.5 685.1 441.4 652.0 297.2 1,390.6 Iraq 11,962 7.7 114.4 801.2 456.0 459.7 147.3 514.3 254.1 915.6 Jordan 2,648 7.0 26.0 159.0 96.0 89.0 35.2 95.6 54.2 185.0 Kuwait 1,240 12.8 1.8 156.4 107.2 51.0 23.6 94.7 39.9 158.2 Lebanon 2,202 6.4 7.0 133.2 67.0 73.3 8.4 59.6 72.2 140.2 Libya 3,128 3.7 7.1 107.4 47.8 66.7 27.5 71.6 15.5 114.5 Morocco 17,598 4.2 197.7 533.9 312.2 419.3 195.2 351.3 185.0 731.5 Occupied Palestinian Territoriesa 1,525 7.4 15.8 96.7 54.7 57.9 18.7 60.9 32.9 112.5 Oman 1,274 11.4 10.6 134.4 84.9 60.1 42.2 74.6 28.2 145.0 Pakistan 72,760 8.5 3,909.2 2,271.2 3,310.5 2,869.8 1,426.3 3,332.6 1,421.5 6,180.4 Qatar 393 16.0 2.3 60.6 46.8 16.1 10.8 45.5 6.6 62.9 Saudi Arabia 10,544 9.4 70.5 921.7 597.1 395.1 145.3 583.4 263.5 992.2 Sudan 16,584 3.1 232.4 290.0 210.4 311.9 61.7 289.8 170.8 522.3 Syria 8,516 6.2 150.4 377.9 260.2 268.0 94.8 281.9 151.5 528.2 Tunisia 5,966 4.6 52.8 220.8 117.9 155.8 66.7 130.1 76.9 273.6 United Arab Emirates 1,829 20.1 26.4 340.9 272.7 94.6 54.7 247.7 64.9 367.3 Yemen 8,137 7.7 267.4 358.2 290.1 335.4 235.7 265.4 124.5 625.6

EMME Total * 276,025 7.0 7,680 11,556 9,713 9,524 4,512 10,056 4,669 19,237

* The totals may not be the exact sum of the column due to rounding. a. Occupied Palestinian Territories assigned urban/rural distribution of Jordan.

38 39 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

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

Population DM Number of people with DM (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Rural Urban Male Female 20-39 40-59 60-79 Total Afghanistan 21,973 8.3 1,185.2 634.0 973.3 845.9 449.4 976.6 393.2 1,819.2 Algeria 28,950 5.5 247.5 1,343.5 693.1 897.9 288.5 829.4 473.1 1,591.0 Armenia 2,968 10.7 52.9 263.2 124.9 191.2 21.8 131.6 162.8 316.2 Bahrain 645 18.3 2.7 115.6 67.3 51.1 13.2 56.7 48.4 118.3 Egypt 63,676 12.3 1,879.1 5,923.7 3,440.7 4,362.1 1,669.6 3,709.3 2,423.9 7,802.8 Iran 65,757 4.4 455.6 2,440.3 1,438.5 1,457.5 764.3 1,322.5 809.0 2,895.9 Iraq 23,293 9.1 185.8 1,940.5 1,061.2 1,065.1 284.2 1,197.8 644.2 2,126.3 Jordan 5,054 9.3 45.7 426.0 244.9 226.8 57.1 284.7 129.8 471.7 Kuwait 2,178 16.4 3.0 354.8 219.8 137.9 47.6 139.7 170.4 357.7 Lebanon 3,214 9.1 9.9 282.8 139.5 153.2 10.1 138.2 144.4 292.7 Libya 5,215 4.7 10.8 231.8 94.7 147.9 41.7 166.8 34.0 242.6 Morocco 28,128 5.4 264.7 1,250.4 645.5 869.6 277.1 770.7 467.3 1,515.1 Occupied Palestinian Territoriesa 3,543 8.2 28.2 263.2 147.6 143.7 43.8 159.7 87.9 291.4 Oman 2,710 11.9 10.7 312.7 173.3 150.0 97.1 146.8 79.5 323.4 Pakistan 136,909 8.5 5,700.0 5,906.8 5,890.5 5,716.2 2,754.9 6,078.1 2,773.7 11,606.8 Qatar 537 18.2 2.6 95.0 63.1 34.5 10.3 43.5 43.8 97.6 Saudi Arabia 21,851 9.6 99.8 2,001.5 1,146.4 954.9 355.9 1,017.0 728.5 2,101.3 Sudan 29,070 3.9 334.4 810.7 472.8 672.3 114.3 645.0 385.8 1,145.1 Syria 16,711 8.6 285.6 1,155.9 721.4 720.0 189.2 828.9 423.3 1,441.4 Tunisia 8,442 6.0 69.5 436.2 214.2 291.6 80.1 259.5 166.2 505.8 United Arab Emirates 2,482 24.5 31.4 575.7 409.7 197.3 76.0 230.9 300.2 607.0 Yemen 20,253 8.6 501.7 1,239.3 874.9 866.0 604.4 804.2 332.3 1,740.9

EMME Total * 493,560 8.0 11,407 28,004 19,257 20,153 8,251 19,938 11,222 39,410

* The totals may not be the exact sum of the column due to rounding.

a. Occupied Palestinian Territories assigned urban/rural distribution of Jordan.

38 39 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.14 Prevalence estimates of impaired glucose tolerance (IGT), 2003 – Eastern Mediterranean and Middle East Region

Population IGT Number of people with IGT (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Male Female 20-39 40-59 60-79 Total Afghanistan 11,130 7.6 286.3 554.7 321.6 337.3 182.1 841.1 Algeria 17,737 7.3 649.5 650.3 417.5 625.5 256.8 1,299.8 Armenia 2,607 7.0 58.7 124.4 42.5 78.4 62.3 183.2 Bahrain 439 17.2 40.0 35.7 26.8 38.7 10.1 75.6 Egypt 39,299 4.6 886.3 934.7 676.2 699.8 445.0 1,821.0 Iran 38,506 7.7 999.3 1,956.7 1,086.5 1,238.0 631.4 2,956.0 Iraq 11,962 7.3 435.3 433.0 282.0 422.7 163.7 868.3 Jordan 2,648 6.9 95.8 87.3 67.8 79.9 35.4 183.1 Kuwait 1,240 16.8 118.2 89.9 71.7 103.2 33.1 208.0 Lebanon 2,202 3.5 32.0 45.6 13.2 32.7 31.7 77.6 Libya 3,128 7.3 122.1 106.3 71.0 111.6 45.9 228.5 Morocco 17,598 7.6 644.9 685.4 402.0 655.2 273.1 1,330.3 Occupied Palestinian Territories 1,525 7.2 54.0 55.1 36.3 51.3 21.5 109.1 Oman 1,274 9.7 56.8 66.8 48.8 57.4 17.3 123.5 Pakistan 72,760 7.8 1,980.7 3,727.3 2,035.3 2,303.7 1,369.0 5,708.0 Qatar 393 16.9 42.4 24.0 21.6 38.0 6.8 66.4 Saudi Arabia 10,544 1.0 48.5 57.1 24.1 56.0 25.6 105.7 Sudan 16,584 2.3 143.4 242.8 94.9 183.9 107.5 386.2 Syria 8,516 6.9 292.4 295.0 207.8 268.3 111.4 587.4 Tunisia 5,966 7.8 230.4 234.9 132.3 224.5 108.5 465.3 United Arab Emirates 1,829 17.2 210.2 104.7 90.4 176.7 47.8 314.9 Yemen 8,137 9.5 270.6 501.1 364.5 307.4 99.8 771.7

EMME Total * 276,025 6.8 7,698 11,013 6,535 8,090 4,086 18,711

* The totals may not be the exact sum of the column due to rounding.

40 41 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.15 Prevalence estimates of impaired glucose tolerance (IGT), 2025 – Eastern Mediterranean and Middle East Region

Population IGT Number of people with IGT (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Male Female 20-39 40-59 60-79 Total Afghanistan 21,973 7.6 573.2 1,106.2 628.2 679.4 371.8 1,679.5 Algeria 28,950 9.0 1,307.8 1,287.6 564.3 1,376.5 654.7 2,595.5 Armenia 2,968 8.2 83.6 159.7 39.8 98.9 104.6 243.3 Bahrain 645 20.7 68.4 65.2 32.1 48.7 52.7 133.5 Egypt 63,676 5.1 1,599.0 1,668.6 970.5 1,233.5 1,063.7 3,267.7 Iran 65,757 8.7 2,025.7 3,674.7 1,690.5 2,384.9 1,625.0 5,700.4 Iraq 23,293 8.0 932.2 925.0 511.5 944.5 401.2 1,857.3 Jordan 5,054 8.1 213.0 198.3 105.1 224.5 81.6 411.3 Kuwait 2,178 19.6 219.4 208.1 121.9 164.4 141.2 427.5 Lebanon 3,214 4.6 65.4 83.3 15.1 71.2 62.5 148.8 Libya 5,215 8.7 229.4 225.2 99.6 251.5 103.5 454.6 Morocco 28,128 8.9 1,237.8 1,262.6 547.2 1,302.8 650.5 2,500.5 Occupied Palestinian Territories 3,543 7.4 134.0 129.7 81.5 127.1 55.2 263.8 Oman 2,710 10.1 114.1 158.4 108.4 116.3 47.9 272.5 Pakistan 136,909 8.0 3,714.0 7,218.6 3,847.6 4,316.0 2,769.1 10,932.6 Qatar 537 20.7 64.4 46.5 26.3 36.6 48.0 110.8 Saudi Arabia 21,851 1.0 86.9 134.7 55.4 99.8 66.4 221.6 Sudan 29,070 2.5 277.2 459.7 155.5 363.8 217.6 736.9 Syria 16,711 8.3 693.1 686.1 365.0 723.7 290.5 1,379.2 Tunisia 8,442 9.5 399.4 405.5 152.8 426.9 225.2 804.9 United Arab Emirates 2,482 20.8 312.3 204.2 120.0 167.2 229.2 516.5 Yemen 20,253 9.3 723.7 1,162.2 856.4 791.4 238.2 1,885.9

EMME Total * 493,560 7.4 15,074 21,470 11,095 15,950 9,500 36,545

* The totals may not be the exact sum of the column due to rounding.

40 41 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.16 Data sources: prevalence estimates of diabetes mellitus (DM) and impaired glucose tolerance (IGT) – European Region

Country Data used Screening method Diagnostic criteria Sample size Age (yrs) Albaniaa Greece (Katsilambros et al, 1993)68 SR Known diabetes 9,092 20-79 Andorra Spain (Castell et al, 1999)69 OGTT WHO – 1985 3,839 30-79 Austriab,c Germany (Rathmann et al, 2003 and Thefeld et al, 1999)70,37 SR/OGTT WHO – 1999 8,477 18-79 Azerbaijan Republic Turkey (Satman et al, 2002)55 2BG WHO – 1999 24,788 20+ Belarusc Poland (Szurkowska et al and Lopatynski et al, 2001)71,72 OGTT WHO – 1985 6,842 35+ Belgium The Netherlands (Mooy et al, 1995)73 OGTT WHO – 1985 2,540 50-74 Bosnia and Herzegovina Turkey (Satman et al, 2002)55 2BG WHO – 1999 24,788 20+ Bulgaria Turkey (Satman et al, 2002)55 2BG WHO – 1999 24,788 20+ Croatiaa Greece (Katsilambros et al, 1993)68 SR Known diabetes 9,092 20-79 Cyprusa Greece (Katsilambros et al, 1993)68 SR Known diabetes 9,092 20-79 Czech Republicc Poland (Szurkowska et al and Lopatynski et al, 2001)71,72 OGTT WHO – 1985 6,842 35+ Denmark Sweden (Eliasson et al, 2002)74 OGTT WHO – 1999 6,952 25-74 Estoniac Poland (Szurkowska et al and Lopatynski et al, 2001)71,72 OGTT WHO – 1985 6,842 35+ Finland Finland (Tuomilehto et al, 1986 and 1991)75,76 OGTT WHO – 1985 3,329 45-79 Francec Italy (Verillo et al, 1985 and Garancini et al, 1995)77,78 OGTT WHO – 1980 3,772 20+ Georgia, Republic of Turkey (Satman et al, 2002)55 2BG WHO – 1999 24,788 20+ Germanyb,c Germany (Rathmann et al, 2003 and Thefeld et al, 1999)70,37 SR/OGTT WHO – 1999 8,477 18-79 Greecea Greece (Katsilambros et al, 1993)68 SR Known diabetes 9,092 20-79 Hungaryc Poland (Szurkowska et al and Lopatynski et al, 2001)71,72 OGTT WHO – 1985 6,842 35+ Icelandd Iceland (Vilbergsson et al, 1997)79 OGTT (50-100g) WHO – 1985 18,887 30-79 Ireland, Republic of c United Kingdom (Unwin et al, 1997 and Yudkin et al, 1993)80,81 OGTT WHO – 1985 2,529 25-75 Israelc,e Israel (Bar-On et al, 1992 and Stern et al, 1999)82,83 OGTT WHO – 1980/1985 6,918 25-64 Italyc Italy (Verillo et al, 1985 and Garancini et al, 1995)77,78 OGTT WHO – 1980 3,772 20+ Kazakhstan Uzbekistan (King et al, 1998)84 2BG WHO – 1994 1,956 35+ Kyrgyzstan Uzbekistan (King et al, 1998)84 2BG WHO – 1994 1,956 35+ Latviac Poland (Szurkowska et al and Lopatynski et al, 2001)71,72 OGTT WHO – 1985 6,842 35+ Lithuaniac Poland (Szurkowska et al and Lopatynski et al, 2001)71,72 OGTT WHO – 1985 6,842 35+ Luxembourg The Netherlands (Mooy et al, 1995)73 OGTT WHO – 1985 2,540 50-74 Macedoniaa Greece (Katsilambros et al, 1993)68 SR Known diabetes 9,092 20-79 Malta Malta (Schranz, 1989)85 OGTT WHO – 1985 1,422 35+ Moldova, Republic of c Poland (Szurkowska et al and Lopatynski et al, 2001)71,72 OGTT WHO – 1985 6,842 35+ Monacoc Italy (Verillo et al, 1985 and Garancini et al, 1995)77,78 OGTT WHO – 1980 3,772 20+ Netherlands The Netherlands (Mooy et al, 1995)73 OGTT WHO – 1985 2,540 50-74 Norway Sweden (Eliasson et al, 2002)74 OGTT WHO – 1999 6,952 25-74 Polandc Poland (Szurkowska et al and Lopatynski et al, 2001)71,72 OGTT WHO – 1985 6,842 35+ Portugal Spain (Castell et al, 1999)69 OGTT WHO – 1985 3,839 30-79 Romaniac Poland (Szurkowska et al and Lopatynski et al, 2001)71,72 OGTT WHO – 1985 6,842 35+ Russian Federationc Poland (Szurkowska et al and Lopatynski et al, 2001)71,72 OGTT WHO – 1985 6,842 35+ San Marinoc Italy (Verillo et al, 1985 and Garancini et al, 1995)77,78 OGTT WHO – 1980 3,772 20+ Serbia and Montenegroa Greece (Katsilambros et al, 1993)68 SR Known diabetes 9,092 20-79 Slovakiac Poland (Szurkowska et al and Lopatynski et al, 2001)71,72 OGTT WHO – 1985 6,842 35+ Sloveniac Poland (Szurkowska et al and Lopatynski et al, 2001)71,72 OGTT WHO – 1985 6,842 35+ Spain Spain (Castell et al, 1999)69 OGTT WHO – 1985 3,839 30-79 Sweden Sweden (Eliasson et al, 2002)74 OGTT WHO – 1999 6,952 25-74 Switzerlandc Germany (Rathmann et al, 2003 and Thefeld et al, 1999)70,37 SR/OGTT WHO – 1999 8,477 18-79 Tajikistan Uzbekistan (King et al, 1998)84 2BG WHO – 1994 1,956 35+ Turkey Turkey (Satman et al, 2002)55 2BG WHO – 1999 24,788 20+ Turkmenistan Uzbekistan (King et al, 1998)84 2BG WHO – 1994 1,956 35+ Ukrainec Poland (Szurkowska et al and Lopatynski et al, 2001)71,72 OGTT WHO – 1985 6,842 35+ United Kingdomc United Kingdom (Unwin et al, 1997 and Yudkin et al, 1993)80,81 OGTT WHO – 1985 2,529 25-75 Uzbekistan Uzbekistan (King et al, 1998)84 2BG WHO – 1994 1,956 35+

a. Because of the absence of data for IGT in the study used for diabetes, IGT figures were calculated from Turkish data. b. IGT prevalences were derived from the data of Rathmann et al. c. The prevalences for the studies based on the German, Italian, Israeli, Polish and the United Kingdom studies were obtained by combining the data from the two studies respectively.

42 43 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

d. Because of the absence of data for IGT in the study used for diabetes, IGT figures were calculated from Netherlands data. e. IGT prevalence for Israel was derived only from the data in Bar-On et al.

42 43 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.17 Prevalence estimates of diabetes mellitus (DM), 2003 – European Region

Population DM Number of people with DM (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Rural Urban Male Female 20-39 40-59 60-79 Total Albania 1,966 3.8 34.9 40.1 4.0 27.2 43.7 75.0 Andorraa 50 7.7 1.9 2.0 0.1 1.3 2.5 3.9 Austria 5,991 9.6 258.5 317.5 38.8 172.7 364.5 576.0 Azerbaijan Republic 5,154 6.9 122.1 235.4 143.6 213.9 44.7 159.8 152.9 357.5 Belarus 7,336 6.9 309.1 374.3 63.4 242.3 377.7 683.4 Belgium 7,531 4.2 140.6 174.5 3.1 71.1 240.9 315.1 Bosnia and Herzegovina 3,074 9.6 117.2 178.2 24.5 141.0 129.9 295.4 Bulgaria 5,894 10.0 135.8 455.4 235.7 355.5 37.6 248.1 305.5 591.2 Croatia 3,412 5.8 82.4 116.7 5.3 56.8 137.1 199.1 Cyprus 541 5.1 12.3 15.4 0.9 9.4 17.5 27.7 Czech Republic 7,734 9.5 365.2 369.6 66.8 286.2 381.9 734.9 Denmark 3,863 6.9 120.9 144.0 23.3 87.0 154.6 264.9 Estonia 991 9.7 43.4 52.9 8.6 33.3 54.4 96.3 Finland 3,775 7.2 130.3 143.2 10.3 56.3 207.0 273.5 France 42,546 6.2 1,306.3 1,347.3 175.0 1,045.3 1,433.3 2,653.6 Georgia, Republic of 3,681 9.0 102.8 229.5 129.0 203.4 25.6 134.7 172.1 332.4 Germany 61,895 10.2 2,879.3 3,415.0 374.0 1,752.7 4,167.6 6,294.3 Greece 8,069 6.1 217.0 276.0 12.9 129.0 351.0 493.0 Hungary 7,350 9.7 336.3 375.1 62.6 259.5 389.2 711.4 Iceland 192 2.0 2.1 1.7 0.2 1.2 2.4 3.7 Ireland, Republic of 2,674 3.4 43.6 46.2 6.0 34.4 49.4 89.8 Israel 3,959 7.1 140.9 140.7 36.8 102.7 142.1 281.6 Italy 43,925 6.6 1,400.2 1,479.9 185.7 1,009.4 1,684.9 2,880.1 Kazakhstan 10,235 5.5 147.3 411.6 305.2 253.8 39.1 288.8 231.1 558.9 Kyrgyzstan 2,896 4.3 57.7 67.1 71.4 53.5 9.1 62.1 53.6 124.8 Latvia 1,758 9.9 77.5 96.1 15.1 58.4 100.1 173.6 Lithuania 2,648 9.4 114.7 134.2 24.6 84.8 139.5 248.9 Luxembourg 327 3.8 5.8 6.8 0.1 3.0 9.3 12.5 Macedonia 1,428 4.9 30.9 39.0 2.5 23.2 44.2 69.9 Malta 280 9.2 10.6 15.3 0.3 9.0 16.5 25.8 Moldova, Republic of 2,915 9.3 117.2 124.6 26.6 97.8 117.3 241.8 Monacoa 23 6.1 0.7 0.7 0.1 0.6 0.8 1.4 Netherlands 11,678 3.7 203.4 228.8 5.3 118.3 308.5 432.2 Norway 3,154 6.7 95.5 116.2 19.8 69.6 122.3 211.7 Poland 27,852 9.0 1,238.7 1,267.8 239.0 1,002.5 1,265.0 2,506.5 Portugal 7,471 7.8 278.5 305.9 14.9 170.9 398.7 584.5 Romania 16,392 9.3 760.0 759.2 154.7 519.0 845.6 1,519.2 Russian Federation 105,244 9.2 4,417.7 5,275.9 899.4 3,637.5 5,156.7 9,693.6 San Marinoa 20 6.1 0.6 0.6 0.1 0.5 0.7 1.2 Serbia and Montenegro 7,542 5.6 182.0 240.1 11.8 127.1 283.2 422.1 Slovakia 3,903 8.7 167.5 171.3 35.9 135.6 167.2 338.7 Slovenia 1,511 9.6 72.2 73.1 13.1 53.5 78.6 145.2 Spain 30,329 9.9 1,209.7 1,794.6 838.4 973.2 1,192.6 3,004.3 Sweden 6,290 7.3 206.4 250.5 36.3 140.1 280.5 456.9 Switzerland 5,310 9.5 235.0 270.0 35.3 166.6 303.1 504.9 Tajikistan 3,174 3.7 62.9 53.8 70.3 46.4 9.6 57.5 49.6 116.7 Turkey 42,411 7.0 514.1 2,444.6 1,254.3 1,704.4 370.4 1,440.7 1,147.7 2,958.7 Turkmenistan 2,648 4.0 42.5 62.5 61.7 43.3 9.7 55.7 39.6 105.0 Ukraine 35,625 9.7 1,552.3 1,901.1 302.2 1,154.7 1,996.6 3,453.4 United Kingdom 42,423 3.9 813.7 857.9 89.4 588.9 993.3 1,671.5 Uzbekistan 14,144 4.0 244.0 316.5 333.0 227.5 48.7 287.7 224.1 560.5

EUR Total * 621,235 7.8 1,429 4,276 22,337 26,041 4,462 17,388 26,528 48,378

* The totals may not be the exact sum of the column due to rounding. a. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that of developed world population 2003.

44 45 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

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

Population DM Number of people with DM (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Rural Urban Male Female 20-39 40-59 60-79 Total Albania 2,559 5.1 61.3 69.9 4.5 43.5 83.2 131.2 Andorraa 52 9.5 2.5 2.5 0.1 1.3 3.5 4.9 Austria 5,887 11.9 338.3 364.5 28.2 187.0 487.5 702.8 Azerbaijan Republic 6,793 9.4 156.8 479.5 259.4 376.9 53.6 285.3 297.3 636.3 Belarus 7,233 10.7 356.5 416.6 58.5 259.3 455.3 773.1 Belgium 7,658 5.2 180.4 214.2 2.6 74.9 317.1 394.6 Bosnia and Herzegovina 3,270 12.3 165.6 236.8 20.7 161.2 220.5 402.4 Bulgaria 4,871 11.6 93.7 471.2 223.1 341.7 28.8 233.3 302.8 564.9 Croatia 3,304 6.7 96.6 123.9 4.6 58.5 157.5 220.5 Cyprus 637 6.3 18.3 21.8 1.0 10.5 28.6 40.1 Czech Republic 7,599 11.7 441.9 445.5 51.9 292.2 543.3 887.4 Denmark 3,988 8.3 148.3 182.2 20.3 83.3 226.8 330.4 Estonia 814 11.0 41.7 47.7 6.4 30.2 52.8 89.4 Finland 3,822 10.0 186.0 198.0 9.3 47.1 327.6 383.9 France 45,141 7.3 1,609.5 1,675.8 156.3 1,058.2 2,070.8 3,285.3 Georgia, Republic of 3,341 10.7 79.0 278.7 142.5 215.2 22.1 143.1 192.5 357.7 Germany 60,030 11.9 3,459.1 3,684.5 293.8 1,852.9 4,997.0 7,143.7 Greece 7,767 7.3 254.3 312.1 9.2 153.4 403.8 566.4 Hungary 6,807 11.2 364.7 397.0 49.4 261.7 450.6 761.7 Iceland 229 2.5 3.2 2.6 0.2 1.4 4.2 5.8 Ireland, Republic of 3,290 4.1 66.0 68.5 6.0 45.3 83.2 134.5 Israel 5,776 8.1 243.4 224.9 48.9 151.2 268.2 468.3 Italy 40,482 7.9 1,583.5 1,614.8 116.4 1,093.1 1,988.8 3,198.3 Kazakhstan 11,358 7.0 153.9 642.6 429.9 366.6 47.7 371.7 377.2 796.5 Kyrgyzstan 4,355 5.8 86.9 164.8 143.6 108.1 16.5 124.0 111.1 251.6 Latvia 1,610 11.1 84.4 93.7 12.7 60.0 105.5 178.2 Lithuania 2,626 10.8 136.0 148.1 21.2 96.8 166.1 284.1 Luxembourg 415 4.4 8.4 9.8 0.2 3.7 14.3 18.1 Macedonia 1,598 6.1 43.6 53.1 2.5 28.7 65.5 96.7 Malta 304 11.6 15.4 19.7 0.3 7.9 26.9 35.1 Moldova, Republic of 3,095 9.8 148.2 154.2 28.2 106.3 168.0 302.4 Monacoa 24 7.2 0.9 0.9 0.1 0.6 1.1 1.7 Netherlands 12,538 5.1 290.9 344.4 4.4 127.8 503.2 635.3 Norway 3,534 8.2 129.3 159.1 18.6 73.0 196.8 288.5 Poland 28,567 11.0 1,545.9 1,606.7 217.8 1,017.5 1,917.3 3,152.6 Portugal 7,456 9.5 344.4 361.8 11.0 210.7 484.5 706.2 Romania 15,860 10.6 834.3 842.7 123.0 645.1 908.8 1,676.9 Russian Federation 98,969 10.9 4,909.1 5,837.5 784.7 3,536.9 6,425.0 10,746.6 San Marinoa 21 7.2 0.7 0.8 0.1 0.5 0.9 1.5 Serbia and Montenegro 7,597 6.4 214.6 268.4 11.4 134.7 336.9 483.0 Slovakia 4,127 10.7 219.2 224.1 31.7 153.6 258.1 443.3 Slovenia 1,451 12.0 86.8 86.7 9.5 54.7 109.2 173.5 Spain 29,155 10.1 1,478.9 1,466.0 40.0 874.0 2,030.9 2,944.9 Sweden 6,373 8.6 245.6 302.6 32.9 131.5 383.8 548.2 Switzerland 5,114 12.6 308.0 338.5 24.5 147.2 474.8 646.5 Tajikistan 5,305 5.1 110.1 158.2 158.2 110.1 20.1 139.2 109.0 268.3 Turkey 59,689 9.1 551.7 4,878.5 2,285.4 3,144.8 435.1 2,665.9 2,329.1 5,430.2 Turkmenistan 4,537 5.5 75.6 171.9 142.5 105.0 18.4 127.4 101.6 247.5 Ukraine 31,102 10.8 1,558.4 1,799.5 247.7 1,142.4 1,967.8 3,357.9 United Kingdom 45,322 4.7 1,079.8 1,061.5 79.4 628.2 1,433.7 2,141.4 Uzbekistan 22,883 5.7 422.3 875.0 753.5 543.8 92.7 662.5 542.1 1,297.3

EUR Total * 646,334 9.1 1,730 8,120 27,842 30,796 3,325 19,800 35,512 58,638

* The totals may not be the exact sum of the column due to rounding.

a. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that of developed world population from 2003 to 2025.

44 45 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.19 Prevalence estimates of impaired glucose tolerance (IGT), 2003 – European Region

Population IGT Number of people with IGT (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Male Female 20-39 40-59 60-79 Total Albania 1,966 6.5 45.2 81.9 35.7 53.9 37.4 127.1 Andorraa 50 9.9 2.0 2.9 1.3 1.8 1.9 4.9 Austria 5,991 5.8 161.0 184.2 0.7 84.2 260.4 345.3 Azerbaijan Republic 5,154 6.5 108.6 228.4 95.2 137.8 104.1 337.0 Belarus 7,336 17.0 487.1 760.0 287.8 484.5 474.7 1,247.1 Belgium 7,531 6.4 237.8 243.7 54.8 141.6 285.0 481.5 Bosnia and Herzegovina 3,074 7.4 77.4 148.7 46.6 99.8 79.8 226.1 Bulgaria 5,894 8.0 162.3 308.5 78.9 188.7 203.2 470.8 Croatia 3,412 7.9 92.1 177.6 46.2 107.6 115.9 269.7 Cyprus 541 7.4 14.2 26.0 7.9 17.5 14.8 40.2 Czech Republic 7,734 17.0 563.8 754.4 300.4 539.5 478.3 1,318.3 Denmark 3,863 8.6 107.3 225.3 62.9 105.7 164.0 332.5 Estonia 991 17.3 67.4 104.3 38.1 65.0 68.6 171.7 Finland 3,775 6.6 101.6 148.3 0.5 42.4 207.0 249.9 France 42,546 5.6 974.6 1,415.2 457.4 829.3 1,103.1 2,389.9 Georgia, Republic of 3,681 7.6 92.2 189.1 54.2 110.3 116.9 281.3 Germany 61,895 6.3 1,849.6 2,049.5 6.4 840.5 3,052.2 3,899.1 Greece 8,069 8.0 232.4 411.6 112.4 239.4 292.2 644.0 Hungary 7,350 17.2 519.4 747.8 281.7 496.7 488.8 1,267.2 Iceland 192 5.5 5.6 4.9 1.6 3.5 5.3 10.5 Ireland, Republic of 2,674 4.9 85.8 44.1 44.1 53.1 32.6 129.9 Israel 3,959 5.4 129.7 82.6 43.3 85.8 83.2 212.3 Italy 43,925 5.8 1,042.0 1,513.3 467.0 800.6 1,287.6 2,555.2 Kazakhstan 10,235 5.4 207.5 344.5 98.2 250.1 203.7 552.0 Kyrgyzstan 2,896 4.9 54.9 88.2 30.7 61.1 51.3 143.1 Latvia 1,758 17.5 120.1 187.3 66.6 114.4 126.4 307.4 Lithuania 2,648 17.0 179.9 271.2 107.8 167.4 175.8 451.1 Luxembourg 327 6.0 9.9 9.7 2.5 6.1 11.0 19.6 Macedonia 1,428 7.3 36.3 67.3 22.1 44.1 37.5 103.6 Malta 280 7.5 10.1 11.0 1.3 10.7 9.1 21.1 Moldova, Republic of 2,915 16.0 189.6 277.8 123.4 196.1 147.9 467.4 Monacoa 23 5.5 0.5 0.8 0.3 0.4 0.6 1.3 Netherlands 11,678 5.9 352.0 334.6 90.5 232.6 363.6 686.6 Norway 3,154 8.5 85.1 183.3 53.8 84.8 129.9 268.4 Poland 27,852 16.6 1,950.2 2,675.6 1,091.8 1,952.2 1,581.8 4,625.8 Portugal 7,471 9.9 290.0 452.6 204.9 242.4 295.2 742.6 Romania 16,392 16.8 1,174.4 1,576.0 692.6 1,000.9 1,057.0 2,750.5 Russian Federation 105,244 16.9 7,009.0 10,793.1 4,050.3 7,255.9 6,495.8 17,802.0 San Marinoa 20 5.5 0.4 0.7 0.2 0.4 0.5 1.1 Serbia and Montenegro 7,542 7.7 204.2 375.5 105.5 237.2 236.9 579.7 Slovakia 3,903 16.3 267.3 369.4 163.0 263.9 209.9 636.7 Slovenia 1,511 17.2 111.3 148.3 57.8 103.3 98.5 259.6 Spain 30,329 9.9 1,209.7 1,794.6 838.4 973.2 1,192.6 3,004.3 Sweden 6,290 9.0 181.9 383.7 98.9 169.5 297.2 565.6 Switzerland 5,310 6.1 155.6 169.1 0.5 84.6 239.7 324.8 Tajikistan 3,174 4.5 57.1 86.2 36.7 59.4 47.2 143.3 Turkey 42,411 6.2 910.4 1,735.1 798.9 1,102.9 743.6 2,645.4 Turkmenistan 2,648 4.5 46.6 73.8 30.3 53.7 36.3 120.3 Ukraine 35,625 17.3 2,410.3 3,760.7 1,360.5 2,291.0 2,519.5 6,171.0 United Kingdom 42,423 5.1 1,362.3 783.8 591.3 904.1 650.7 2,146.1 Uzbekistan 14,144 4.6 255.3 392.9 160.3 280.9 207.0 648.2

EUR Total * 621,235 10.2 26,001 37,199 13,404 23,673 26,123 63,200

* The totals may not be the exact sum of the columns due to rounding. a. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that of developed world population 2003.

46 47 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

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

Population IGT Number of people with IGT (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Male Female 20-39 40-59 60-79 Total Albania 2,559 7.4 70.0 120.0 38.8 79.4 71.8 190.0 Andorraa 52 10.6 2.4 3.2 1.1 1.8 2.6 5.6 Austria 5,887 7.9 230.3 234.4 0.4 102.1 362.1 464.6 Azerbaijan Republic 6,793 7.6 179.4 339.7 103.6 220.6 194.9 519.1 Belarus 7,233 18.3 536.8 787.5 243.2 505.3 575.9 1,324.4 Belgium 7,658 7.4 276.6 287.1 47.3 140.7 375.7 563.7 Bosnia and Herzegovina 3,270 8.6 104.2 177.8 37.4 109.5 135.1 282.0 Bulgaria 4,871 8.7 148.1 276.1 54.0 172.7 197.6 424.2 Croatia 3,304 8.4 100.8 177.9 39.3 106.3 133.1 278.7 Cyprus 637 8.1 19.3 32.3 8.5 19.3 23.9 51.7 Czech Republic 7,599 19.1 637.2 811.9 219.1 556.0 673.9 1,449.1 Denmark 3,988 9.9 128.6 267.4 56.9 99.9 239.2 396.0 Estonia 814 18.6 62.2 88.8 26.6 58.0 66.4 151.0 Finland 3,822 9.4 159.1 200.3 0.5 35.8 323.1 359.3 France 45,141 6.3 1,187.3 1,636.8 411.6 823.7 1,588.8 2,824.0 Georgia, Republic of 3,341 8.3 96.5 181.6 42.5 109.2 126.5 278.2 Germany 60,030 7.9 2,366.1 2,380.4 4.7 1,004.2 3,737.6 4,746.5 Greece 7,767 8.9 258.1 430.4 77.6 273.2 337.8 688.5 Hungary 6,807 18.7 537.6 733.3 210.7 498.6 561.7 1,271.0 Iceland 229 6.6 7.7 7.4 1.6 4.1 9.4 15.1 Ireland, Republic of 3,290 5.1 106.8 62.3 42.8 71.1 55.2 169.1 Israel 5,776 5.9 214.4 129.1 57.4 126.0 160.1 343.5 Italy 40,482 6.5 1,124.3 1,526.3 302.1 832.7 1,515.8 2,650.6 Kazakhstan 11,358 6.3 279.8 431.8 101.7 296.6 313.2 711.5 Kyrgyzstan 4,355 5.7 100.3 147.4 43.6 108.2 95.9 247.7 Latvia 1,610 18.6 125.4 174.6 52.2 114.9 132.8 299.9 Lithuania 2,626 18.4 202.7 279.8 88.5 184.4 209.6 482.5 Luxembourg 415 6.5 13.7 13.5 3.1 7.1 16.9 27.1 Macedonia 1,598 8.1 47.3 81.6 20.8 52.8 55.3 129.0 Malta 303 8.5 12.7 13.0 1.4 9.7 14.6 25.7 Moldova, Republic of 3,095 17.4 227.8 311.5 117.8 209.7 211.8 539.3 Monacoa 24 6.1 0.6 0.9 0.2 0.5 0.8 1.5 Netherlands 12,538 7.3 447.7 463.9 79.5 235.5 596.6 911.5 Norway 3,534 9.8 112.4 234.7 51.7 87.7 207.7 347.1 Poland 28,567 18.5 2,278.3 3,010.0 914.1 1,981.9 2,392.3 5,288.3 Portugal 7,456 10.6 334.2 459.2 148.4 286.5 358.5 793.4 Romania 15,860 18.1 1,246.2 1,631.4 518.0 1,225.8 1,133.8 2,877.6 Russian Federation 98,969 18.5 7,361.1 10,924.1 3,258.1 6,911.1 8,116.0 18,285.2 San Marinoa 21 6.1 0.5 0.8 0.2 0.4 0.7 1.3 Serbia and Montenegro 7,597 8.2 229.7 395.4 95.0 248.2 281.9 625.1 Slovakia 4,127 18.3 326.0 427.9 134.1 296.6 323.2 753.9 Slovenia 1,451 19.3 124.0 156.0 40.2 103.6 136.2 280.0 Spain 29,155 10.9 1,395.2 1,780.4 506.9 1,170.3 1,498.3 3,175.5 Sweden 6,373 10.2 212.6 436.7 87.0 158.0 404.3 649.3 Switzerland 5,114 8.4 215.2 212.1 0.4 79.8 347.1 427.3 Tajikistan 5,305 5.2 114.4 163.8 58.0 126.1 94.1 278.2 Turkey 59,689 7.2 1,536.6 2,772.9 898.1 1,941.6 1,469.7 4,309.4 Turkmenistan 4,537 5.3 97.8 143.4 47.4 108.4 85.4 241.2 Ukraine 31,102 18.4 2,339.6 3,385.9 1,027.5 2,212.9 2,485.1 5,725.5 United Kingdom 45,322 5.3 1,507.9 901.2 538.8 917.3 953.0 2,409.1 Uzbekistan 22,883 5.5 521.2 743.0 236.0 571.2 457.0 1,264.2

EUR Total * 646,334 10.9 29,965 40,589 11,097 25,597 33,860 70,553

* The totals may not be the exact sum of the column due to rounding.

a. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that of developed world population from 2003 to 2025.

46 47 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.21 Data sources: prevalence estimates of diabetes mellitus (DM) and impaired glucose tolerance (IGT) – North American Region

Country Data used Screening method Diagnostic criteria Sample size Age (yrs) Anguilla Jamaica (Wilks et al, 1999)86 OGTT WHO – 1980 1,303 25-74 Antigua and Barbuda Jamaica (Wilks et al, 1999)86 OGTT WHO – 1980 1,303 25-74 Aruba Jamaica (Wilks et al, 1999)86 OGTT WHO – 1980 1,303 25-74 Bahamas Jamaica (Wilks et al, 1999)86 OGTT WHO – 1980 1,303 25-74 a 87 Barbados Barbados (Hennis et al, 2002) SR or HbA1c > 10% Known diabetes 4,104 40-79 Belize Jamaica (Wilks et al, 1999)86 OGTT WHO – 1980 1,303 25-74 Bermuda Jamaica (Wilks et al, 1999)86 OGTT WHO – 1980 1,303 25-74 British Virgin Islands Jamaica (Wilks et al, 1999)86 OGTT WHO – 1980 1,303 25-74 Canadab Canada (Hux et al, 2002)36 Registry Known diabetes N/A 20+ Cayman Islands Jamaica (Wilks et al, 1999)86 OGTT WHO – 1980 1,303 25-74 Dominica, Commonwealth of Jamaica (Wilks et al, 1999)86 OGTT WHO – 1980 1,303 25-74 Grenada Jamaica (Wilks et al, 1999)86 OGTT WHO – 1980 1,303 25-74 Guadeloupea Guadeloupe (Costagliola et al, 1991)88 SR or FBG > 8.0 WHO – 1980 1,036 18+ Guyana Jamaica (Wilks et al, 1999)86 OGTT WHO – 1980 1,303 25-74 Haiti Jamaica (Wilks et al, 1999)86 OGTT WHO – 1980 1,303 25-74 Jamaica Jamaica (Wilks et al, 1999)86 OGTT WHO – 1980 1,303 25-74 Martiniquea Guadeloupe (Costagliola et al, 1991)87 SR or FBG > 8.0 WHO – 1980 1,036 18+ Mexicoc,d Mexico (Stern et al, 1992 and Posadas-Romero et al, 1994)89,90 OGTT/FBG WHO – 1985 1,451 20-79 St Kitts and Nevis Jamaica (Wilks et al, 1999)86 OGTT WHO – 1980 1,303 25-74 St Lucia Jamaica (Wilks et al, 1999)86 OGTT WHO – 1980 1,303 25-74 St Vincent and the Grenadinesa Barbados (Hennis et al, 2002)87 SR or HbA1c > 10% Known diabetes 4,104 40-79 Trinidad and Tobago Jamaica (Wilks et al, 1999)86 OGTT WHO – 1980 1,303 25-74 USA USA (Harris et al, 1998)91 FBG ADA – 1997 18,825 20+

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, impaired fasting glucose (IFG) figures were calculated from USA data. c. The prevalence was obtained by combining the data from the two studies. d. Because of the absence of data for IGT in the studies used for diabetes, IGT figures were calculated from Brazilian data.

48 49 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.22 Prevalence estimates of diabetes mellitus (DM), 2003 – North American Region

Population DM Number of people with DM (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Rural Urban Male Female 20-39 40-59 60-79 Total Anguillaa 8 5.5 0.3 0.1 0.2 0.2 0.1 0.3 0.1 0.4 Antigua and Barbudaa 41 5.8 1.6 0.7 1.2 1.2 0.4 1.4 0.6 2.4 Arubaa 43 9.7 2.1 2.1 0.6 2.5 1.0 4.2 Bahamas 193 9.0 6.1 11.2 2.8 9.5 5.0 17.3 Barbados 189 8.5 5.2 10.9 7.4 8.7 2.1 8.2 5.8 16.1 Belize 124 5.7 2.6 4.5 3.6 3.5 1.5 4.2 1.4 7.1 Bermudaa 39 9.7 1.9 1.9 0.6 2.3 0.9 3.8 British Virgin Islandsa 13 8.3 0.3 0.8 0.5 0.6 0.2 0.6 0.3 1.1 Canada 22,640 9.0 1,099.3 935.0 158.1 871.0 1,005.1 2,034.3 Cayman Islandsa 22 9.7 1.1 1.1 0.3 1.3 0.5 2.2 Dominica, Commonwealth of a 42 8.4 0.6 3.0 1.7 1.8 0.5 2.1 0.9 3.5 Grenadaa 54 6.8 1.6 2.1 1.8 1.9 0.6 2.2 0.9 3.7 Guadeloupe 289 6.5 0.0 18.7 8.8 10.0 2.3 9.3 7.2 18.8 Guyana 457 6.0 11.9 15.7 9.4 18.2 5.0 15.3 7.3 27.6 Haiti 4,113 5.7 109.9 126.4 79.6 156.7 41.4 127.8 67.1 236.3 Jamaica 1,528 7.2 30.0 80.6 39.4 71.3 17.7 58.0 35.0 110.6 Martinique 265 6.5 16.8 0.4 7.9 9.3 2.1 8.0 7.2 17.3 Mexico 59,336 7.4 631.8 3,776.7 1,616.7 2,791.9 646.6 2,168.7 1,593.2 4,408.5 St Kitts and Nevisa 23 6.6 0.7 0.8 0.8 0.8 0.2 0.9 0.4 1.5 St Lucia 101 6.2 2.8 3.5 3.0 3.3 1.1 3.8 1.4 6.3 St Vincent and the Grenadinesa 71 7.7 1.5 4.0 2.7 2.7 0.8 3.3 1.3 5.4 Trinidad and Tobago 861 7.9 9.7 58.3 10.9 57.0 58.4 9.3 0.2 67.9 USA 199,097 8.0 8,040.5 7,979.5 1,550.8 7,507.3 6,962.0 16,020.0

NA Total * 289,550 7.9 827 4,107 10,947 12,070 2,494 10,817 9,705 23,016

* The totals may not be the exact sum of the column due to rounding. a. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that of the world population 2003.

50 51 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

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

Population DM Number of people with DM (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Rural Urban Male Female 20-39 40-59 60-79 Total Anguillaa 11 6.7 0.4 0.3 0.4 0.4 0.1 0.4 0.2 0.7 Antigua and Barbudaa 57 8.2 1.6 3.1 2.3 2.3 0.6 2.7 1.4 4.6 Arubaa 59 10.9 3.2 3.2 0.8 3.8 1.9 6.4 Bahamas 266 11.4 10.5 19.9 3.1 15.6 11.6 30.3 Barbados 217 12.8 6.2 21.6 13.5 14.3 1.7 11.6 14.4 27.8 Belize 216 7.8 4.6 12.3 8.5 8.5 2.6 10.5 3.8 16.9 Bermudaa 54 10.9 2.9 3.0 0.7 3.4 1.7 5.9 British Virgin Islandsa 18 9.6 0.2 1.5 0.9 0.9 0.2 1.0 0.5 1.7 Canada 27,135 11.2 1,650.9 1,380.5 162.0 941.6 1,927.8 3,031.5 Cayman Islandsa 31 10.9 1.7 1.7 0.4 2.0 1.0 3.4 Dominica, Commonwealth of a 58 9.8 0.7 5.0 2.8 2.9 0.7 3.3 1.7 5.7 Grenadaa 74 8.4 1.9 4.3 3.1 3.1 0.8 3.6 1.8 6.2 Guadeloupe 345 8.2 0.0 28.3 13.4 14.9 2.0 12.1 14.1 28.3 Guyana 480 9.5 13.5 32.0 14.2 31.3 4.1 24.3 17.1 45.5 Haiti 6,679 7.0 150.1 314.2 156.5 307.7 79.8 251.1 133.3 464.2 Jamaica 2,197 9.6 39.7 170.1 75.1 134.7 24.0 110.7 75.2 209.8 Martinique 305 8.2 0.4 24.6 11.8 13.1 1.8 11.0 12.2 25.0 Mexico 87,640 10.3 968.8 8,065.8 3,234.7 5,800.0 800.9 4,452.3 3,781.4 9,034.6 St Kitts and Nevisa 32 8.0 1.0 1.6 1.3 1.3 0.3 1.5 0.8 2.6 St Lucia 132 8.4 3.7 7.4 5.4 5.7 1.3 6.6 3.2 11.1 St Vincent and the Grenadinesa 97 9.4 1.5 7.7 4.5 4.6 1.1 5.3 2.7 9.1 Trinidad and Tobago 1,042 11.8 12.2 111.0 43.7 79.5 10.9 62.0 50.3 123.2 USA 247,219 9.3 11,735.1 11,345.4 1,753.7 8,099.7 13,227.0 23,080.5

NA Total * 374,364 9.7 1,207 8,811 16,996 19,179 2,854 14,036 19,285 36,175

* The totals may not be the exact sum of the column due to rounding.

a. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that of world population growth from 2003 to 2025.

50 51 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.24 Prevalence estimates of impaired glucose tolerance (IGT), 2003 – North American Region

Population IGT Number of people with IGT (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Male Female 20-39 40-59 60-79 Total Anguillaa 8 11.3 0.4 0.5 0.2 0.4 0.3 0.9 Antigua and Barbudaa 41 11.3 1.9 2.8 1.3 1.9 1.5 4.6 Arubaa 43 11.3 2.0 2.9 1.3 2.0 1.5 4.9 Bahamas 193 10.7 7.7 13.0 6.5 8.5 5.7 20.7 Barbados 189 11.6 8.5 13.6 5.6 9.6 6.8 22.1 Belize 124 9.8 4.7 7.3 4.6 4.5 3.0 12.1 Bermudaa 39 11.3 1.8 2.6 1.2 1.8 1.4 4.4 British Virgin Islandsa 13 11.3 0.6 0.9 0.4 0.6 0.5 1.5 Canadab 22,640 7.1 1,002.7 601.7 277.2 723.1 604.1 1,604.4 Cayman Islandsa 22 11.3 1.0 1.5 0.7 1.0 0.8 2.5 Dominica, Commonwealth of a 42 11.3 1.9 2.8 1.3 1.9 1.5 4.8 Grenadaa 54 11.3 2.5 3.6 1.7 2.5 1.9 6.1 Guadeloupe 289 11.9 13.7 20.8 8.5 14.4 11.6 34.5 Guyana 457 10.2 16.3 30.3 16.6 18.6 11.4 46.5 Haiti 4,113 10.0 144.2 268.1 148.6 158.3 105.4 412.3 Jamaica 1,528 10.8 63.8 101.5 51.6 62.9 50.8 165.3 Martinique 265 12.2 12.8 19.6 7.8 12.7 11.9 32.4 Mexico 59,336 6.6 1,715.4 2,199.7 1,506.0 1,548.6 860.5 3,915.1 St Kitts and Nevisa 23 11.3 1.1 1.6 0.7 1.1 0.8 2.7 St Lucia 101 10.7 4.1 6.7 3.5 4.3 3.0 10.7 St Vincent and the Grenadinesa 71 11.3 3.3 4.7 2.2 3.3 2.5 8.0 Trinidad and Tobago 861 11.1 38.1 57.5 26.6 41.4 27.6 95.5 USAb 199,097 7.0 8,650.6 5,255.8 2,481.1 6,292.6 5,132.6 13,906.4

NA Total * 289,550 7.0 11,699 8,619 4,555 8,916 6,847 20,318

* The totals may not be the exact sum of the column due to rounding. a. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that of world population 2003. b. Prevalence figures are for impaired fasting glucose (IFG) (not IGT) as only fasting specimens were measured for the majority of NHANES III participants.

52 53 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

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

Population IGT Number of people with IGT (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Male Female 20-39 40-59 60-79 Total Anguillaa 11 12.5 0.6 0.8 0.3 0.5 0.5 1.3 Antigua and Barbudaa 57 12.5 3.0 4.0 1.5 2.8 2.7 7.1 Arubaa 59 12.5 3.2 4.2 1.6 2.9 2.8 7.4 Bahamas 266 12.5 13.4 19.9 7.1 13.6 12.6 33.3 Barbados 217 14.7 14.4 17.5 4.3 12.2 15.4 31.9 Belize 216 11.3 10.0 14.2 6.7 10.5 7.1 24.3 Bermudaa 54 12.5 2.9 3.8 1.5 2.7 2.6 6.7 British Virgin Islandsa 18 12.5 1.0 1.3 0.5 0.9 0.9 2.3 Canadab 27,135 8.1 1,344.0 866.0 283.6 766.2 1,160.2 2,210.0 Cayman Islandsa 31 12.5 1.7 2.2 0.8 1.5 1.5 3.9 Dominica, Commonwealth of a 58 12.5 3.1 4.1 1.6 2.9 2.8 7.2 Grenadaa 74 12.5 4.0 5.3 2.0 3.7 3.6 9.3 Guadeloupe 345 14.1 21.1 27.5 7.7 18.2 22.7 48.6 Guyana 480 12.7 22.6 38.2 12.0 26.3 22.6 60.8 Haiti 6,679 10.5 247.1 452.1 233.4 282.2 183.6 699.2 Jamaica 2,197 12.2 110.8 157.8 60.9 110.7 97.0 268.6 Martinique 305 14.1 18.7 24.4 6.7 16.7 19.7 43.2 Mexico 87,640 7.6 2,832.7 3,841.9 1,719.9 2,987.2 1,967.4 6,674.5 St Kitts and Nevisa 32 12.5 1.7 2.3 0.9 1.6 1.5 4.0 St Lucia 132 12.6 7.0 9.6 3.5 6.9 6.2 16.6 St Vincent and the Grenadinesa 97 12.5 5.2 6.9 2.6 4.9 4.7 12.2 Trinidad and Tobago 1,042 13.7 61.6 80.9 23.9 57.6 61.0 142.4 USAb 247,219 7.8 11,790.3 7,505.9 2,826.9 6,709.0 9,760.2 19,296.2

NA Total * 374,364 7.9 16,520 13,091 5,210 11,042 13,359 29,611

* The totals may not be the exact sum of the column due to rounding.

a. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that of world population growth from 2003 to 2025. b. Prevalence figures are for IFG (not IGT) as only fasting specimens were measured for the majority of NHANES III participants.

52 53 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.26 Data sources: prevalence estimates of diabetes mellitus (DM) and impaired glucose tolerance (IGT) – South and Central American Region

Country Data used Screening method Diagnostic criteria Sample size Age (yrs) Argentinaa,b Argentina (Hernandez et al, 1987)92 2BG (50g) WHO – 1980 809 20-74 Bolivia Bolivia (Barceló et al, 2001)93 2BG WHO – 1985 2,948 25+ Brazil Brazil (Oliveira et al, 1996 and Malerbi et al, 1992)94,95 OGTT WHO – 1985 23,898 30-69 Chile Paraguay (Jimenez et al, 1998)96 OGTT WHO – 1985 1,606 20-74 Colombia Colombia (Aschner et al, 1993)97 2BG WHO – 1985 670 30-79 Costa Ricac Mexico (Stern et al, 1992 and Posadas-Romero et al, 1994)89,90 OGTT/FBG WHO – 1985 1,451 20-79 Cuba Jamaica (Wilks et al, 1999)86 OGTT WHO – 1980 1,303 25-74 Dominican Republic Jamaica (Wilks et al, 1999)86 OGTT WHO – 1980 1,303 25-74 Ecuador Bolivia (Barceló et al, 2001)93 2BG WHO – 1985 2,948 25+ El Salvadorc Mexico (Stern et al, 1992 and Posadas-Romero et al, 1994)89,90 OGTT/FBG WHO – 1985 1,451 20-79 French Guiana Suriname (Schaad et al, 1985)98 OGTT WHO – 1980 1,218 30+ Guatemalac Mexico (Stern et al, 1992 and Posadas-Romero et al, 1994)89,90 OGTT/FBG WHO – 1985 1,451 20-79 Hondurasc Mexico (Stern et al, 1992 and Posadas-Romero et al, 1994)89,90 OGTT/FBG WHO – 1985 1,451 20-79 Netherlands Antillesb Barbados (Hennis et al, 2002)87 SR or HbA1c > 10% Known Diabetes 4,104 40-79 Nicaraguac Mexico (Stern et al, 1992 and Posadas-Romero et al, 1994)89,90 OGTT/FBG WHO – 1985 1,451 20-79 Panamac Mexico (Stern et al, 1992 and Posadas-Romero et al, 1994)89,90 OGTT/FBG WHO – 1985 1,451 20-79 Paraguay Paraguay (Jimenez et al, 1998)96 OGTT WHO – 1985 1,606 20-74 Peru Bolivia (Barceló et al, 2001)93 2BG WHO – 1985 2,948 25+ Puerto Rico Jamaica (Wilks et al, 1999)86 OGTT WHO – 1980 1,303 25-74 Suriname Suriname (Schaad et al, 1985)98 OGTT WHO – 1980 1,218 30+ Uruguay Paraguay (Jimenez et al, 1998)96 OGTT WHO – 1985 1,606 20-74 Venezuela Brazil (Oliveira et al, 1996 and Malerbi et al, 1992)94,95 OGTT WHO – 1985 23,898 30-69

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)97 Netherlands Antilles: Jamaica (Wilks et al, 1999)86 c. Diabetes prevalence was derived by combining the data of the two studies indicated. IGT prevalence was calculated from Brazilian data.

54 55 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.27 Prevalence estimates of diabetes mellitus (DM), 2003 – South and Central American Region

Population DM Number of people with DM (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Rural Urban Male Female 20-39 40-59 60-79 Total Argentina 23,958 5.4 69.6 1,234.8 562.6 741.8 313.0 456.9 534.5 1,304.5 Bolivia 4,480 4.8 43.4 173.5 99.6 117.3 32.8 110.7 73.4 216.9 Brazil 109,901 5.2 548.1 5,133.9 2,496.0 3,186.0 732.3 2,733.7 2,216.1 5,682.0 Chile 9,864 5.6 45.3 511.9 231.2 326.0 77.7 268.2 211.2 557.1 Colombia 25,524 4.3 150.3 948.2 491.6 606.9 118.4 615.9 364.2 1,098.5 Costa Rica 2,493 6.9 52.4 119.5 66.3 105.6 22.7 87.5 61.8 172.0 Cuba 7,980 13.2 124.7 928.4 386.1 667.0 144.8 548.1 360.1 1,053.0 Dominican Republic 4,991 10.0 100.1 399.6 190.8 308.9 84.0 279.9 135.9 499.7 Ecuador 7,548 4.8 79.3 281.5 170.9 189.9 55.5 185.9 119.3 360.7 El Salvador 3,620 6.2 79.9 145.2 79.5 145.6 32.3 104.8 88.0 225.1 French Guiana 100 11.1 1.3 9.7 4.9 6.1 2.3 6.5 2.3 11.0 Guatemala 5,620 5.5 127.9 180.6 117.0 191.5 48.1 147.5 113.0 308.5 Honduras 3,302 5.7 65.0 122.4 70.6 116.9 30.7 90.3 66.5 187.5 Netherlands Antilles 148 12.3 3.1 15.2 7.4 10.8 1.6 9.5 7.1 18.2 Nicaragua 2,567 6.1 32.4 125.0 58.0 99.4 26.7 78.5 52.1 157.4 Panama 1,779 7.3 33.5 95.9 50.0 79.4 17.1 64.4 47.9 129.4 Paraguay 2,979 3.9 31.0 84.2 51.7 63.5 21.9 58.2 35.1 115.2 Peru 15,397 5.1 120.1 672.3 367.4 425.1 118.4 402.9 271.2 792.5 Puerto Rico 2,671 13.2 47.7 303.6 115.5 235.8 40.3 183.4 127.7 351.3 Suriname 251 8.6 6.5 15.1 8.4 13.3 5.7 10.0 6.0 21.7 Uruguay 2,217 6.8 6.5 143.6 54.5 95.6 15.6 60.1 74.5 150.1 Venezuela 14,460 5.2 47.7 697.8 341.3 404.2 100.9 366.2 278.3 745.5

SACA Total * 251,850 5.6 1,816 12,342 6,021 8,137 2,043 6,869 5,246 14,158

* The totals may not be the exact sum of the column due to rounding.

56 57 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

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

Population DM Number of people with DM (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Rural Urban Male Female 20-39 40-59 60-79 Total Argentina 31,775 5.8 68.6 1,773.8 836.1 1,006.3 377.6 667.3 797.5 1,842.4 Bolivia 7,927 5.7 58.1 391.6 209.1 240.7 60.1 231.7 158.0 449.8 Brazil 150,418 7.1 671.8 9,984.9 4,555.5 6,101.2 855.0 4,613.8 5,188.0 10,656.7 Chile 13,327 6.8 55.1 851.2 356.0 550.3 91.9 376.9 437.5 906.3 Colombia 39,178 5.8 217.4 2,057.0 1,024.6 1,249.8 157.5 1,131.9 985.0 2,274.4 Costa Rica 3,909 9.4 77.2 290.5 139.3 228.4 33.3 164.3 170.2 367.7 Cuba 8,749 17.3 124.2 1,388.1 541.3 970.9 109.3 747.1 655.8 1,512.3 Dominican Republic 7,081 13.0 123.8 796.4 331.6 588.6 109.4 483.5 327.3 920.2 Ecuador 11,887 6.4 112.0 651.1 357.0 406.0 81.1 389.3 292.7 763.1 El Salvador 5,775 8.2 120.9 353.0 168.0 305.9 49.4 242.2 182.3 473.9 French Guiana 190 13.7 2.2 23.9 11.4 14.7 9.4 9.1 7.7 26.1 Guatemala 11,171 6.5 214.5 513.2 271.4 456.3 105.7 368.6 253.3 727.7 Honduras 6,123 7.2 105.0 336.2 163.9 277.2 60.1 219.5 161.6 441.1 Netherlands Antilles 180 15.4 3.3 24.3 11.3 16.3 1.8 10.1 15.6 27.6 Nicaragua 5,124 7.7 56.5 338.5 146.0 249.0 53.4 200.9 140.8 395.0 Panama 2,590 10.0 47.0 213.1 96.7 163.4 21.7 120.7 117.7 260.1 Paraguay 5,533 4.8 47.8 217.6 114.9 150.5 41.2 124.8 99.4 265.4 Peru 23,753 6.7 169.8 1,418.3 724.1 864.0 168.3 815.2 604.7 1,588.2 Puerto Rico 3,251 15.6 48.8 459.3 168.4 339.7 43.7 252.5 211.8 508.1 Suriname 315 12.3 8.0 30.7 15.6 23.2 5.7 21.4 11.7 38.7 Uruguay 2,627 7.2 5.8 182.6 71.6 116.8 17.7 78.1 92.6 188.4 Venezuela 22,997 6.6 67.5 1,455.4 686.4 836.5 145.4 657.4 720.1 1,522.9

SACA Total * 363,881 7.2 2,405 23,751 11,000 15,156 2,599 11,926 11,631 26,156

* The totals may not be the exact sum of the column due to rounding.

56 57 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.29 Prevalence estimates of impaired glucose tolerance (IGT), 2003 – South and Central American Region

Population IGT Number of people with IGT (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Male Female 20-39 40-59 60-79 Total Argentina 23,958 9.8 798.0 1,551.5 498.7 1,188.4 662.4 2,349.4 Bolivia 4,480 7.1 124.2 193.1 103.3 115.9 98.0 317.2 Brazil 109,901 6.8 3,232.8 4,264.5 2,605.6 3,193.6 1,698.1 7,497.3 Chile 9,864 9.8 335.6 632.5 224.9 520.2 223.0 968.1 Colombia 25,524 4.5 445.4 690.9 457.7 436.8 241.8 1,136.3 Costa Rica 2,493 6.8 76.8 92.4 59.2 71.6 38.4 169.2 Cuba 7,980 12.2 407.4 563.4 241.3 388.3 341.1 970.7 Dominican Republic 4,991 10.4 206.1 313.0 168.6 214.2 136.3 519.1 Ecuador 7,548 7.1 216.3 319.0 172.2 198.1 165.0 535.2 El Salvador 3,620 6.5 103.1 133.9 93.0 88.0 56.0 237.0 French Guiana 100 7.3 2.6 4.7 2.7 3.4 1.2 7.3 Guatemala 5,620 6.3 162.5 191.9 147.8 130.2 76.4 354.4 Honduras 3,302 6.3 94.4 112.7 88.1 76.6 42.4 207.1 Netherlands Antilles 148 12.3 7.1 11.1 3.9 8.5 5.8 18.2 Nicaragua 2,567 6.2 70.8 87.8 69.1 59.8 29.6 158.5 Panama 1,779 6.9 55.1 66.8 42.6 50.4 28.9 121.9 Paraguay 2,979 8.5 91.3 161.0 75.1 132.8 44.4 252.3 Peru 15,397 7.2 441.6 668.1 351.7 406.3 351.7 1,109.7 Puerto Rico 2,671 12.2 126.3 199.9 76.5 130.8 118.9 326.2 Suriname 251 7.1 6.0 11.9 7.8 6.4 3.6 17.9 Uruguay 2,217 10.3 75.9 152.2 43.8 111.8 72.4 228.1 Venezuela 14,460 6.7 433.5 535.6 350.3 411.1 207.7 969.1

SACA Total * 251,850 7.3 7,513 10,958 5,884 7,943 4,643 18,470

* The totals may not be the exact sum of the column due to rounding.

58 59 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

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

Population IGT Number of people with IGT (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Male Female 20-39 40-59 60-79 Total Argentina 31,775 10.4 1,139.2 2,162.5 630.0 1,701.4 970.2 3,301.7 Bolivia 7,927 7.5 244.5 352.2 169.1 226.9 200.8 596.7 Brazil 150,418 7.8 4,935.4 6,809.5 2,818.1 5,081.0 3,845.8 11,744.9 Chile 13,327 10.6 494.0 922.4 260.8 696.9 458.8 1,416.5 Colombia 39,178 5.0 734.3 1,211.5 577.8 739.5 628.5 1,945.8 Costa Rica 3,909 7.6 133.8 163.2 78.1 120.9 98.0 297.0 Cuba 8,749 14.6 582.3 698.2 180.3 502.3 597.9 1,280.5 Dominican Republic 7,081 12.0 349.8 500.7 202.0 346.7 301.8 850.5 Ecuador 11,887 8.3 425.8 561.3 223.0 385.6 378.4 987.0 El Salvador 5,775 7.2 177.4 239.6 123.8 186.6 106.6 417.1 French Guiana 190 7.6 5.2 9.2 4.9 5.7 3.8 14.4 Guatemala 11,171 6.6 327.1 407.0 280.7 298.8 154.6 734.1 Honduras 6,123 6.7 183.0 229.8 149.8 169.0 93.9 412.8 Netherlands Antilles 180 14.0 10.6 14.4 4.2 8.5 12.3 25.1 Nicaragua 5,124 6.7 151.4 192.3 124.4 143.7 75.7 343.8 Panama 2,590 7.8 88.6 112.4 49.4 85.8 65.9 201.0 Paraguay 5,533 9.2 184.2 327.5 130.8 261.2 119.7 511.7 Peru 23,753 8.3 831.2 1,144.3 444.6 780.1 750.7 1,975.4 Puerto Rico 3,251 13.5 179.2 259.4 76.6 173.2 188.9 438.6 Suriname 315 8.1 8.2 17.1 7.0 12.1 6.3 25.4 Uruguay 2,627 10.7 96.7 184.3 49.0 141.0 91.0 281.0 Venezuela 22,997 7.5 758.6 956.0 478.1 709.2 527.2 1,714.6

SACA Total * 363,881 8.1 12,041 17,475 7,062 12,776 9,677 29,515

* The totals may not be the exact sum of the column due to rounding.

58 59 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.31 Data sources: prevalence estimates of diabetes mellitus (DM) and impaired glucose tolerance (IGT) – South-East Asian Region

Country Data used Screening method Diagnostic criteria Sample size Age (yrs) Bangladesh Bangladesh (Sayeed et al, 1997a, 1997b)99,100 OGTT WHO – 1980 2,371 20+ Bhutan India (Ramachandran et al, 2001)101 OGTT WHO – 1999 11,216 20+ India India (Ramachandran et al, 2001)101 OGTT WHO – 1999 11,216 20+ Maldives Sri Lanka (Fernando et al, 1994)102 OGTT WHO – 1985 633 30-64 Mauritius Mauritius (Dowse et al, 1990)49 OGTT WHO – 1985 4,929 25-74 Nepal India (Ramachandran et al, 2001)101 OGTT WHO – 1999 11,216 20+ Sri Lanka Sri Lanka (Fernando et al, 1994)102 OGTT WHO – 1985 633 30-64

Table 1.32 Prevalence estimates of diabetes mellitus (DM), 2003 – South-East Asian Region

Population DM Number of people with DM (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Rural Urban Male Female 20-39 40-59 60-79 Total Bangladesh 75,020 3.9 1,945.2 970.2 1,496.3 1,419.1 951.6 1,360.1 603.7 2,915.4 Bhutan 1,054 3.7 28.9 9.8 19.1 19.5 7.9 19.0 11.7 38.7 India 603,677 5.9 13,290.5 22,213.1 17,969.8 17,533.8 7,147.9 18,239.4 10,116.4 35,503.6 Maldives 144 1.8 1.4 1.2 1.3 1.2 0.5 1.6 0.4 2.6 Mauritius 786 10.7 34.4 50.1 41.2 43.3 14.8 45.4 24.3 84.5 Nepal 12,004 4.1 307.8 180.6 245.2 243.2 106.7 247.0 134.6 488.4 Sri Lanka 12,607 2.1 158.9 104.1 137.7 125.4 38.9 176.6 47.5 263.0

SEA Total * 705,292 5.6 15,767 23,529 19,911 19,386 8,268 20,089 10,939 39,296

* The totals may not be the exact sum of the column due to rounding.

Table 1.34 Prevalence estimates of impaired glucose tolerance (IGT), 2003 – South-East Asian Region

Population IGT Number of people with IGT (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Male Female 20-39 40-59 60-79 Total Bangladesh 75,020 7.1 2,746.9 2,596.3 2,273.6 2,137.1 932.5 5,343.2 Bhutan 1,054 14.1 73.8 74.3 77.5 47.4 23.2 148.1 India 603,677 14.2 44,069.0 41,561.5 42,484.2 30,100.3 13,046.0 85,630.4 Maldives 144 3.1 2.3 2.2 1.2 2.5 0.8 4.4 Mauritius 786 16.2 50.0 77.0 46.4 57.2 23.3 127.0 Nepal 12,004 14.0 850.8 833.5 897.4 551.3 235.7 1,684.3 Sri Lanka 12,607 3.7 240.4 220.8 93.2 281.7 86.3 461.2

SEA Total * 705,292 13.2 48,033 45,365 45,873 33,178 14,348 93,399

* The totals may not be the exact sum of the column due to rounding.

60 61 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.33 Prevalence estimates of diabetes mellitus (DM), 2025 – South-East Asian Region

Population DM Number of people with DM (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Rural Urban Male Female 20-39 40-59 60-79 Total Bangladesh 130,288 4.8 3,034.1 3,273.0 3,217.9 3,089.2 1,439.0 3,355.1 1,513.0 6,307.1 Bhutan 2,044 4.3 51.1 37.7 44.2 44.5 19.7 44.4 24.6 88.7 India 909,790 8.1 18,553.8 54,922.1 37,275.7 36,200.2 11,827.7 37,417.5 24,230.7 73,475.9 Maldives 304 2.1 2.6 3.9 3.3 3.2 1.2 4.2 1.1 6.5 Mauritius 986 14.7 42.4 102.4 68.7 76.1 15.9 66.4 62.5 144.8 Nepal 21,644 5.1 498.5 609.8 552.7 555.6 235.8 568.6 303.9 1,108.3 Sri Lanka 15,971 2.7 192.8 242.6 217.3 218.1 45.0 279.2 111.1 435.3

SEA Total * 1,081,026 7.5 22,375 59,191 41,380 40,187 13,584 41,735 26,247 81,567

* The totals may not be the exact sum of the column due to rounding.

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

Population IGT Number of people with IGT (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Male Female 20-39 40-59 60-79 Total Bangladesh 130,288 7.8 5,154.7 4,951.2 3,491.0 4,394.1 2,220.8 10,105.9 Bhutan 2,044 14.1 144.2 143.4 152.0 94.7 40.9 287.6 India 909,790 14.5 68,123.4 63,865.6 55,892.0 50,190.2 25,906.8 131,989.0 Maldives 304 3.3 5.1 4.9 2.5 5.9 1.7 10.0 Mauritius 986 17.7 70.8 104.1 45.2 74.5 55.1 174.9 Nepal 21,644 14.1 1,538.6 1,511.5 1,584.0 1,032.7 433.4 3,050.1 Sri Lanka 15,971 4.2 337.1 338.7 95.5 398.8 181.5 675.8

SEA Total * 1,081,026 13.5 75,374 70,919 61,262 56,191 28,840 146,293

* The totals may not be the exact sum of the column due to rounding.

60 61 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.36 Data sources: prevalence estimates of diabetes mellitus (DM) and impaired glucose tolerance (IGT) – Western Pacific Region

Country Data used Screening method Diagnostic criteria Sample size Age (yrs) Australia Australia (Dunstan et al, 2002)103 OGTT WHO – 1999 11,247 25+ Brunei Darussalam Singapore (Ministry of Health Survey, 1999)104 OGTT WHO – 1985 3,568 18-69 Cambodiaa Thailand (National Health Examination Survey, 1996 )105 FBG WHO – 1980 13,519 15+ China, Hong Kongb Hong Kong (Janus et al, 2000 and Cockram et al, 1993)106,107 OGTT WHO -1985 4,413 20-79 China, Macau Hong Kong (Janus et al, 2000 and Cockram et al, 1993)106,107 OGTT WHO -1985 4,413 20-79 China, People’s Republic of People’s Republic of China (Pan et al, 1997)108 OGTT WHO – 1985 213,515 25-64 Cook Islands Rarotonga (King et al, 1986)109 OGTT WHO – 1985 1,127 20+ East Timorc Indonesia (Waspadji et al, 1983)110 OGTT WHO – 1985 2,704 15+ Fiji Fiji (Zimmet et al, 1983)111 OGTT WHO – 1980 2,638 20+ French Polynesia Samoa (Collins et al, 1994)112 OGTT WHO – 1985 1,776 25-74 Guam Kiribati (King et al, 1984)113 OGTT WHO – 1980 2,938 20+ Indonesia Indonesia (Waspadji et al, 1983)110 OGTT WHO – 1985 2,704 15+ Japanb Japan (Ohmura et al, 1993 and Sekikawa et al, 2000)114,115 OGTT WHO – 1985 5,211 40+ Kiribati Kiribati (King et al, 1984)113 OGTT WHO – 1980 2,938 20+ Korea, Democratic People’s Republic of Republic of Korea (Park et al, 1995)116 OGTT WHO – 1985 2,520 30+ Korea, Republic of Republic of Korea (Park et al, 1995)116 OGTT WHO – 1985 2,520 30+ Lao People’s Democratic Republic Vietnam (Quoc et al, 1994)117 OGTT WHO – 1985 4,912 15+ Malaysia Singapore (Ministry of Health Survey, 1999)104 OGTT WHO – 1985 3,568 18-69 Marshall Islands Kiribati (King et al, 1984)113 OGTT WHO – 1980 2,938 20+ Micronesia Kiribati (King et al, 1984)113 OGTT WHO – 1980 2,938 20+ Mongolia Mongolia (Suvd et al, 2002)118 OGTT WHO – 1999 2,996 35+ Myanmar Vietnam (Quoc et al, 1994)117 OGTT WHO – 1985 4,912 15+ Nauru Nauru (Zimmet et al, 1984)119 OGTT WHO – 1980 1,583 20+ New Caledonia New Caledonia (Zimmet et al, 1982)120 OGTT WHO – 1980 707 20+ New Zealandc New Zealand (Ministry of Health, 2002)121 SR Known Diabetes 7,862 25+ Niue Niue (King et al, 1986)109 OGTT WHO – 1985 1,149 20+ Palau Kiribati (King et al, 1984)113 OGTT WHO – 1980 2,938 20+ Papua New Guinea Fiji Melanesians (Zimmet et al, 1983)111 OGTT WHO – 1980 1,340 20+ Philippinesa Thailand (National Health Examination Survey, 1996 )105 FBG WHO – 1980 13,519 15+ Samoa Samoa (Collins et al, 1994)112 OGTT WHO – 1985 1,776 25-74 Singapore, Republic of Singapore (Ministry of Health Survey, 1999)104 OGTT WHO – 1985 3,568 18-69 Solomon Islands Fiji Melanesians (Zimmet et al, 1983)111 OGTT WHO – 1980 1,340 20+ Taiwanb Taiwan (Chou et al, 1992, 1994)122,123 OGTT WHO – 1985 4,287 30-79 Thailanda Thailand (National Health Examination Survey, 1996 )105 FBG WHO – 1980 13,519 15+ Tokelau Samoa (Collins et al, 1994)112 OGTT WHO – 1985 1,776 25-74 Tonga Tonga (Colagiuri et al, 2002)124 OGTT WHO – 1999 1,024 15+ Tuvalu Samoa (Collins et al, 1994)112 OGTT WHO – 1985 1,776 25-74 Vanuatu Fiji Melanesians (Zimmet et al, 1983)111 OGTT WHO – 1980 1,340 20+ Vietnam Vietnam (Quoc et al, 1994)117 OGTT WHO – 1985 4,912 15+

a. Because of the absence of data for IGT in the study used for diabetes, IGT figures were calculated from unpublished Indonesian data (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. Because of the absence of data for IGT in the study used for diabetes, IGT figures were calculated from Australian data.

62 63 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.37 Prevalence estimates of diabetes mellitus (DM), 2003 – Western Pacific Region

Population DM Number of people with DM (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Rural Urban Male Female 20-39 40-59 60-79 Total Australia 13,805 6.2 475.6 378.8 39.4 319.8 495.1 854.4 Brunei Darussalam 209 10.7 3.4 18.8 9.6 12.6 2.3 14.5 5.4 22.2 Cambodia 6,332 2.0 78.0 47.2 44.3 80.9 32.4 65.0 27.7 125.2 China, Hong Kong 5,424 8.8 232.7 247.2 46.7 204.2 229.0 479.9 China, Macau 323 8.2 12.7 13.9 2.7 13.7 10.2 26.6 China, People’s Republic of 877,935 2.7 11,106.7 12,702.3 10,750.5 13,058.5 2,068.1 11,022.2 10,718.7 23,809.0 Cook Islandsa 13 6.6 0.0 0.0 0.3 0.5 0.2 0.4 0.2 0.8 East Timor 403 1.4 4.8 0.8 2.8 2.8 0.5 3.0 2.0 5.6 Fiji 480 8.3 19.0 20.7 18.4 21.3 6.9 24.4 8.4 39.7 French Polynesia 147 8.0 3.5 8.2 5.3 6.4 1.0 7.0 3.8 11.7 Guam 93 6.7 2.1 4.2 3.3 2.9 1.2 3.4 1.6 6.2 Indonesia 132,849 1.9 1,028.8 1,518.7 1,194.8 1,352.7 242.4 1,213.4 1,091.7 2,547.5 Japan 97,090 6.9 3,476.7 3,252.2 365.5 2,617.3 3,746.0 6,728.9 Kiribatia 60 6.2 1.3 2.4 1.8 1.9 0.8 1.9 1.0 3.7 Korea, Democratic People’s Republic of 14,835 5.2 171.5 602.9 430.9 343.4 147.4 375.7 251.2 774.4 Korea, Republic of 34,147 6.4 1,209.7 976.2 383.4 1,120.1 682.4 2,185.9 Lao People’s Democratic Republic 2,658 1.1 14.9 13.0 6.0 21.9 6.8 9.8 11.3 27.9 Malaysia 13,280 9.4 323.5 928.1 527.3 724.3 134.6 688.4 428.6 1,251.6 Marshall Islandsa 46 8.6 0.4 3.6 2.0 2.0 0.8 2.1 1.2 4.0 Micronesiaa 82 6.7 1.6 3.9 2.7 2.8 1.1 2.8 1.6 5.5 Mongolia 1,451 1.4 4.3 15.9 9.9 10.3 5.2 11.2 3.9 20.2 Myanmar 28,474 1.1 166.2 145.4 68.8 242.9 70.8 116.1 124.7 311.6 Naurua 8 30.2 0.0 0.0 1.1 1.2 0.5 1.3 0.5 2.3 New Caledoniab 140 3.8 0.5 4.8 2.1 3.2 0.8 2.5 2.0 5.3 New Zealand 2,603 7.6 96.8 99.8 20.3 87.6 88.8 196.6 Niuea 1 6.8 0.0 0.0 0.0 0.1 0.0 0.1 0.0 0.1 Palaua 12 8.7 0.1 0.9 0.5 0.5 0.2 0.5 0.3 1.0 Papua New Guinea 2,551 1.9 23.8 25.3 20.4 28.7 4.3 25.2 19.5 49.1 Philippines 42,133 2.4 269.0 741.2 399.2 611.1 239.5 519.3 251.4 1,010.2 Samoa 74 5.9 3.0 1.4 1.9 2.5 0.4 2.0 2.0 4.4 Singapore, Republic of 3,032 12.3 172.3 201.3 32.2 191.6 149.7 373.6 Solomon Islands 221 2.1 2.0 2.5 1.9 2.6 0.4 2.2 1.9 4.5 Taiwana 13,767 5.6 307.1 458.7 94.9 326.5 344.3 765.7 Thailand 42,236 2.1 574.9 306.6 348.4 533.1 206.3 440.6 234.5 881.5 Tokelaua 1 6.4 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.1 Tongaa 65 12.4 4.1 4.0 3.5 4.6 1.6 4.4 2.2 8.2 Tuvalua 7 8.6 0.2 0.4 0.2 0.3 0.0 0.3 0.2 0.6 Vanuatu 101 2.2 1.0 1.2 0.9 1.3 0.2 1.1 0.9 2.2 Vietnam 46,620 1.0 319.7 161.5 95.0 386.2 112.2 161.3 207.7 481.2

WP Total * 1,383,705 3.1 14,128 17,286 19,938 23,091 4,274 19,603 19,152 43,029

* The totals may not be the exact sum of the column due to rounding. a. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that of world population 2003. 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.

64 65 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

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

Population DM Number of people with DM (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Rural Urban Male Female 20-39 40-59 60-79 Total Australia 16,950 7.7 720.5 580.1 41.9 377.1 881.6 1,300.6 Brunei Darussalam 332 15.0 5.1 44.9 22.1 27.9 3.3 22.5 24.2 50.0 Cambodia 12,191 2.1 119.4 140.4 98.0 161.8 67.7 120.6 71.5 259.8 China, Hong Kong 6,765 12.8 386.6 476.8 40.1 275.6 547.7 863.4 China, Macau 425 12.9 23.5 31.4 3.0 15.4 36.4 54.8 China, People’s Republic of 1,079,641 4.3 14,475.7 31,654.3 19,913.2 26,216.7 2,091.9 19,172.6 24,865.4 46,130.0 Cook Islandsa 17 7.3 0.0 0.0 0.5 0.8 0.2 0.6 0.4 1.3 East Timor 764 1.6 9.7 2.9 6.2 6.4 1.2 6.1 5.2 12.6 Fiji 641 10.3 22.2 43.8 31.2 34.8 7.6 37.1 21.3 66.0 French Polynesia 217 10.8 5.3 18.1 10.1 13.3 1.3 12.6 9.5 23.4 Guam 148 7.5 2.5 8.7 5.7 5.4 2.0 4.8 4.4 11.2 Indonesia 186,983 2.8 1,374.0 3,835.6 2,507.1 2,702.5 321.6 2,543.9 2,344.1 5,209.6 Japan 90,130 7.9 3,654.0 3,495.2 265.7 2,509.8 4,373.7 7,149.1 Kiribatia 82 7.9 1.5 5.0 3.3 3.2 1.0 3.2 2.2 6.5 Korea, Democratic People’s Republic of 18,008 6.3 177.6 957.0 635.4 499.2 150.3 586.5 397.8 1,134.6 Korea, Republic of 39,095 8.3 1,819.7 1,423.4 293.4 1,515.9 1,433.8 3,243.1 Lao People’s Democratic Republic 4,933 1.1 28.8 25.2 12.2 41.8 12.2 19.5 22.3 54.0 Malaysia 21,032 12.4 449.0 2,153.1 1,088.4 1,513.7 205.9 1,207.1 1,189.1 2,602.1 Marshall Islandsa 64 10.3 0.5 6.1 3.3 3.2 1.0 3.3 2.3 6.6 Micronesiaa 113 8.5 1.8 7.8 4.8 4.8 1.5 4.8 3.3 9.6 Mongolia 2,355 2.0 6.8 39.4 22.7 23.5 7.8 27.6 10.9 46.3 Myanmar 41,135 1.3 294.5 257.7 136.0 416.1 86.4 201.3 264.4 552.2 Naurua 10 33.0 0.0 0.0 1.7 1.7 0.6 1.9 0.9 3.5 New Caledoniab 217 4.7 0.6 9.7 3.9 6.4 1.1 4.4 4.8 10.3 New Zealand 3,106 9.0 135.2 143.0 20.6 96.2 161.3 278.1 Niuea 2 7.6 0.0 0.0 0.1 0.1 0.0 0.1 0.0 0.1 Palaua 16 10.3 0.1 1.6 0.9 0.8 0.2 0.8 0.6 1.7 Papua New Guinea 4,546 2.9 45.9 84.7 52.1 78.5 11.5 65.2 53.9 130.6 Philippines 69,936 3.0 363.3 1,707.8 811.3 1,259.8 375.0 1,066.1 630.0 2,071.2 Samoa 109 6.1 3.7 2.9 3.4 3.3 0.8 3.6 2.3 6.6 Singapore, Republic of 3,884 19.5 330.8 426.8 31.5 234.6 491.5 757.6 Solomon Islands 480 2.9 4.1 10.0 5.4 8.7 1.5 7.1 5.5 14.1 Taiwana 18,911 6.6 480.5 759.2 115.2 498.1 626.5 1,239.8 Thailand 55,716 2.6 940.2 518.1 570.4 887.9 198.5 719.0 540.8 1,458.3 Tokelaua 1 7.6 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.1 Tongaa 90 15.9 6.3 8.0 6.2 8.1 2.2 7.6 4.5 14.3 Tuvalua 9 10.8 0.2 0.8 0.4 0.6 0.1 0.5 0.4 1.0 Vanuatu 195 3.2 2.0 4.2 2.4 3.8 0.6 2.9 2.7 6.2 Vietnam 71,403 1.4 523.6 458.0 255.7 725.9 146.2 358.6 476.7 981.6

WP Total * 1,750,653 4.3 18,865 42,006 33,765 41,997 4,513 31,735 39,514 75,762

* The totals may not be the exact sum of the column due to rounding.

a. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that of world population growth from 2003 to 2025. 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.

64 65 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.39 Prevalence estimates of impaired glucose tolerance (IGT), 2003 – Western Pacific Region

Population IGT Number of people with IGT (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Male Female 20-39 40-59 60-79 Total Australia 13,805 9.4 561.0 730.0 212.0 552.1 526.9 1,291.0 Brunei Darussalam 209 20.6 22.8 20.1 16.7 22.6 3.8 43.0 Cambodia 6,332 9.0 271.2 298.7 216.5 231.7 121.7 569.9 China, Hong Kong 5,424 10.9 318.1 274.2 91.7 268.7 231.9 592.2 China, Macau 323 10.4 17.9 15.6 5.1 18.1 10.4 33.6 China, People’s Republic of 877,935 3.8 9,277.2 23,874.7 4,812.7 16,268.9 12,070.4 33,152.0 Cook Islandsa 13 10.0 0.6 0.7 0.3 0.5 0.4 1.3 East Timor 403 9.4 20.7 17.4 12.9 16.2 9.1 38.1 Fiji 480 10.2 20.3 28.8 18.1 22.1 8.9 49.1 French Polynesia 147 6.0 3.7 5.1 2.4 4.3 2.1 8.8 Guam 93 17.7 7.9 8.5 5.1 8.1 3.2 16.5 Indonesia 132,849 9.7 6,924.2 5,989.0 4,391.5 4,819.9 3,701.8 12,913.2 Japan 97,090 13.0 5,554.2 7,057.8 2,294.1 5,049.1 5,268.7 12,612.0 Kiribatia 60 17.1 4.6 5.6 3.5 4.5 2.1 10.2 Korea, Democratic People’s Republic of 14,835 8.4 634.5 605.0 272.7 559.9 406.9 1,239.5 Korea, Republic of 34,147 8.4 1,455.9 1,408.9 583.5 1,367.8 913.6 2,864.8 Lao People’s Democratic Republic 2,658 1.3 5.9 29.4 9.4 14.1 11.7 35.2 Malaysia 13,280 17.7 1,173.7 1,174.3 919.9 1,131.3 296.9 2,348.0 Marshall Islandsa 46 17.1 3.6 4.3 2.7 3.5 1.7 7.9 Micronesiaa 82 17.1 6.4 7.7 4.9 6.3 3.0 14.1 Mongolia 1,451 7.7 40.7 70.7 52.1 37.2 22.1 111.4 Myanmar 28,474 1.4 66.4 326.3 98.0 166.3 128.4 392.7 Naurua 8 20.3 0.8 0.8 0.6 0.6 0.3 1.5 New Caledonia 140 4.6 2.6 3.8 1.8 2.8 1.8 6.4 New Zealand 2,603 9.4 105.0 140.0 40.2 106.6 98.1 244.9 Niuea 1 6.9 0.0 0.0 0.0 0.0 0.0 0.1 Palaua 12 17.1 0.9 1.1 0.7 0.9 0.4 2.0 Papua New Guinea 2,551 9.1 86.7 144.9 95.9 96.2 39.6 231.7 Philippines 42,133 9.3 2,060.4 1,846.9 1,442.7 1,499.4 965.2 3,907.2 Samoa 74 5.3 1.7 2.3 1.2 1.6 1.2 4.0 Singapore, Republic of 3,032 16.6 251.7 252.3 133.0 286.1 84.8 504.0 Solomon Islands 221 9.0 7.4 12.5 8.6 7.6 3.8 19.9 Taiwana 13,767 3.1 196.1 235.0 103.0 177.0 151.1 431.1 Thailand 42,236 9.9 2,223.4 1,962.5 1,359.9 1,657.6 1,168.3 4,185.9 Tokelaua 1 6.4 0.0 0.0 0.0 0.0 0.0 0.1 Tongaa 65 7.2 2.1 2.6 1.2 2.5 1.0 4.7 Tuvalua 7 6.4 0.2 0.3 0.1 0.2 0.1 0.4 Vanuatu 101 9.4 3.5 6.0 3.8 3.9 1.8 9.4 Vietnam 46,620 1.4 111.3 524.3 165.2 246.5 223.9 635.6

WP Total * 1,383,705 5.7 31,445 47,088 17,384 34,663 26,487 78,534

66 67 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

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

Population IGT Number of people with IGT (000’s) (20-79) prevalence in the 20-79 age group Country (000’s) % Male Female 20-39 40-59 60-79 Total Australia 16,950 10.6 798.4 1,003.6 224.3 638.5 939.3 1,802.0 Brunei Darussalam 332 20.8 36.7 32.4 22.6 30.6 16.0 69.1 Cambodia 12,191 9.2 567.4 554.4 429.6 397.0 295.2 1,121.8 China, Hong Kong 6,765 14.6 479.5 505.9 78.5 350.5 556.4 985.3 China, Macau 425 14.6 28.8 33.2 5.8 19.4 36.9 62.0 China, People’s Republic of 1,079,641 5.0 14,118.8 40,145.7 4,298.8 24,699.1 25,266.6 54,264.5 Cook Islandsa 17 11.2 0.9 1.1 0.4 0.8 0.8 1.9 East Timor 764 10.2 43.1 34.6 24.3 31.1 22.4 77.8 Fiji 641 11.3 30.1 42.7 20.4 31.2 21.1 72.7 French Polynesia 217 7.1 6.7 8.6 2.9 7.1 5.3 15.3 Guam 148 17.3 12.1 13.6 8.3 9.8 7.6 25.7 Indonesia 186,983 11.2 11,801.3 9,138.8 4,925.0 8,796.2 7,219.0 20,940.2 Japan 90,130 14.1 5,663.7 7,014.4 1,633.4 4,881.6 6,163.0 12,678.0 Kiribatia 82 18.1 6.9 8.0 4.2 6.7 3.9 14.9 Korea, Democratic People’s Republic of 18,008 9.5 873.1 830.3 264.9 823.3 615.2 1,703.4 Korea, Republic of 39,095 10.8 2,164.0 2,043.9 446.2 1,838.2 1,923.6 4,208.0 Lao People’s Democratic Republic 4,933 1.4 11.6 56.2 16.9 27.9 22.9 67.8 Malaysia 21,032 18.4 1,933.5 1,926.4 1,299.5 1,802.8 757.7 3,860.0 Marshall Islandsa 64 18.1 5.3 6.2 3.3 5.2 3.1 11.5 Micronesiaa 113 18.1 9.5 11.0 5.8 9.2 5.4 20.5 Mongolia 2,355 8.7 84.6 120.5 65.2 84.9 54.9 205.0 Myanmar 41,135 1.7 122.5 558.3 121.3 286.5 272.9 680.7 Naurua 10 21.2 1.1 1.1 0.7 0.9 0.6 2.2 New Caledonia 217 5.2 5.1 6.2 2.3 4.8 4.2 11.3 New Zealand 3,106 10.8 146.5 187.6 40.8 115.3 177.9 334.1 Niuea 2 7.4 0.1 0.1 0.0 0.1 0.0 0.1 Palaua 16 18.1 1.4 1.6 0.8 1.3 0.8 3.0 Papua New Guinea 4,546 9.7 165.6 275.9 158.0 189.0 94.5 441.6 Philippines 69,936 10.4 4,002.7 3,271.1 2,105.7 2,864.0 2,304.1 7,273.8 Samoa 109 5.5 2.7 3.3 1.9 2.7 1.4 5.9 Singapore, Republic of 3,884 17.5 352.1 329.4 126.8 288.6 266.2 681.6 Solomon Islands 480 9.5 16.7 28.7 17.4 18.8 9.2 45.4 Taiwana 18,911 3.5 307.9 357.6 123.6 265.3 276.7 665.6 Thailand 55,716 12.0 3,773.1 2,891.3 1,302.6 2,679.0 2,682.9 6,664.4 Tokelaua 1 7.1 0.0 0.0 0.0 0.0 0.0 0.1 Tongaa 90 7.8 3.2 3.8 1.5 3.7 1.8 7.0 Tuvalua 9 7.1 0.3 0.4 0.1 0.3 0.2 0.7 Vanuatu 195 9.9 7.0 12.3 6.9 7.9 4.5 19.3 Vietnam 71,403 1.7 222.8 980.5 207.5 508.1 487.7 1,203.3

WP Total * 1,750,653 6.9 47,807 72,441 17,998 51,727 50,522 120,248

* The totals may not be the exact sum of the column due to rounding.

a. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that of world population growth from 2003 to 2025.

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Clin Pediatr (Phila) 1998; prospects: the 1994 revision. Estimates and projections of 37:111-115. urban and rural populations and of urban agglomerations. 14. Fagot-Campagna A, Pettitt DJ, Engelgau MM, Burrows NR, United Nations, New York, 1995. Geiss LS, Valdez R, Beckles GL, Saaddine J, Gregg EW, 33. Ramachandran A, Snehalatha C, Latha E, Manoharan M, Williamson DF, Narayan KM. Type 2 diabetes among North Vijay V. Impacts of urbanisation on the lifestyle and on the American children and adolescents: an epidemiologic prevalence of diabetes in native Asian Indian population. review and a public health perspective. J Pediatr 2000; Diabetes Res Clin Pract 1999; 44:207-213. 136:664-672. 34. Ramachandran A, Snehalatha C, Vijay V, King H. Impact of 15. Alberti K. The clinical implications of impaired glucose poverty on the prevalence of diabetes and its complications tolerance. Diabet Med 1996; 13:927-937. in urban southern India. Diabet Med 2002; 19:130-135. 16. Unwin N, Shaw J, Zimmet P, Alberti KG. Impaired glucose 35. Ministry of Health NZ. Diabetes in New Zealand: Models and tolerance and impaired fasting glycaemia: the current status forecasts 1996-2011. Wellington, New Zealand, 2002. on definition and intervention. Diabet Med 2002; 36. Hux J, Tang M. Patterns of Prevalence and Incidence of 19:708-723. Diabetes. In Diabetes in Ontario: An ICES Practice Atlas: 17. Shaw JE, Zimmet PZ, de Courten M, Dowse GK, Chitson P, Institute for Clinical Evaluative Sciences, ed. Hux J, Booth G, Gareeboo H, Hemraj F, Fareed D, Tuomilehto J, Alberti KG. Laupacis A. 2002:1.2-1.18. Impaired fasting glucose or impaired glucose tolerance. 37. Thefeld W. Prevalence of diabetes mellitus in the adult What best predicts future diabetes in Mauritius? Diabetes German population. Gesundheitswesen 1999; Care 1999; 22:399-402. 61 Spec No: S85-89.

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38. Dunstan DW, Zimmet PZ, Welborn TA, De Courten MP, 54. Ghannem H, Hadj Fredj A. Prevalence of cardiovascular risk Cameron AJ, Sicree RA, Dwyer T, Colagiuri S, Jolley D, factors in the urban population of Soussa in Tunisia. J Public Knuiman M, Atkins R, Shaw JE. The rising prevalence of Health Med 1997; 19:392-396. diabetes and impaired glucose tolerance: the Australian 55. Satman I, Yilmaz T, Sengul A, Salman S, Salman F, Uygur S, Diabetes, Obesity and Lifestyle Study. Diabetes Care 2002; Bastar I, Tutuncu Y, Sargin M, Dinccag N, Karsidag K, 25:829-834. Kalaca S, Ozcan C, King H. Population-Based Study of 39. Guest C, O’Dea K, Hopper J, Nankervis A, Larkins R. Diabetes and Risk Characteristics in Turkey: Results of the The prevalence of glucose intolerance in Aborigines and Turkish Diabetes Epidemiology Study (TURDEP). Diabetes Europids of south-eastern Australia. Diabetes Res Clin Care 2002; 25:1551-1556. Pract 1992; 15:227-235. 56. Al-Mahroos F, McKeigue PM. High prevalence of diabetes 40. Rathmann W, Haastert B, Icks A, Lowel H, Meisinger C, in Bahrainis. Associations with ethnicity and raised plasma Holle R, Giani G. High prevalence of undiagnosed diabetes cholesterol. Diabetes Care 1998; 21:936-942. mellitus in Southern Germany: Target populations for 57. Herman WH, Ali MA, Aubert RE, Engelgau MM, Kenny SJ, efficient screening. The KORA survey 2000. Diabetologia Gunter EW, Malarcher AM, Brechner RJ, Wetterhall SF, 2003; 46:182-189. DeStefano F, Thompson T, Smith P, Badran A, Sous E, 41. Harris M, Hadden W, Knowler W, Bennett P. Prevalence Habib M, Hegazy M, abd el Shakour S, Ibrahim AS, of diabetes and impaired glucose tolerance and plasma el Moneim el Behairy A. Diabetes mellitus in Egypt: risk glucose levels in US population aged 20-74 years. Diabetes factors and prevalence. Diabet Med 1995; 12:1126-1131. 1987; 36:523-534. 58. Arab M. Epidemiology of diabetes mellitus in Egypt. 42. McLarty DG, Swai AB, Kitange HM, Masuki G, Mtinangi BL, Egyptian J Diab 1997; 2:1-14. Kilima PM, Makene WJ, Chuwa LM, Alberti KG. Prevalence of 59. Amini M, Afshin-Nia F, Bashardoost N, Aminorroaya A, diabetes and impaired glucose tolerance in rural Tanzania. Shahparian M, Kazemi M. Prevalence and risk factors of Lancet 1989; 1:871-875. diabetes mellitus in the Isfahan city population (aged 40 or 43. Aspray TJ, Mugusi F, Rashid S, Whiting D, Edwards R, over) in 1993. Diabetes Res Clin Pract 1997; 38:185-190. Alberti KG, Unwin NC. Rural and urban differences in 60. Ajlouni K, Jaddou H, Batieha A. Diabetes and impaired diabetes prevalence in Tanzania: the role of obesity, glucose tolerance in Jordan: prevalence and associated risk physical inactivity and urban living. Trans R Soc Trop Med factors. J Intern Med 1998; 244:317-323. Hyg 2000; 94:637-644. 61. Abdella N, Al Arouj M, Al Nakhi A, Al Assoussi A, Moussa M. 44. Mbanya JC, Ngogang J, Salah JN, Minkoulou E, Balkau B. Non-insulin-dependent diabetes in Kuwait: prevalence rates Prevalence of NIDDM and impaired glucose tolerance in a and associated risk factors. Diabetes Res Clin Pract 1998; rural and an urban population in Cameroon. Diabetologia 42:187-196. 1997; 40:824-829. 62. Salti S, Khogali M, Alam S, Abu Haidar N, Masri A. 45. Amoah AG, Owusu SK, Adjei S. Diabetes in Ghana: a Epidemiology of diabetes mellitus in relation to other community based prevalence study in Greater Accra. cardiovascular risk factors in Lebanon. East Mediterr Diabetes Res Clin Pract 2002; 56:197-205. Health J 1997; 3:462-471. 46. Omar MA, Seedat MA, Motala AA, Dyer RB, Becker P. 63. Kadiki OA, Roaed RB. Epidemiological and clinical patterns The prevalence of diabetes mellitus and impaired glucose of diabetes mellitus in Benghazi, Libyan Arab Jamahiriya. tolerance in a group of urban South African blacks. S Afr East Mediterr Health J 1999; 5:6-13. Med J 1993; 83:641-643. 64. Al-Lawati JA, Al Riyami AM, Mohammed AJ, Jousilahti P. 47. Levitt NS, Katzenellenbogen JM, Bradshaw D, Hoffman MN, Increasing prevalence of diabetes mellitus in Oman. Diabet Bonnici F. The prevalence and identification of risk factors Med 2002; 19:954-957. for NIDDM in urban Africans in Cape Town, South Africa. 65. Asfour MG, Lambourne A, Soliman A, Al-Behlani S, Diabetes Care 1993; 16:601-607. Al-Asfoor D, Bold A, Mahtab H, King H. High prevalence of 48. Elbagir MN, Eltom MA, Elmahadi EM, Kadam IM, Berne C. diabetes mellitus and impaired glucose tolerance in the A population-based study of the prevalence of diabetes and Sultanate of Oman: results of the 1991 national survey. impaired glucose tolerance in adults in northern Sudan. Diabet Med 1995; 12:1122-1125. Diabetes Care 1996; 19:1126-1128. 66. El-Hazmi M, Warsy A, Al-Swailem A, Al-Swailem A, 49. Dowse GK, Gareeboo H, Zimmet PZ, Alberti KG, Sulaimani R. Diabetes mellitus as a health problem in Saudi Tuomilehto J, Fareed D, Brissonnette LG, Finch CF. High Arabia. East Mediterr Health J 1998; 4:58-67. prevalence of NIDDM and impaired glucose tolerance 67. Malik M, Bakir A, Abi Saab B, Roglic G, King H. Prevalence in Indian, Creole, and Chinese Mauritians. Mauritius of Diabetes, Impaired Fasting Glucose, Impaired Glucose Noncommunicable Disease Study Group. Diabetes 1990; Tolerance, Hypertension and Obesity in the Multi-ethnic 39:390-396. Population of the United Arab Emirates. Unpublished, 50. Shera AS, Rafique G, Khawaja IA, Ara J, Baqai S, King H. Abu Dhabi, 2002. Pakistan national diabetes survey: prevalence of glucose 68. Katsilambros N, Aliferis K, Darviri C, Tsapogas P, Alexiou Z, intolerance and associated factors in Shikarpur, Sindh Tritos N, Arvanitis M. Evidence for an increase in the Province. Diabet Med 1995; 12:1116-1121. prevalence of known diabetes in a sample of an urban 51. Shera AS, Rafique G, Khawaja IA, Baqai S, King H. Pakistan population in Greece. Diabet Med 1993; 10:87-90. National Diabetes Survey: prevalence of glucose intolerance 69. Castell C, Tresserras R, Serra J, Goday A, Lloveras G, and associated factors in Baluchistan province. Diabetes Salleras L. Prevalence of diabetes in Catalonia (Spain): Res Clin Pract 1999; 44:49-58. an oral glucose tolerance test-based population study. 52. Shera AS, Rafique G, Khawaja IA, Baqai S, Khan IA, King H, Diabetes Res Clin Pract 1999; 43:33-40. Ahmed KI. Pakistan National Diabetes Survey prevalence of 70. Rathmann W, Haastert B, Icks A, Lowel H, Meisinger C, glucose intolerance and associated factors in North West at Holle R, Giani G. High prevalence of undiagnosed diabetes Frontier Province (NWFP) of Pakistan. J Pak Med Assoc 1999; mellitus in Southern Germany: target populations for 49:206-211. efficient screening. The KORA survey 2000. Diabetologia 53. Papoz L, Ben Khalifa F, Eschwege E, Ben Ayed H. Diabetes 2003; 46:182-189. mellitus in Tunisia: description in urban and rural 71. Szurkowska M, Szybinski Z, Nazim A, Szafraniec K, populations. Int J Epidemiol 1988; 17:419-422. Jedrychowski W. Prevalence of type II diabetes mellitus in

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population of Krakow. Pol Arch Med Wewn 2001; 88. Costagliola D, Delaunay C, Moutet JP, Kankambega P, 106:771-779. Demeulemeester R, Donnet JP, Papoz L, Eschwege E. The 72. Lopatynski J, Mardarowicz G, Nicer T, Szczesniak G, prevalence of diabetes mellitus in the adult population Krol H, Matej A, Szydlowski W, Paszkowski J, Dabek K, of Guadeloupe as estimated by history or fasting Zmurowska B, Szyprowska-Grzegorczyk E. The prevalence hyperglycemia. Diabetes Res Clin Pract 1991; 12:209-216. of type II diabetes mellitus in rural and urban population 89. Stern MP, Gonzalez C, Mitchell BD, Villalpando E, Haffner SM, over 35 years of age in Lublin region (Eastern Poland). Pol Hazuda HP. Genetic and environmental determinants of Arch Med Wewn 2001; 106:781-786. type II diabetes in Mexico City and San Antonio. Diabetes 73. Mooy JM, Grootenhuis PA, de Vries H, Valkenburg HA, 1992; 41:484-492. Bouter LM, Kostense PJ, Heine RJ. Prevalence and 90. Posadas-Romero C, Yamamoto-Kimura L, Lerman-Garber I, determinants of glucose intolerance in a Dutch caucasian Zamora-Gonzalez J, Fajardo-Gutierrez A, Velazquez L, population. The Hoorn Study. Diabetes Care 1995; Cardoso-Saldaana G. The prevalence of NIDDM and 18:1270-1273. associated coronary risk factors in Mexico City. Diabetes 74. Eliasson M, Lindahl B, Lundberg V, Stegmayr B. No increase Care 1994; 17:1441-1448. in the prevalence of known diabetes between 1986 and 91. Harris MI, Flegal KM, Cowie CC, Eberhardt MS, Goldstein DE, 1999 in subjects 25-64 years of age in northern Sweden. Little RR, Wiedmeyer HM, Byrd-Holt DD. Prevalence of Diabet Med 2002; 19:874-880. diabetes, impaired fasting glucose, and impaired glucose 75. Tuomilehto J, Nissinen A, Kivela SL, Pekkanen J, Kaarsalo E, tolerance in U.S. adults. The Third National Health and Wolf E, Aro A, Punsar S, Karvonen MJ. Prevalence of diabetes Nutrition Examination Survey, 1988-1994. Diabetes Care mellitus in elderly men aged 65 to 84 years in eastern and 1998; 21:518-524. western Finland. Diabetologia 1986; 29:611-615. 92. Hernandez RE, Cardonnet LJ, Libman C, Gagliardino JJ. 76. Tuomilehto J, Korhonen HJ, Kartovaara L, Salomaa V, Prevalence of diabetes and obesity in an urban population Stengard JH, Pitkanen M, Aro A, Javela K, Uusitupa M, of Argentina. Diabetes Res Clin Pract 1987; 3:277-283. Pitkaniemi J. Prevalence of diabetes mellitus and impaired 93. Barceló A, Daroca MC, Ribera R, Duarte E, Zapata A, glucose tolerance in the middle-aged population of three Vohra M. Diabetes in Bolivia. Rev Panam Salud Publica 2001; areas in Finland. Int J Epidemiol 1991; 20:1010-1017. 10:318-323. 77. Verrillo A, de Teresa A, La Rocca S, Giarrusso PC. Prevalence 94. Oliveira JE, Milech A, Franco LJ, The Cooperative Group for of diabetes mellitus and impaired glucose tolerance in a the Study of Diabetes Prevalence in Rio De Janeiro. The rural area of Italy. Diabetes Res Clin Pract 1985; 2:301-306. prevalence of diabetes in Rio de Janeiro, Brazil. Diabetes 78. Garancini MP, Calori G, Ruotolo G, Manara E, Izzo A, Ebbli E, Care 1996; 19:663-666. Bozzetti AM, Boari L, Lazzari P, Gallus G. Prevalence of 95. Malerbi DA, Franco LJ, The Brazilian Cooperative Group on NIDDM and impaired glucose tolerance in Italy: an OGTT- the Study of Diabetes. Multicenter study of the prevalence based population study. Diabetologia 1995; 38:306-313. of diabetes mellitus and impaired glucose tolerance in the 79. Vilbergsson S, Sigurdsson G, Sigvaldason H, Hreidarsson AB, urban Brazilian population aged 30-69 yr. Diabetes Care Sigfusson N. Prevalence and incidence of NIDDM in Iceland: 1992; 15:1509-1516. evidence for stable incidence among males and females 96. Jimenez JT, Palacios M, Canete F, Barriocanal LA, Medina U, 1967-1991 – the Reykjavik Study. Diabet Med 1997; Figueredo R, Martinez S, de Melgarejo MV, Weik S, Kiefer R, 14:491-498. Alberti KG, Moreno-Azorero R. Prevalence of diabetes 80. Unwin N, Harland J, White M, Bhopal R, Winocour P, mellitus and associated cardiovascular risk factors in an Stephenson P, Watson W, Turner C, Alberti KG. Body mass adult urban population in Paraguay. Diabet Med 1998; index, waist circumference, waist-hip ratio, and glucose 15:334-338. intolerance in Chinese and Europid adults in Newcastle, UK. 97. Aschner P, King H, Triana de Torrado M, Rodriguez BM. J Epidemiol Community Health 1997; 51:160-166. Glucose intolerance in Colombia. A population-based survey 81. Yudkin JS, Forrest RD, Jackson CA, Burnett SD, Gould MM. in an urban community. Diabetes Care 1993; 16:90-93. The prevalence of diabetes and impaired glucose tolerance 98. Schaad JD, Terpstra J, Oemrawsingh I, Nieuwenhuijzen in a British population. Diabetes Care 1993; 16:1530. Kruseman AC, Bouwhuis-Hoogerwerf ML. Diabetes 82. Bar-On H, Friedlander Y, Kidron M, Kark J. Serum glucose prevalence in the three main ethnic groups in Surinam and insulin characteristics and prevalence of diabetes (South-America): a population survey. Neth J Med 1985; mellitus and impaired glucose tolerance in the adult Jewish 28:17-22. population of Jerusalem. J Cardiovasc Dis 1992; 2:75-81. 99. Sayeed MA, Ali L, Hussain MZ, Rumi MA, Banu A, Azad 83. Stern E, Raz I, Weitzman S. Prevalence of diabetes mellitus Khan AK. Effect of socioeconomic risk factors on the among workers in Israel: a nation-wide study. Acta Diabetol difference in prevalence of diabetes between rural and 1999; 36:169-172. urban populations in Bangladesh. Diabetes Care 1997; 20: 84. King H, Abdullaev B, Djumaeva S, Nikitin V, Ashworth L, 551-555. Dobo MG. Glucose intolerance and associated factors in 100. Sayeed MA, Hussain MZ, Banu A, Rumi MA, Azad Khan AK. the Fergana Valley, Uzbekistan. Diabet Med 1998; Prevalence of diabetes in a suburban population of 15:1052-1062. Bangladesh. Diabetes Res Clin Pract 1997; 34:149-155. 85. Schranz AG. Abnormal glucose tolerance in the Maltese. 101. Ramachandran A, Snehalatha C, Kapur A, Vijay V, Mohan V, A population-based longitudinal study of the natural history Das AK, Rao PV, Yajnik CS, Prasanna Kumar KM, Nair JD. of NIDDM and IGT in Malta. Diabetes Res Clin Pract 1989; High prevalence of diabetes and impaired glucose tolerance 7:7-16. in India: National Urban Diabetes Survey. Diabetologia 86. Wilks R, Rotimi C, Bennett F, McFarlane-Anderson N, 2001; 44:1094-1101. Kaufman JS, Anderson SG, Cooper RS, Cruickshank JK, 102. Fernando DJ, Siribaddana S, de Silva D. Impaired glucose Forrester T. Diabetes in the Caribbean: results of a tolerance and diabetes mellitus in a suburban Sri Lankan population survey from Spanish Town, Jamaica. Diabet Med community. Postgrad Med J 1994; 70:347-349. 1999; 16:875-883. 103. Dunstan DW, Zimmet PZ, Welborn TA, De Courten MP, 87. Hennis A, Wu SY, Nemesure B, Li X, Leske MC. Diabetes Cameron AJ, Sicree RA, Dwyer T, Colagiuri S, Jolley D, in a Caribbean population: epidemiological profile and Knuiman M, Atkins R, Shaw JE. The rising prevalence of implications. Int J Epidemiol 2002; 31:234-239. diabetes and impaired glucose tolerance: the Australian

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Diabetes, Obesity and Lifestyle Study. Diabetes Care 2002; 119. Zimmet P, King H, Taylor R, Raper LR, Balkau B, Borger J, 25:829-834. Heriot W, Thoma K. The high prevalence of diabetes 104. Epidemiology and Disease Control Department. National mellitus, impaired glucose tolerance and diabetic Health Survey 1998 Singapore. Ministry of Health, retinopathy in Nauru – the 1982 survey. Diabetes Res Clin Singapore, 1999. Pract 1984; 1:13-18. 105. Thai Health Research Institute. Report of the First National 120. Zimmet P, Canteloube D, Genelle B, LeGonidec G, Health Examination 1991-1992. Thai Health Research Couzigou P, Peghini M, Charpin M, Bennett P, Kuberski T, Institute, Bangkok, 1996; pp. 107-110. Kleiber N, Taylor R. The prevalence of diabetes mellitus 106. Janus ED, Watt NM, Lam KS, Cockram CS, Siu ST, Liu LJ, and impaired glucose tolerance in Melanesians and part- Lam TH on behalf of the Hong Kong Cardiovascular Risk Polynesians in rural New Caledonia and Ouvea (Loyalty Factor Steering Committee. The prevalence of diabetes, Islands). Diabetologia 1982; 23:393-398. association with cardiovascular risk factors and implications 121. Ministry of Health NZ. Diabetes in New Zealand: Models and of diagnostic criteria (ADA 1997 and WHO 1998) in a 1996 forecasts 1996-2011. New Zealand, Wellington, 2002. community-based population study in Hong Kong Chinese. 122. Chou P, Chen HH, Hsiao KJ. Community-based Diabet Med 2000; 17:741-745. epidemiological study on diabetes in Pu-Li, Taiwan. 107. Cockram CS, Woo J, Lau E, Chan JC, Chan AY, Lau J, Diabetes Care 1992; 15:81-89. Swaminathan R, Donnan SP. The prevalence of diabetes 123. Chou P, Liao MJ, Kuo HS, Hsiao KJ, Tsai ST. A population mellitus and impaired glucose tolerance among Hong Kong survey on the prevalence of diabetes in Kin-Hu, Kinmen. Chinese adults of working age. Diabetes Res Clin Pract Diabetes Care 1994; 17:1055-1058. 1993; 21:67-73. 124. Colagiuri S, Colagiuri R, Na’ati S, Muimuiheata S, Hussain Z, 108. Pan XR, Yang WY, Li GW, Liu J, National Diabetes Prevention Palu T. The prevalence of diabetes in the Kingdom of Tonga. and Control Cooperative Group. Prevalence of diabetes and Diabetes Care 2002; 25:1378-1383. its risk factors in China, 1994. Diabetes Care 1997; 125. CIA. World Factbook 2002. http://www.cia.gov/cia/ 20:1664-1669. publications/factbook/index.html. Central Intelligence 109. King H, Taylor R, Koteka G, Nemaia H, Zimmet P, Bennett PH, Agency, 2002. Raper LR. Glucose tolerance in Polynesia. Population-based surveys in Rarotonga and Niue. Med J Aust 1986; 145: 505-509. 110. Waspadji S, Ranakusuma AB, Suyono S, Supartondo S, Sukaton U. Diabetes mellitus in an urban population in Jakarta, Indonesia. Tohoku J Exp Med 1983; 141 Suppl: 219-228. 111. Zimmet P, Taylor R, Ram P, King H, Sloman G, Raper LR, Hunt D. Prevalence of diabetes and impaired glucose tolerance in the biracial (Melanesian and Indian) population of Fiji: a rural-urban comparison. Am J Epidemiol 1983; 118:673-688. 112. Collins VR, Dowse GK, Toelupe PM, Imo TT, Aloaina FL, Spark RA, Zimmet PZ. Increasing prevalence of NIDDM in the Pacific island population of Western Samoa over a 13- year period. Diabetes Care 1994; 17:288-296. 113. King H, Taylor R, Zimmet P, Pargeter K, Raper LR, Beriki T, Tekanene J. Non-insulin-dependent diabetes (NIDDM) in a newly independent Pacific nation: the Republic of Kiribati. Diabetes Care 1984; 7:409-415. 114. Ohmura T, Ueda K, Kiyohara Y, Kato I, Iwamoto H, Nakayama K, Nomiyama K, Ohmori S, Yoshitake T, Shinkawu A, Hasuo Y, Fujishima M. Prevalence of type 2 (non-insulin-dependent) diabetes mellitus and impaired glucose tolerance in the Japanese general population: the Hisayama Study. Diabetologia 1993; 36:1198-1203. 115. Sekikawa A, Eguchi H, Tominaga M, Igarashi K, Abe T, Manaka H, Sasaki H, Fukuyama H, Kato T, Kiyohara Y, Fujishima M. Prevalence of type 2 diabetes mellitus and impaired glucose tolerance in a rural area of Japan. The Funagata diabetes study. J Diabetes Complications 2000; 14:78-83. 116. Park Y, Lee H, Koh CS, Min H, Yoo K, Kim Y, Shin Y. Prevalence of diabetes and IGT in Yonchon County, South Korea. Diabetes Care 1995; 18:545-548. 117. Quoc PS, Charles MA, Cuong NH, Lieu LH, Tuan NA, Thomas M, Balkau B, Simon D. Blood glucose distribution and prevalence of diabetes in Hanoi (Vietnam). Am J Epidemiol 1994; 139:713-722. 118. Suvd J, Gerel B, Otgooloi H, Purevsuren D, Zolzaya H, Roglic G, King H. Glucose intolerance and associated factors in Mongolia: results of a national survey. Diabet Med 2002; 19:502-508.

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1.2 Complications of Diabetes

Introduction mainly to the rapid rise in its prevalence that has occurred in the latter part of Over the last 30 years, type 2 diabetes the 20th century. The main relevance of has changed from being seen as a diabetes complications in a public health relatively mild ailment associated perspective is the relationship to human with ageing and the elderly (‘just a suffering and disability, and the huge touch of sugar’) to one of the major socio-economic costs through premature contemporary causes of premature morbidity and mortality (1). mortality and morbidity in most countries. In virtually every developed Chronic elevation of blood glucose, even society, diabetes is ranked among the when no symptoms are present to alert leading causes of blindness, renal failure the individual to the presence of diabetes, and lower limb amputation. Through will eventually lead to tissue damage, its effects on cardiovascular disease with consequent, and often serious, (70-80% of people with diabetes die of disease. Whilst evidence of tissue damage cardiovascular disease), it is also now one can be found in many organ systems, it of the leading causes of death. is the kidneys, eyes, peripheral nerves and vascular tree, which manifest the The changing perceptions of diabetes most significant, and sometimes fatal, relate partly to a better appreciation diabetic complications. Indeed, diabetic of its devastating complications, but complications are those aspects of the disease that are most feared (such as blindness and amputation), and account The major diabetic complications for much of the social and financial burden of diabetes. �� The mechanism by which diabetes leads �� to these complications is complex, and not yet fully understood, but involves the �� direct toxic effects of high glucose levels, �� along with the impact of elevated blood �� pressure, abnormal lipid levels and both functional and structural abnormalities of �� small blood vessels. ��

In an attempt to better describe and understand the burden of diabetic complications, this section presents data on the rates of myocardial infarction, stroke, diabetic retinopathy, diabetic nephropathy, diabetic peripheral neuropathy and lower extremity �� amputations. The results of each study �� are presented against the country in �� which it was conducted, although given �� the design and small size of some of the studies, the results should not necessarily �� be seen as being representative of that �� country.

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Major diabetic complications Figure 1.11 Number of people with diabetes entering the Australian Over the last two or three decades, there dialysis register, 1980-2000 (4) has been an increasing awareness of the �� magnitude of the problem presented by diabetic complications. The major complications are: ��

• Cardiovascular disease � � �

Cardiovascular disease is the major � � ��

cause of death in diabetes, and � � �

people with diabetes without previous � �

myocardial infarction have been shown � �

� ��

to have as high a risk of myocardial � � infarction as have non-diabetic patients �

with previous myocardial infarction (2) �� (see Chapter 3).

• Nephropathy � �� Diabetes is an increasingly important cause of renal failure (see Figure 1.11), �� and indeed has now become the single most common cause of end stage renal disease (ie that which requires either dialysis or kidney transplantation) in • Amputation the USA (3). Through effects on peripheral nerves and arteries, diabetes can lead to foot • Neuropathy ulceration, infection and the need for Diabetes leads to a wide range of amputation. People with diabetes carry effects on the peripheral nervous a risk of amputation that may be more system, but the most common than 25 times greater than that seen in manifestation of diabetic neuropathy those without diabetes (7). is sensory loss in the feet. Although neuropathy can sometimes lead to Methods severe pain, it is often silent. However, even in the absence of symptoms, it Details of the methods used in this report puts the individual at high risk of foot on diabetes complications are found in ulceration and amputation. Appendix 1.2. The main principles in collating available prevalence data were: • Retinopathy Diabetic retinopathy is probably the 1 Studies were identified through most characteristic, easily identifiable a detailed literature search, as and treatable complication of diabetes, well as contact with IDF member but remains an important cause of organizations. visual loss in the developed world (5). 2 Studies with ≥100 participants were Since type 2 diabetes often remains included; where more than one undiagnosed for several years, a study was available for a country, significant number of people, even preference was given to larger and in developed countries, already have population-based studies, those retinopathy and other complications at published after 1989, and those with the time of diagnosis of diabetes (6). the fewest restrictions.

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3 Prevalences are reported for age range of the population was not myocardial infarction, stroke, available, the mean or median age is retinopathy, neuropathy and reported. nephropathy, and incidence and 5 Diagnostic criteria for each prevalence for lower extremity complication are recorded, as amputations. variation in definitions can affect the 4 Where possible, the age ranges of the prevalences reported. populations are reported. Where the

Profile: Janelle Colquhoun

Janelle Colquhoun was determined not to let diabetes interrupt her plans to perform onstage when diagnosed with type 1 diabetes at the age of 10. Headstrong, independent and driven since childhood, Janelle became the successful opera singer that she had always wanted to be.

But now at 37, “I am not dead, but I am paying the penalty for my years of careless control,” Janelle says. “My diabetes always came second to the rest of my life, having to fit in when I had time for it.” Janelle is blind, has kidney failure and has lost sensation in her hands and feet.

“While my doctor tried to convince me that I needed to take good care of my diabetes, I heard his words as ‘live a boring and non-eventful life, doing and eating exactly the same things at the same time each day’,” says Janelle, recalling her earlier years. “I wanted to have an exciting life, travel the world, keep long hours in a theatre and do things when it suited me.” His further threats of “if you don’t get better diabetic control you’ll be dead by the time you’re 30”, only pushed Janelle towards partying harder, taking greater risks, and cramming more into life before reaching 30.

Although it is too late to reverse the complications, Janelle has well-controlled diabetes now. The turning point in her diabetes control came when she was sent to a live-in diabetic clinic for one month after she had nearly died due to hyperglycaemia caused by an extreme weight- reduction diet. The clinic changed her into an educated person with diabetes. Says Janelle: “This was the first time I became aware that I could control my diabetes and live a full and exciting life.”

“The clinic rather than lecturing me about being a bad diabetic taught me how to be a good doctor,” she explains. “We were given the same information that the doctors base their advice on to give us best control, as they explained we are living with diabetes every minute and need to make the day-to-day choices.”

At the clinic in Germany, where she was living at the time, Janelle learnt about all aspects of diabetes and how to manage it. Although it required hard work on her part, Janelle found that she was in a position to make her own decisions. “We tried out different injection

74 75 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

6 For some countries, results from more numbers of individuals within a country than one study are presented. This is who may have complications are not usually because they cover different estimated, nor is a national prevalence. aspects of the diabetic population. Furthermore, data have not been projected from one country onto other There are some important differences countries. This is for two reasons: firstly, between this section and Chapter 1.1 on such calculations require knowledge of diabetes prevalence and IGT. The total the age and sex structure of both the

regimes under the doctor’s supervision until we worked out a regime to suit our lifestyle and circumstances. For the first time I was allowed to use my own intellect to make decisions and could plan a regime that suited my timetable and lifestyle.”

Before reaching this point, Janelle was busy fulfilling her dreams to perform onstage. She sang with the Australian Opera, and subsequently travelled the world. She then lived in Germany, singing with the Frankfurt Opera. “Often I did not even bother to blood test, as I knew it would be high,” recalls Janelle, “I always had a fear of having a hypoglycaemia onstage and never working again so purposely left it this way.”

She lost her eyesight due to diabetic retinopathy while living in Germany. She went through painful laser treatment before undergoing 12 eye operations to save her sight. After a prolonged period in hospital, the eye specialists released her into a world of blackness, and she returned home to Australia.

Adjusting to life without sight was more difficult than for a person without diabetes. Since Janelle had lost all sensation in her feet and hands many years earlier due to diabetic neuropathy, identifying surfaces, temperature, even learning to walk along the street with a white cane was near impossible. Obviously learning Braille was out of the question. Fortunately, technology has helped with the use of screen reading computers and it has allowed Janelle to read and write again, and participate in the world around her.

With the help of her husband, Janelle established Salubrious Productions, a growing company which represents professional artistes with disability. Not long after her marriage, Janelle discovered a large lump in her breast, which was surgically removed and diagnosed as diabetic mastopathy, one of the lesser known complications.

Janelle’s return to the stage and an active life was cut short again when her kidneys began to fail due to diabetic nephropathy. Janelle recalls that difficult year: “I had an important year planned with many major singing engagements. I spent most of the year in bed, often unable to get up and mostly too exhausted to sing.”

“I wish I had made educated choices when I was younger,” says Janelle, “however I am not without hope for the future.” She is on a waiting list for pancreas/kidney transplant and has hopes that advances in science and technology will bring her sight back. She regularly speaks at conferences and is active in Diabetes Australia. “Life continues to be full and eventful for people experiencing diabetes, and for those of us with complications also.”

74 75 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

original study population, and of the type 2 diabetes, the prevalence of overt target (national diabetic) population. In nephropathy ranged from 5.4% to 20.0% most cases, neither of these is known. in clinic-based populations and from 9.2% Secondly, many studies are clinic based, to 32.9% in population-based studies. and so their generalizability is limited. For microalbuminuria, fifty percent of Results the prevalences were between 18.3% and 24.5% for type 1 diabetes, and between The results are provided in Tables 1.41 21.4% and 42.0% for type 2 diabetes. – 1.50. A brief summary of results for For overt nephropathy, fifty percent of each complication is presented below. the prevalences in type 1 diabetes were Comments have excluded studies between 6.0% and 15.3%, and between focusing on children. 9.2% and 19.1% for type 2 diabetes.

Cardiovascular disease Neuropathy The prevalence of coronary heart disease The prevalence of neuropathy in those (CHD) in those with diabetes (both type 1 with type 1 diabetes ranged from 3.0% and type 2) ranged from 1.0% to 25.2% in to 65.8% in clinic-based populations and clinic-based populations and from 1.8% from 12.8% to 54.0% in population-based to 43.4% in population-based studies. studies. The prevalence of stroke in those with diabetes (type 1 and type 2) ranged from Among those with type 2 diabetes, 1% to 11.3% in clinic-based populations the prevalence of neuropathy ranged and from 2.8% to 12.5% in population- from 7.6% to 68.0% in clinic-based based studies. populations and from 13.1% to 45.0% in population-based studies. Fifty percent For CHD, fifty percent of the prevalences of the neuropathy prevalences for type 1 were between 0.5% and 8.7% for type 1 diabetes were between 22.4% and 30.1%, diabetes, and between 9.8% and 22.3% and between 19.3% and 33.7% for type 2 for type 2 diabetes. For stroke, fifty diabetes. percent of the prevalences in type 1 diabetes were between 0.5% and 4.3%, Retinopathy and between 4.1% and 6.7% for type 2 The prevalence of retinopathy in those diabetes. with type 1 diabetes ranged from 10.8% to 60.0 % in clinic-based populations Nephropathy and from 14.5% to 79.0% in population- The prevalence of microalbuminuria based studies. Among those with type 2 in those with type 1 diabetes ranged diabetes, the prevalence of retinopathy from 4.3% to 37.6% in clinic-based ranged from 10.6% to 47.3% in clinic- populations and from 12.3% to 27.2% in based populations and from 10.1% to population-based studies. Among those 55.0% in population-based studies. Fifty with type 2 diabetes the prevalence of percent of the retinopathy prevalences for microalbuminuria ranged from 2.5% to type 1 diabetes were between 33.5% and 57.0% in clinic-based population and 53.5%, and between 24.8% and 36.1% for from 18.9% to 42.1% in population-based type 2 diabetes. studies. Amputation The prevalence of overt nephropathy in The prevalence of lower extremity those with type 1 diabetes ranged from amputations ranged from 0.2% to 4.8% 0.7% to 27% in clinic-based populations and the incidence ranged from 46.1 per and from 0.3% to 24% in population- 100,000 diabetic population to 810 per based studies. Among those with 100,000 diabetic population. Fifty percent

76 77 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

of the amputation prevalences were defined as the absence of ankle reflexes between 0.9% and 2.4%, and between 169 in one study (9), and as the presence per 100,000 diabetic population and 457 of symptoms and clinical signs (using per 100,000 diabetic population for the validated scales) in another (10). The incidence of amputations. inconsistent use of diagnostic tools to classify a complication has been shown Discussion to dramatically affect the prevalence reported. The Diabetes Control and The aims of this section were to describe Complications Trial (DCCT) compared the burden of diabetic complications, the prevalence of neuropathy using 11 and to be able to examine the differences different criteria and found that within existing between countries and between the one population, the prevalence of ethnic groups. In order to do this with neuropathy varied from 0.3%, using confidence, it is necessary that there is a sensory examination, reflexes and degree of uniformity in the methodology symptoms, through to 21.8% using nerve of the different studies. This, however, conduction tests (11). was not the case. Another example of the variability For each of the complications, a brought about by changing methodology wide range of results was found, but is highlighted by a study on amputation. understanding the underlying causes of A study by Humphrey compared the this diversity is difficult. For example, incidence of lower extremity amputations the low prevalence of neuropathy seen in one population, when primary or all in Mauritius (8) could be due to a low amputations were included (12). The inherent risk for neuropathy in that incidence of lower extremity amputations population, the availability of high quality varied from 276 per 100,000 person diabetes care, the relative youth of a years (primary amputation) to 388 per population in a developing country, the 100,000 person years (all amputations). methods used in the study for defining Further differences in amputation neuropathy or the population-based incidences are likely to be due to the study design. In the absence of similar (rather imprecise) method of estimating studies, it is almost impossible to the total diabetic population from which determine which of these explanations those with amputations were drawn. may be correct. One large study, EURODIAB, examined The problem of accurately describing the the prevalence of retinopathy, neuropathy burden and making comparisons is made and nephropathy in type 1 diabetes particularly difficult by the relative lack of across several European countries population-based studies. Studies based (13,14). This study used standard in secondary care tend to over-represent methodology, making it possible to gain those with advanced disease, as those some insight into whether observed requiring more intensive monitoring differences in prevalence estimates are are generally referred on for specialist due to methodological problems or care. Furthermore, prevalences in clinic represent actual differences. The study populations will depend on local referral found the prevalence of complications patterns, which are likely to vary widely did vary between centres. The prevalence around the world. of retinopathy ranged from 21% in a clinic in Germany to 60% in a Portuguese clinic. Neither the diagnostic tools nor However, much less variation was seen diagnostic thresholds used to define for neuropathy and microalbuminuria, a complication were equivalent across for which the prevalences clustered fairly studies. For example, neuropathy was tightly around 25% and 23% respectively.

76 77 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes Chapter 1

Any conclusions about the burden of disease attributable to diabetic complications must be very guarded, and comparisons between different parts of the world should be extremely cautious. Nevertheless, some tentative comments can be made:

• The prevalence of retinopathy is probably around 30% in type 2 diabetes, but notably was above this in five out of the six studies reported from the Asian and Pacific island nations of the Western Pacific Region. • Of the six population-based studies giving figures for neuropathy in type 2 diabetes, the two with the highest prevalence were both from the USA. • Populations from Europe had high rates of heart disease and stroke, while migrant Indian (Mauritius and Fiji) populations also had high rates of heart disease. • No discernable patterns relating to geographic distribution or study design were apparent for nephropathy or amputations.

In summary, the interpretation of these studies of diabetic complications is severely hampered by the lack of population-based studies, and the wide variability in study design. Nevertheless, the data from EURODIAB would indicate that at least for some complications in type 1 diabetes, genuine differences exist between countries. What is absolutely clear from this review is that there are large parts of the world for which there are no useful data, and that there is a great need for population-based studies, using standardized protocols so that meaningful estimates of the prevalence of diabetic complications can be made.

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78 Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.41 Data sources: prevalence of cardiovascular disease

Region Country Data used Study type Sample size Age sample Duration DM (yrs) Diagnostic criteria – CHD# Diagnostic criteria – stroke+ AFR South Africa Rotchford et al, 200215 Clinic (secondary care) 253 21-81 4 ± N/A N/A Self-report / medical record review EMME Pakistan Hashim et al, 199916 Clinic (primary care) 805 31->70 N/A Medical record review / self-report (MI, angina) Medical record review (includes TIA) Sudan Elmahdi et al, 199117 Clinic (secondary care) 413 20+ <5->15 Self-report confirmed by ECG (CHD) Self-report (stroke, TIA) EUR Austria Mühlhauser et al, 199218 Clinic (primary care) 375 median=67 median=6 Self-report (MI) Self-report (stroke) Belgium Van Acker et al, 200119 Clinic (secondary care) 1,653 21-69 range 5-27 Medical record review (CHD) Medical record review (CBVD) Denmark Gall et al, 199120 Clinic (secondary care) 549 <76 range 0-20 ECG (Minnesota codes) N/A Estonia Vides et al, 200121 Register 181 15-82 11 ± 10 ECG / self-report / medical record review (CHD) Self-report / medical record review (CBVD) Finland Hu, 200322 Population based 172 25-64 N/A Self-report Self-report Isomaa et al, 200123 Clinic (primary care) 1,697 35-70 N/A Self-report / medical record review (MI) Self-report / medical record review (stroke) France Le Floch et al, 200024 Clinic (primary care) 7,391 mean=63 11 ± 0.1 Self-report / medical record review (CHD) Self-report / medical record review (CBVD) Delcourt et al, 199825 Clinic (secondary care) 427 35-74 11 ± 7 Self-report / ECG (MI) N/A Germany Liebl et al, 200226 Clinic (primary and secondary care) 2,701 mean=67 N/A Medical record review (MI, angina, congestive heart failure, Medical record review (stroke) coronary bypass surgery) Netherlands Reenders et al, 199327 Clinic (primary care) 387 mean=68 8 ± 6 Medical record review (MI, angina) Medical record review (stroke) de Visser et al, 200228 Population based 281 22-96 8 ± 7 Medical record review (MI, PTCA, coronary artery bypass) Medical record review (stroke, TIA) Verhoeven et al, 199129 Clinic (primary care) 137 mean=68 8 ± 7 ECG (Minnesota codes) N/A Serbia and Montenegro Miljus, 200230 N/A N/A N/A N/A N/A N/A Vlajinac et al, 199231 Population based 152 35-54 N/A ECG (Minnesota codes) questionnaire (MI, angina) N/A Slovakia Slovakian Diabetes Societya, 32 Clinic (secondary care) N/A N/A N/A N/A N/A Spain Diamante, 199733 Clinic (secondary care) 1,822 >18 14 ± 9 Self-report (CHD) Self-report (stroke) Esmatjes et al, 199634 Clinic (primary and secondary care) 1,157 45-70 9 ± 7 Self-report (CHD) Self-report (stroke) Sweden Lundman et al, 199835 Clinic (primary and secondary care) 4,027 ≥18 10 ± 7 Medical record review (MI, angina) Medical record review (stroke) United Kingdom Morgan et al, 200036 Clinic (primary and secondary care) 10,287 mean=61 N/A Hospital codes and primary care audit (CHD) Hospital codes and primary care audit (CBVD) NA USA Maser at al, 199137 Clinic (secondary care) 657 mean=28 19 ± 8 ECG / medical record review (MI, angina) N/A Alexander et al, 200038 Population based N/A ≥20 N/A Self-report, Rose questionnaire (MI, angina) N/A Qureshi et al, 199839 Population based 1,532 40-74 N/A Self-report (MI) Self-report (stroke) Barzilay et al, 200140 Population based 479 ≥65 N/A Medical record review (MI, angina, congestive heart failure, Medical record review (stroke, TIA) coronary bypass surgery) SEA Bangladesh Chuang et al, 2002c, 41 Clinic (secondary care) 1,607 10-91 8 ± 6 Medical record review (CHD) Medical record review (CBVD) Sayeed et al, 199842 Clinic (secondary care) 693 30-60 0 – 2 ECG and Self-report (MI, angina) N/A India Ramachandran et al, 1999c, 43 Clinic (secondary care) 3,010 mean=52 8 ± 6 ECG (Minnesota codes) / medical record review (MI) N/A Ramachandran et al, 200044 Clinic (secondary care) 617 10-50 median=4 ECG (Minnesota codes) / medical record review (MI) N/A Mauritius Collins et al, 199345 Population based 259 35-74 N/A ECG (Minnesota codes) N/A Sri Lanka Chuang et al, 2002c, 41 Clinic (secondary care) 1,213 14-91 8 ± 7 Medical record review (CHD) Medical record review (CBVD) Fernando et al, 199346 Clinic (secondary care) 500 mean=52 8 ± N/A ECG (Minnesota codes) Questionnaire WP China, People’s Republic of Chuang et al, 2002c, 41 Clinic (secondary care) 2,430 7-92 8 ± 6 Medical record review (CHD) Medical record review (CBVD) Chi et al, 200147 Clinic (secondary care) 447 35-54 range <7-14 ECG (Minnesota codes) / self-report (MI, angina) Self-report (stroke) Fiji (Asian Indian) Tuomilehto et al, 198848 Population based 151 N/A N/A ECG (Minnesota codes) N/A Indonesia Chuang et al, 2002c, 41 Clinic (secondary care) 2,093 22-89 8 ± 6 Medical record review (CHD) Medical record review (CBVD) Japan Kuzuya et al, 199449 Clinic (secondary care) 2,120 <24->75 11 ± N/A Doctor questionnaire (CHD) Doctor questionnaire (CBVD) Korea, Republic of Chuang et al, 2002c, 41 Clinic (secondary care) 952 15-92 11 ± 7 Medical record review (CHD) Medical record review (CBVD) Lee et al, 199550 Clinic (secondary care) 631 30-75 8 ± 7 ECG (Minnnesota codes) / self-report (MI, angina) Self-report (stroke) Malaysia Chuang et al, 2002c, 41 Clinic (secondary care) 1,045 15-87 11 ± 7 Medical record review (CHD) Medical record review (CBVD) Nauru Collins et al, 199345 Population based 215 35-80 N/A ECG (Minnesota codes) N/A New Zealand (European) Simmons et al, 199651 Population based 176 median=61 N/A Self-report (MI) N/A New Zealand (Maori) Simmons et al, 199651 Population based 286 median=50 N/A Self-report (MI) N/A New Zealand (Pacific Islanders) Simmons et al, 199651 Population based 495 median=52 N/A Self-report (MI) N/A

80 81 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Region Country Data used Study type Sample size Age sample Duration DM (yrs) Diagnostic criteria – CHD# Diagnostic criteria – stroke+ Philippines Chuang et al, 2002c, 41 Clinic (secondary care) 2,657 7-93 9 ± 7 Medical record review (CHD) Medical record review (CBVD) Singapore, Republic of Chuang et al, 2002c, 41 Clinic (secondary care) 1,674 4-91 10 ± 8 Medical record review (CHD) Medical record review (CBVD) Thai et al, 199052 Population based 117 18+ N/A ECG (Minnesota codes) / self-report (MI, angina) N/A Taiwan Chuang et al, 2002c, 41 Clinic (secondary care) 2,420 15-92 10 ± 7 Medical record review (CHD) Medical record review (stroke) Fuh, 2002a, 53 Clinic (secondary care) 4,535 N/A N/A N/A N/A Thailand Tatsanavivat et al, 199854 Population based 278 ≥30 N/A ECG (Minnesota codes) N/A Thai Multicenter Group, 199455 Clinic (secondary care) 1,747 24-88 8 ± 7 ECG Self-report (CBVD) / examination Tandhanand et al, 200156 Clinic (secondary care) 2,379 mean=59 10 ± 7 Medical record review (CHD) Medical record review (CBVD) Vietnam Chuang et al, 2002c, 41 Clinic (secondary care) 1,169 3-89 6 ± 5 Medical record review (CHD) Medical record review (CBVD) a. Unpublished data b. Abstract only c. Extra details supplied by authors

CBVD cerebrovascular disease CHD coronary heart disease DM diabetes mellitus ECG electrocardiogram MI myocardial infarction N/A not available PTCA percutaneous transluminal coronary angioplasty TIA transient ischaemic attack

Diagnostic tool: # – The type of CHD (eg 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 (eg stroke or stroke and TIA) reported is stated. If this was not reported in the study, the term CBVD is used.

82 83 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.42 Prevalence of cardiovascular disease

Prevalence of cardiovascular disease (%) Coronary heart disease Stroke Region Country Total DM UnDM Type 1 DM Type 2 DM Total DM UnDM Type 1 DM Type 2 DM AFR South Africa 7.5 EMME Pakistan 19.8 6.2 Sudan 5.1 4.4 EUR Austria 11.3 6.2 Belgium 21.0 6.2 30.8 Denmark 26.4 Estonia 7.7 2.8 Finland 8.1 7.6 13.4 5.2 France 13.5 16.3 13.3 4.1 4.3 4.1 8.4 Germany 10.6 6.7 Netherlands 9.0 5.0 20.9 9.1 40.0 Serbia and Montenegro 3.3 35.5 Slovakia 6.0 5.6 Spain 0.5 0.5 11.0 5.0 Sweden 11.5 4.7 12.3 11.3 3.1 12.3 United Kingdom 25.2 9.6 NA USA 3.4 9.8 10.7 5.0 (incl UnDM) (incl UnDM) 43.4 12.5 SEA Bangladesh 2.0 1.0 18.6 India 11.4 0.5 Mauritius Male 22.0 Female 33.7 Sri Lanka 6.0 2.0 12.0 3.6 WP China, People’s Republic of 1.0 5.0 8.7 3.4 Fiji (Asian Indian) 31.3 Indonesia 5.0 4.0 Japan 2.1 5.7 Korea, Republic of 3.0 6.0 7.8 8.4 Malaysia 12.0 6.0 Nauru 15.8 New Zealand (European) 11.0 New Zealand (Maori) 11.0 New Zealand (Pacific Islanders) 6.0 Philippines 3.0 6.0

84 85 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Prevalence of cardiovascular disease (%) Coronary heart disease Stroke Region Country Total DM UnDM Type 1 DM Type 2 DM Total DM UnDM Type 1 DM Type 2 DM Singapore, Republic of 5.0 3.0 12.8 (incl UnDM) Taiwan 4.0 6.0 18.1 4.7 Thailand 1.8 10.5 3.7 3.0 3.0 Vietnam 1.0 3.0

DM diabetes mellitus Total DM previously diagnosed diabetes (both type 1 and type 2) UnDM undiagnosed diabetes

84 85 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.43 Data sources: prevalence of diabetic nephropathy

Overt Microalbuminuria Region Country Data used Study type Sample size Age sample Duration DM (yrs) Diagnostic criteria Diagnostic criteria AFR Ethiopia Rahlenbeck et al, 199757 Clinic (secondary care) 170 mean=42 6 ± 5 Albuminuria 30-299 mg/le Albuminuria >300mg/le Nigeria Erasmus et al, 199258 Clinic (secondary care) 113 mean=51 5 ± 1 Albuminuria 20-199 µg/mine N/A South Africa Kalk et al, 199759 Clinic (secondary care) 448 mean=54 6 ± 6 A/CR 3.0-19.9 mg/mmol A/CR >19.9 mg/mmol Rotchford et al, 200215 Clinic (secondary care) 253 21-81 4 ± N/A Men A/CR 2.6-19.9 mg/mmol, women A/CR 3.6-19.9 mg/mmol A/CR ≥20 mg/mmol Levitt et al, 199760 Clinic (primary care) 243 20-85 8 ± 8 A/CR >3.4 mg/mmole N/A Zambia Rolfe, 198861 Population based 600 mean=49 9 ± 6 N/A Grade 2 proteinuria EMME Egypt Herman et al, 199862 Population based 283 20+ N/A A/CR 100 – 299 mg/g A/CR ≥300 mg/g Saudi Arabia Alzaid et al, 199463 Clinic (secondary care) 211 56 10 ± 5 AER 30-300 mg/24hr Dipstick proteinuria Sudan Elmahdi et al, 199117 Clinic (secondary care) 413 20+ <5->15 N/A Proteinuria >0.5g/24h or blood urea of >40mg% e EUR Austria Mühlhauser et al, 199218 Clinic (primary care) 375 median=67 median=6 Albuminuria 21-200 mg/l Albuminuria >200 mg/l EuroDiab, 1994c, 13 Clinic (secondary care) 111 15-60 16 ± 10 AER 20-199 µg/min AER ≥200 µg/min Belgium Bouten et al, 199664 Clinic (secondary care) 271 mean=37 15 ±10 AER 20-200 µg/mine N/A Van Acker et al, 200119 Clinic (secondary care) 1,653 21-69 range 5-27 Albuminuria ≥ 30mg/dl N/A EuroDiab, 1994c, 13 Clinic (secondary care) 123 15-60 15 ± 9 AER 20-199 µg/min AER ≥200 µg/min Croatia EuroDiab, 1994c, 13 Clinic (secondary care) 138 15-60 14 ± 9 AER 20-199 µg/min AER ≥200 µg/min Czech Republic Perusicova et al, 1993b, 65 Register 1,443 >18 N/A N/A N/A Czech Health Statistics, 2002a, 66 Population based N/A N/A N/A N/A N/A Denmark Mortensen et al, 199067 Clinic (secondary care) 957 <20 5 ± 3 AER >20-150µg/mine AER>150µg/mine Gall et al, 199120 Clinic (secondary care) 549 <76 range 0-20 AER 31-299 mg/24hr AER ≥300 mg/24hr Finland EuroDiab, 1994c, 13 Clinic (secondary care) 139 15-60 15 ± 10 AER 20-199 µg/min AER ≥200 µg/min France EuroDiab, 1994c, 13 Clinic (secondary care) 116 15-60 16 ± 10 AER 20-199 µg/min AER ≥200 µg/min Delcourt et al, 199825 Clinic (secondary care) 427 35-74 11 ± 7 AER 31-300mg/24hr AER >300 mg./24hr or proteinuria >0.5g/24h Germany Bennett et al, 200168 Clinic (secondary care) 214 N/A N/A A/CR 30-299 mg/g A/CR ≥300 mg/g EuroDiab, 1994c,d, 13 Clinic (secondary care) 241 15-60 15 ± 10 AER 20-199 µg/min AER ≥200 µg/min Greece EuroDiab, 1994c, 13 Clinic (secondary care) 231 15-60 13 ± 8 AER 20-199 µg/min AER ≥200 µg/min Ireland, Republic of EuroDiab, 1994c, 13 Clinic (secondary care) 112 15-60 15 ± 9 AER 20-199 µg/min AER ≥200 µg/min Hungary EuroDiab, 1994c,d, 13 Clinic (secondary care) 131 15-60 15 ± 9 AER 20-199 µg/min AER ≥200 µg/min Israel Norymberg et al, 199169 Clinic (secondary care) 1,019 31+ 12 ± 9 N/A Proteinuria >30mg/dle Italy EuroDiab, 1994c,d, 13 Clinic (secondary care) 944 15-60 14 ± 9 AER 20-199 µg/min AER ≥200 µg/min Luxembourg EuroDiab, 1994c, 13 Clinic (secondary care) 102 15-60 14 ± 9 AER 20-199 µg/min AER >200 µg/min Netherlands EuroDiab, 1994c, 13 Clinic (secondary care) 128 15-60 16 ± 10 AER 20-199 µg/min AER ≥200 µg/min Reenders et al, 199327 Clinic (primary care) 376 mean=68 8 ± 6 AER 20-200 mg/le AER >200 mg/le Verhoeven et al, 199129 Clinic (primary care) 137 mean=68 8 ± 7 Albuminuria 20-200 µg/min Proteinuria >0.5 g/24h Norway Joner et al, 199270 Population based 351 8-30 10 ± 3 AER 16 -200 µg/mine AER >200 µg/mine Poland EuroDiab, 1994c, 13 Clinic (secondary care) 116 15-60 15 ± 10 AER 20-199 µg/min AER ≥200 µg/min Bennett et al, 200168 Clinic (secondary care) 186 N/A N/A A/CR 30-299 mg/g A/CR ≥ 300 mg/g Portugal EuroDiab, 1994c, 13 Clinic (secondary care) 137 15-60 15 ± 10 AER 20-199 µg/min AER ≥200 µg/min Romania EuroDiab, 1994c, 13 Clinic (secondary care) 110 15-60 13 ± 8 AER 20-199 µg/min AER ≥200 µg/min Slovakia Slovakian Diabetes Societya, 32 Clinic (secondary care) N/A N/A N/A N/A N/A Spain Diamante, 199733 Clinic (secondary care) 1,822 >18 14 ± 9 AER 20-200 µg/mine AER >200 µg/mine Esmatjes et al, 199634 Clinic (primary and secondary care) 1,157 45-70 9 ± 7 AER 20-200 µg/mine AER >200 µg/mine Sweden Lundman et al, 199835 Clinic (secondary care) 4,027 18+ 10 ± 7 N/A Proteinuria ≥300mg/ge Ukraine Kravchenko et al, 199671 Clinic (secondary care) 4,123 14-75 N/A Albuminuria ≥20 mg/le N/A United Kingdom Higgs et al, 199272 Population based 358 6-92 11 ± N/A A/CR ≥2.5 mg/mmol Albustix reading ≥0.3 g/l Harvey et al, 2001c, 73 Population based 903 3-80 N/A AER 20-200 µg/mine AER >200 µg/mine EuroDiab, 1994c, 13 Clinic (secondary care) 175 15-60 17 ± 10 AER 20-199 µg/min AER ≥200 µg/min NA USA Garg et al, 200274 Population based 1,192 20-80+ N/A A/CR 3.0-37.8mg/mmol A/CR >37.8mg/mmol Orchard et al, 199075 Clinic (secondary care) 592 18-30+ 16 ± N/A AER 20-200µg/mine AER >200 µg/mine SACA Brazil Foss et al, 198976 Clinic (secondary care) 546 25-84 8 ± 7 N/A Proteinuria >200 mg/24hre

86 87 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Overt Microalbuminuria Region Country Data used Study type Sample size Age sample Duration DM (yrs) Diagnostic criteria Diagnostic criteria SEA India Ramachandran et al, 200044 Clinic (secondary care) 617 10-50 median=4 N/A Proteinuria ≥500 mg/24hre Ramachandran et al, 1999c, 43 Clinic (secondary care) 3,010 mean=52 8 ± 6 N/A Proteinuria ≥500 mg/24hre Mohan et al, 200077 Clinic (secondary care) 1,848 mean=52 7 ± 6 Proteinuria 150-499 mg/24hre Proteinuria ≥500 mg/24hre Mauritius Dowse et al, 199878 Population based 746 25+ 6 ± N/A Albuminuria 30-299 mg/ml Albuminuria ≥300 mg/ml Sri Lanka Weerasuriya et al, 199879 Clinic (primary care) 597 25-65 0 ± 0 N/A Albuminuria >50 mg/l WP Australia AusDiab Study Group, 200280 Population based 459 25+ median=5 A/CR 3.5-19.9 mg/mmol A/CR ≥20 mg/mmol China, Hong Kong Ko et al, 199981 Clinic (secondary care) 150 <40 5 ± 0 A/CR ≥3.5 mg/mmol and AER ≥20 µg/mine N/A Chan et al, 199382 Clinic (secondary care) 397 mean=57 range 0-30 A/CR 5.4-40.3 mg/mmole A/CR >40.3 mg/mmole China, People’s Republic of Chi et al, 200147 Clinic (secondary care) 447 35-54 N/A N/A Semi quantitative test Indonesia Diabcare Asia, 2003a, 83 Clinic (primary care) 717 25-85 7 ± 6 Albuminuria 20-300mg/l / A/CR 2.5-25mg/mol (men) Albuminuria >300 mg/l / A/CR >25 mg/mol A/CR 3.5-25 mg/mol (females) Japan Kuzuya et al, 199449 Clinic (secondary care) 2,120 <24->75 11 ± N/A Doctor report Doctor report Kawano et al, 20019 Clinic 6,472 mean=61 10 ± 10 Doctor report Doctor report Korea, Republic of Lee et al, 199550 Clinic (secondary care) 631 30-75 8 ± 7 AER 20-200 µg/mine AER >200 µg/mine Malaysia Shriwas et al, 199684 Clinic (secondary care) 131 0-80+ range <5->20 N/A Dipstick proteinuria or creatinine > 97µmol/l Nauru Collins et al, 198985 Population based 318 25+ range 0->15 Albuminuria 30 -299 µg/ml Albuminuria ≥300 µg/ml New Zealand (European) Simmons et al, 199486 Clinic (primary and secondary care) 297 18-79 range 0-47 AER 30-299 mg/24hr AER ≥300mg/24hr New Zealand (Pacific Islanders) Simmons et al, 199486 Clinic (primary and secondary care) 123 18-79 range 0-32 AER 30-299 mg/24hr AER ≥300mg/24hr Philippines Lantion-Ang, 200087 Clinic (primary care) 359 7-93 9 ± 7 Albuminuria 20-300 mg/l Albuminuria >300 mg/l Samoa Collins et al, 199588 Population based 141 25-74 4 ± N/A Albuminuria 30-299 µg/ml Albuminuria ≥300 µg/ml Singapore, Republic of Thai et al, 199052 Population based 117 18+ N/A N/A Albuminuria ≥30 mg/dl or creatinine ≥1.5 mg/dl Taiwan Fuh, 2002a, 53 Clinic (secondary care) 4,535 N/A N/A N/A A/CR >300 mg/g or blood urea >26 mg/dl or serum creatinine >1.3 mg/dl Thailand Thai Multicenter Group, 199455 Clinic (secondary care) 2,060 24-88 8 ± 7 N/A Dipstick proteinuria 2+ Vietnam Diabcare Asia, 2003a, 83 Clinic (primary care) 521 1-85 7 ± 5 Albuminuria 20-300mg/l / A/CR 2.5-25mg/mol (men) Albuminuria >300 mg/l / A/CR >25 mg/mol A/CR 3.5-25 mg/mol (females) a. Unpublished data b. Abstract only c. Extra details supplied by authors d. More than one centre used to derive prevalence figure e. Diagnosis of nephropathy required two or more urine samples

A/CR albumin/creatinine ratio AER albumin excretion rate DM diabetes mellitus N/A not available

88 89 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.44 Prevalence of diabetic nephropathy

Prevalence of diabetic nephropathy (%) Overt Microalbuminuria Region Country Total DM UnDM Type 1 DM Type 2 DM Total DM UnDM Type 1 DM Type 2 DM AFR Ethiopia 17.1 34.1 Nigeria 57.0 South Africa 14.5 31.0 13.4 32.8 5.3 36.7a Zambia 23.8 EMME Egypt 6.7 6.8 14.3 14.1 Saudi Arabia 12.8 36.0 Sudan 9.2 EUR Austria 15.0 32.0 3.6 23.4 Belgium 14.0 35.4a 37.6a 35.6a 13.0 25.2 Croatia 15.9 29.0 Czech Republic 13.8 7.3a Denmark 0.7 4.3 14.0 27.0 Finland 15.1 23.7 France 11.2 21.6 6.1 21.8 Germany 7.9 14.5 7.5 21.6 Greece 6.5 23.8 Ireland, Republic of 12.5 17.9 Hungary 6.1 19.8 Israel 7.0 Italy 6.9 19.3 Luxembourg 3.9 23.5 Netherlands 7.0 23.4 13.0 44.0 16.0 42.0 Norway 0.3 12.3 Poland 8.6 19.8 9.7 18.8 Portugal 15.8 24.8 Romania 17.3 26.4 Slovakia 7.6 Spain 5.0 14.1 5.4 23.1 Sweden 12.1 11.8 12.1 Ukraine 9.6 United Kingdom 24.0 17.0 9.6 27.2 (cumulative (cumulative prevalence) prevalence) 5.7 21.7 NA USA 6.1 28.1 26.4 21.6

90 91 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Prevalence of diabetic nephropathy (%) Overt Microalbuminuria Region Country Total DM UnDM Type 1 DM Type 2 DM Total DM UnDM Type 1 DM Type 2 DM SACA Brazil 11.3 SEA India 7.1 19.7 (persistant 5.5%) 10.7 2.5 Mauritius 3.8 10.7 Sri Lanka 29.0a WP Australia 8.9 3.9 9.2 19.2 10.5 18.9 China, Hong Kong 22.7a 24.8a 20.0 27.0 China, People’s Republic of 57.1 Indonesia 3.3 4.6 Japan 20.1 27.0 19.5 27.3 Korea, Republic of 14.0 20.0 Malaysia 28.2 Nauru 24.4 32.9 38.9 42.1 New Zealand (European) 5.4 22.1 New Zealand (Pacific Islanders) 13.0 33.3 Philippines 1.0 48.7 Samoa 5.0 19.9 (incl UnDM) (incl UnDM) Singapore, Republic of 18.3 Taiwan 19.0 Thailand 18.7 Vietnam 6.1 14.2

a. Includes both micro and macroalbuminuria

DM diabetes mellitus Total DM previously diagnosed diabetes (both type 1 and type 2) UnDM undiagnosed diabetes

90 91 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.45 Data sources: prevalence of diabetic neuropathy

Region Country Data used Study type Sample size Age sample Duration DM (yrs) Diagnostic criteria AFR South Africa Levitt et al, 199760 Clinic (primary care) 243 20-85 8 ± 8 Clinical score Tanzania Wikblad et al, 199789 Clinic (secondary care) 153 mean=44 5 ± 6 Clinical store, quantitative sensory testing (NDS, NSS) Zambia Rolfe, 198890 Clinic (secondary care) 600 ≥35 7 ± 6 Clinical score EMME Egypt Herman et al, 199862 Population based 509 ≥20 N/A Quantitative sensory testing Saudi Arabia Akbar et al, 200091 Clinic (secondary care) 237 mean=54 11 ± 7 Clinical score (DNI) Nielsen, 199892 Clinic (secondary care) 375 median=50 median=8 Clinical score Sudan Elmahdi et al, 199117 Clinic (secondary care) 413 20+ N/A Clinical score EUR Austria Mühlhauser et al, 199218 Clinic (primary care) 395 mean=67 N/A Quantitative sensory testing EuroDiab, 1996c, 14 Clinic (secondary care) 116 15-60 16 ± 10 Clinical score, quantitative sensory testing, autonomic function tests Belgium Van Acker et al, 200119 Clinic (secondary care) 1,653 21-69 range 5-27 Quantitative sensory testing EuroDiab, 1996c, 14 Clinic (secondary care) 116 15-60 15 ± 9 Clinical score, quantitative sensory testing, autonomic function tests Croatia EuroDiab, 1996c, 14 Clinic (secondary care) 132 15-60 14 ± 9 Clinical score, quantitative sensory testing, autonomic function tests Czech Republic Perusicova et al, 1993b, 65 Register 1,443 >18 N/A N/A Finland Partanen et al, 199593 Clinic 132 45-65 0 ± 0 Clinical score, electrophysiology EuroDiab, 1996c, 14 Clinic (secondary care) 138 15-60 15 ± 10 Clinical score, quantitative sensory testing, autonomic function tests France EuroDiab, 1996c, 14 Clinic (secondary care) 104 15-60 16 ± 10 Clinical score, quantitative sensory testing, autonomic function tests Detournay et al, 200094 Clinic (primary and secondary care) 4,119 mean=66 9 ± N/A Medical record review Delcourt et al, 199825 Clinic (secondary care) 427 35-74 11 ± 7 Clinical score, quantitative sensory testing Germany EuroDiab, 1996c,d, 14 Clinic (secondary care) 229 15-60 15 ± 10 Clinical score, quantitative sensory testing, autonomic function tests Greece Manes et al, 200295 Population based 821 18-70 8 ± 7 Clinical score (NDS, NSS), quantitative sensory testing EuroDiab, 1996c,d, 14 Clinic (secondary care) 216 15-60 13 ± 8 Clinical score, quantitative sensory testing, autonomic function tests Hungary EuroDiab, 1996c, 14 Clinic (secondary care) 138 15-60 15 ± 9 Clinical score, quantitative sensory testing, autonomic function tests Ireland, Republic of EuroDiab, 1996c, 14 Clinic (secondary care) 116 15-60 15 ± 9 Clinical score, quantitative sensory testing, autonomic function tests Israel Norymberg et al, 199169 Clinic (secondary care) 1,019 ≥31 12 ± 9 Clinical score Italy Veglio et al, 199396 Clinic (secondary care) 379 15-59 N/A Clinical score, autonomic function tests EuroDiab, 1996c,d, 14 Clinic (secondary care) 894 15-60 14 ± 9 Clinical score, quantitative sensory testing, autonomic function tests Fedele et al, 199797 Clinic (secondary care) 8,757 18-70 12 ± 9 Clinical score (DNI) Luxembourg EuroDiab, 1996c, 14 Clinic (secondary care) 107 15-60 14 ± 9 Clinical score, quantitative sensory testing, autonomic function tests Netherlands Reenders et al, 199327 Clinic (primary care) 387 mean=68 8 ± 6 Clinical score, autonomic function tests Verhoeven et al, 199129 Population based 137 mean=68 8 ± 7 Clinical score EuroDiab, 1996c, 14 Clinic (secondary care) 134 15-60 16 ± 10 Clinical score, quantitative sensory testing, autonomic function tests Poland EuroDiab, 1996c, 14 Clinic (secondary care) 117 15-60 15 ± 10 Clinical score, quantitative sensory testing, autonomic function tests Portugal EuroDiab, 1996c, 14 Clinic (secondary care) 130 15-60 15 ± 10 Clinical score, quantitative sensory testing, autonomic function tests Romania EuroDiab, 1996c, 14 Clinic (secondary care) 114 15-60 13 ± 8 Clinical score, quantitative sensory testing, autonomic function tests Spain Esmatjes et al, 199634 Clinic (primary and secondary care) 1,157 45-70 9 ± 7 Clinical score Cabezas-Cerrato, 199898 Population based 2,644 15-74 10 ± 0 Clinical score (NDS, NSS) Sweden Lundman et al, 199835 Clinic (primary and secondary care) 4,027 ≥18 10 ± 7 Clinical score, quantitative sensory testing Turkey Bolukbasi, 1998b, 99 Clinic (secondary care) 297 N/A N/A Clinical score, electrophysiology Ukraine Kravchenko et al, 199671 Clinic (secondary care) 4,123 14-75 N/A Clinical score United Kingdom Abbott et al, 2002100 Clinic (primary and secondary care) 9,710 mean=61 9 ± 11 Clinical score (NDS) Kumar et al, 1994101 Clinic (primary care) 811 34-96 7 ± N/A Clinical score (NDS), quantitative sensory testing EuroDiab, 1996c, 14 Clinic (secondary care) 181 15-60 17 ± 10 Clinical score, quantitative sensory testing, autonomic function tests Walters et al, 1992102 Population based 1,077 30-80+ N/A Clinical score, quantitative sensory testing Young et al, 1993103 Clinic (secondary care) 6,487 18-90 range 0-62 Clinical score (NDS, NSS) NA USA Orchard et al, 199075 Clinic (secondary care) 588 mean=24 16 ± N/A Clinical score Franklin et al, 1990104 Population based 279 20-74 N/A Clinical score Dyck et al, 199310 Population based 359 57 N/A Clinical score (NSS, NDS, NSP), quantitative sensory testing, electrophysiology, autonomic function tests SACA Brazil Foss et al, 1989b,c, 76 Clinic (secondary care) 546 25-84 8 ± 7 Clinical score, quantitative sensory testing SEA India Ramachandran et al, 200044 Clinic (secondary care) 617 10-50 median=4 Clinical score Ramachandran et al, 199943 Clinic (secondary care) 3,010 mean=52 8 ± 6 Clinical score, quantitative sensory testing

92 93 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Region Country Data used Study type Sample size Age sample Duration DM (yrs) Diagnostic criteria Mauritius Shaw et al, 19988 Population based 847 ≥25 N/A Quantitative sensory testing Sri Lanka Weerasuriya et al, 199879 Clinic (primary care) 597 25-65 0 ± 0 Clinical score (NSS, NDS), quantitative sensory testing Fernando, 1996105 Clinic (secondary care) 500 30-60 5 ± 6 Clinical score (NSS, NDS), quantitative sensory testing WP Australia Tapp et al, 2003106 Population based 398 ≥25 median=5 Clinical score (NSS, NDS), quantitative sensory testing, autonomic function tests China, Hong Kong Ko et al, 199981 Clinic (secondary care) 150 <40 5 ± 0 Clinical score, quantitative sensory testing China, People’s Republic of Chuang et al, 2002c, 41 Clinic (secondary care) 2,344 7-92 8 ± 6 Medical record review Indonesia Chuang et al, 2002c, 41 Clinic (secondary care) 2,084 22-89 8 ± 6 Medical record review Japan Kawano et al, 20019 Clinic 6,472 mean=61 10 ± 10 Clinical score Korea, Republic of Chuang et al, 2002c, 41 Clinic (secondary care) 948 15-92 11 ± 7 Medical record review Malaysia Chuang et al, 2002c, 41 Clinic (secondary care) 1,045 15-87 11 ± 7 Medical record review Philippines Chuang et al, 2002c, 41 Clinic (secondary care) 2,635 7-93 9 ± 7 Medical record review Singapore, Republic of Chuang et al, 2002c, 41 Clinic (secondary care) 1,625 4-91 10 ± 8 Medical record review Thai et al, 199052 Population based 117 18+ N/A Clinical score Taiwan Wang et al, 2000107 Population based 219 35-85 N/A Clinical score Fuh, 2002a, 53 Clinic (secondary care) 4,535 N/A N/A Quantitative sensory testing Thailand Tandhanand et al, 200156 Clinic (secondary care) 2,314 mean=59 10 ± 7 Medical record review Vietnam Chuang et al, 2002c, 41 Clinic (secondary care) 1,179 3-89 6 ± 5 Medical record review a. Unpublished data b. Abstract only c. Extra details supplied by authors d. More than one centre used to derive prevalence figure

DM diabetes mellitus DNI diabetic neuropathy index N/A not available NDS neuropathy disability score NSP neuropathy symptom profile NSS neuropathy symptom score

94 95 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.46 Prevalence of diabetic neuropathy

Prevalence of diabetic neuropathy (%) Region Country Total DM UnDM Type 1 DM Type 2 DM AFR South Africa 27.6 Tanzania 28.1 Zambia 31.2 EMME Egypt 21.9 13.6 Saudi Arabia 56.0 19.7 Sudan 31.5 EUR Austria 26.0 23.3 Belgium 33.7 25.7 38.3 29.3 Croatia 57.6 Czech Republic 32.8 Finland 8.3 26.1 France 21.2 8.8 28.8 Germany 20.1 Greece 33.5 25.5 Hungary 29.0 Ireland, Republic of 24.1 Israel 23.4 Italy 28.5 26.0 32.3 Luxembourg 21.5 Netherlands 68.0 18.0 23.9 Poland 25.6 Portugal 36.9 Romania 65.8 Spain 20.0 22.7 12.9 24.1 Sweden 27.3 22.8 27.9 Turkey 26.9 Ukraine 27.9 United Kingdom 22.4 41.6 22.7 16.8 12.8 17.2 28.5 22.7 32.1 NA USA 32.4 27.8 47.6 54.0 45.0 SACA Brazil 50.9

96 97 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Prevalence of diabetic neuropathy (%) Region Country Total DM UnDM Type 1 DM Type 2 DM SEA India 3.0 27.5 Mauritius 12.7 3.6 Sri Lanka 10.0 30.6 WP Australia 7.1 13.1 China, Hong Kong 7.3 7.6 China, People’s Republic of 31.0 Indonesia 55.0 Japan 41.4 Korea, Republic of 33.0 Malaysia 61.0 Philippines 42.0 Singapore, Republic of 12.0 15.9 (incl UnDM) Taiwan 32.4 24.4 Thailand 27.0 Vietnam 44.0

DM diabetes mellitus Total DM previously diagnosed diabetes (both type 1 and type 2) UnDM undiagnosed diabetes

96 97 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.47 Data sources: prevalence of diabetic retinopathy

Region Country Data used Study type Sample size Age sample Duration DM (yrs) Diagnostic criteria AFR Cameroon Moukouri Dit Nyolo et al, 1995123 Clinic (secondary care) 284 10-79 range 0-20 Clinical fundoscopy Ethiopia Seyoum et al, 2001124 Clinic (secondary care) 302 14-85 9 ± 5 Clinical fundoscopy Nigeria Erasmus et al, 1989125 Clinic (secondary care) 377 11-60+ range 0-22 Clinical fundoscopy South Africa Kalk et al, 199759 Clinic (secondary care) 507 mean=54 7 ± 7 Fundus photography Rotchford et al, 200215 Clinic (secondary care) 251 21-81 4 ± N/A Clinical fundoscopy Levitt et al, 199760 Clinic (primary care) 243 20-85 8 ± 8 Clinical fundoscopy Zambia Rolfe et al, 1988126 Clinic (secondary care) 600 mean=49 9 ± 6 Clinical fundoscopy Zimbabwe Bartels et al, 1999127 Clinic (secondary care) 117 N/A N/A Clinical fundoscopy EMME Egypt Herman et al, 199862 Population based 376 20+ N/A Fundus photography Oman el Haddad et al, 1998128 Clinic (secondary care) 500 mean=39 9 ± 4 Clinical fundoscopy Sudan Elmahdi et al, 199117 Clinic (secondary care) 413 20+ <5->15 Clinical fundoscopy EUR Austria EuroDiab, 199413 Clinic (secondary care) 122 15-60 16 ± 10 Fundus photography Mühlhauser et al, 199218 Clinic (primary care) 375 median=67 median=6 Clinical fundoscopy or fundus photography Belgium Van Acker et al, 200119 Clinic (secondary care) 1,653 21-69 range 5-27 Medical record review EuroDiab, 199413 Clinic (secondary care) 123 15-60 15 ± 9 Fundus photography Croatia EuroDiab, 199413 Clinic (secondary care) 140 15-60 14 ± 9 Fundus photography Czech Republic Perusicova et al, 1993b, 65 Register 1,443 >18 N/A N/A Czech Health Statistics, 2002a, 66 Population based N/A N/A N/A N/A Denmark Gall et al, 199120 Clinic (secondary care) 549 <76 range 0-20 Clinical fundoscopy Finland EuroDiab, 199413 Clinic (secondary care) 141 15-60 15 ± 10 Fundus photography Falck et al, 1993129 Clinic (secondary care) 194 4-17 5 ± 3 Fundus photography France EuroDiab, 199413 Clinic (secondary care) 127 15-60 16 ± 10 Fundus photography Detournay et al, 200095 Clinic (primary and secondary care) 4,119 mean=66 9 ± N/A Questionnaire Delcourt et al, 199825 Clinic (secondary care) 427 35-74 11 ± 7 Fundus photography Germany EuroDiab, 1994d, 13 Clinic (secondary care) 229 15-60 15 ± 10 Fundus photography Hesse et al, 2001b, 130 Population based 2,801 mean=66 10 ± 8 Medical record review Greece EuroDiab, 1994d, 13 Clinic (secondary care) 244 15-60 13 ± 8 Fundus photography Hungary EuroDiab, 199413 Clinic (secondary care) 140 15-60 15 ± 9 Fundus photography Ireland, Republic of EuroDiab, 199413 Clinic (secondary care) 124 15-60 15 ± 9 Fundus photography Israel Norymberg et al, 199169 Clinic (secondary care) 1,019 31-71+ 12 ± 9 Clinical fundoscopy Italy EuroDiab, 1994d, 13 Clinic (secondary care) 989 15-60 14 ± 9 Fundus photography Segato et al, 1991131 Population based 1,291 mean=60 range <5->20 Clinical fundoscopy Garancini et al, 1989132 Clinic (secondary care) 748 14-89 range <5->20 Clinical fundoscopy Luxembourg EuroDiab, 199413 Clinic (secondary care) 116 15-60 14 ± 9 Fundus photography Netherlands EuroDiab, 199413 Clinic (secondary care) 136 15-60 16 ± 10 Fundus photography Reenders et al, 199327 Clinic (primary care) 360 mean=68 8 ± 6 Clinical fundoscopy Verhoeven et al, 199129 Population based 137 mean=68 8 ± 7 Clinical fundoscopy and fundus photography Norway Joner et al, 199270 Population based 371 8-30 10 ± 3 Fundus photography Hapnes et al, 1996133 Population based 210 mean=66 9 ± 8 Clinical fundoscopy and fundus photography Poland Luzniak et al, 1997b, 134 Clinic (secondary care) 1,334 N/A N/A N/A Portugal Pinto-Figueiredo et al, 1992135 Clinic (secondary care) 1,302 <9-79 10 ± 10 Clinical fundoscopy and fundus photography EuroDiab, 199413 Clinic (secondary care) 138 15-60 15 ± 10 Fundus photography Russia Betts et al, 1999136 Clinic (secondary care) 266 <16 3 ± N/A Clinical fundoscopy Slovakia Slovakian Diabetes Societya, 32 Clinic (secondary care) N/A N/A N/A N/A Spain Esmatjes et al, 199634 Clinic (primary and secondary care) 1,157 45-70 9 ± 7 Clinical fundoscopy Fernandez-Vigo et al, 1993137 Clinic (primary and secondary care) 1,179 8-93 range <5->15 Clinical fundoscopy and fundus photography Sweden Kernell et al, 1997138 Population based 557 mean=15 5 ± N/A Fundus photography Henricsson et al, 1996139 Population based 2,232 <75 8 ± 8 Fundus photography Larsson et al, 1999140 Population based 285 15-50 17 ± 11 Clinical fundoscopy and fundus photography Falkenberg et al, 1994141 Population based 117 <70 8 ± 5 Fundus photography Ukraine Kravchenko et al, 199671 Clinic (secondary care) 4,123 14-75 N/A Clinical fundoscopy United Kingdom Higgs et al, 199272 Population based 291 6-92 11 ± N/A Fundus photography Sparrow et al, 1993142 Population based 101 28-91 7 ± 6 Clinical fundoscopy and fundus photography EuroDiab, 199413 Clinic (secondary care) 172 15-60 17 ± 10 Fundus photography Broadbent et al, 1999143 Clinic (primary care) 357 13-92 N/A Clinical fundoscopy and fundus photography

98 99 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Region Country Data used Study type Sample size Age sample Duration DM (yrs) Diagnostic criteria NA Barbados Leske et al, 1999144 Population based 636 40-84 median=5 Clinical fundoscopy and fundus photography Mexico Gonzalez Villalpando et al, 1994145 Population based 210 35-65 8 ± 7 Fundus photography USA Dyck et al, 199310 Population based 380 mean=57 range 0-64 Fundus photography Klein et al, 1992146 Population based 435 43-84 range 0-20+ Fundus photography USA (Mexican Americans) Harris et al, 1998147 Population based 308 40+ range 0-15+ Fundus photography USA (Non-Hispanic Blacks) Harris et al, 1998147 Population based 261 40+ range 0-15+ Fundus photography USA (Non-Hispanic Whites) Harris et al, 1998147 Population based 345 40+ range 0-15+ Fundus photography SACA Brazil Foss et al, 1989b, 76 Clinic (secondary care) 546 25-84 8 ± 7 Clinical fundoscopy SEA Bangladesh Chuang et al, 2002c, 41 Clinic (secondary care) 1,608 10-91 8 ± 6 Medical record review India Ramachandran et al, 200044 Clinic (secondary care) 617 10-50 median=4 Clinical fundoscopy Rema et al, 1996148 Clinic (secondary care) 6792 mean=55 9 ± 6 Clinical fundoscopy Ramachandran et al, 199943 Clinic (secondary care) 3010 mean=52 8 ± 6 Clinical fundoscopy Dandona et al, 1999149 Population based 119 31-86 range 0-20+ Clinical fundoscopy Mauritius Dowse et al, 199878 Population based 746 ≥25 6 ± N/A Fundus photography Sri Lanka Fernando et al, 1993150 Clinic (secondary care) 1,003 mean=52 7 ± 4 Clinical fundoscopy Weerasuriya et al, 199879 Clinic (primary care) 597 25-65 0 ± 0 Clinical fundoscopy WP Australia Tapp et al, 2003151 Population based 703 ≥25 median=5 Fundus photography Fairchild et al, 1994152 Clinic (secondary care) 255 median=15 2 ± 18 Fundus photography McKay et al, 2000153 Population based 234 40+ 9.1 ± N/A Fundus photography China, Hong Kong Ko et al, 199981 Clinic (secondary care) 150 <40 5 ± 0 Clinical fundoscopy Wang et al, 1998154 Clinic (secondary care) 465 mean=54 N/A Clinical fundoscopy China, People’s Republic of Chuang et al, 2002c, 41 Clinic (secondary care) 2,228 7-92 8 ± 6 Medical record review Hu et al, 1991155 Clinic (primary care) 423 35-74 0 ± 0 Clinical fundoscopy Chi et al, 200147 Clinic (secondary care) 447 35-54 range <7-14 Clinical fundoscopy Fiji Brooks et al, 1999156 Population based 403 mean=56 8 ± N/A Clinical fundoscopy Indonesia Chuang et al, 2002c, 41 Clinic (secondary care) 2,062 22-89 8 ± 6 Medical record review Japan Kawano et al, 20018 Clinic 6,472 mean=61 10 ± 10 Doctor report Kuzuya et al, 199449 Clinic (secondary care) 2,120 <24->75 11 ± N/A Doctor report Korea, Republic of Chuang et al, 2002c, 41 Clinic (secondary care) 934 15-92 11 ± 7 Medical record review Lee et al, 199550 Clinic (secondary care) 631 30-75 8 ± 7 Clinical fundoscopy Malaysia Chuang et al, 2002c, 41 Clinic (secondary care) 1,045 15-87 11 ± 7 Medical record review Shriwas et al, 199684 Clinic (secondary care) 140 0-80+ range <5->20 Clinical fundoscopy New Zealand Florkowski et al, 2001157 Population based 286 mean=30 10 ± 6 Clinical fundoscopy Phillipines Chuang et al, 2002c, 41 Clinic (secondary care) 2,398 7-93 9 ± 7 Medical record review Samoa Collins et al, 199588 Population based 166 25-74 4 ± N/A Fundus photography Singapore, Republic of Chuang et al, 2002c, 41 Clinic (secondary care) 1,578 4-91 10 ± 8 Medical record review Lau et al, 1995158 Clinic (primary care) 13,296 <30->70 N/A Fundus photography Taiwan Fuh, 2002a, 53 Clinic (secondary care) 4,535 N/A N/A N/A Chen et al, 1992159 Population based 527 40+ <4->10 Clinical fundoscopy Thailand Tandhanand et al, 200156 Clinic (secondary care) 2,034 mean=59 10 ± 7 Medical record review Thai Multicenter Group, 199455 Clinic (secondary care) 2,060 24-88 8 ± 7 Clinical fundoscopy Vietnam Chuang et al, 2002c, 41 Clinic (secondary care) 1,113 3-89 6 ± 5 Medical record review a. Unpublished data b. Abstract only c. Extra details supplied by authors d. More than one centre used to derive prevalence figure

DM diabetes mellitus N/A not available

100 101 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.48 Prevalence of diabetic retinopathy

Prevalence of diabetic retinopathy (%) Proliferative Total retinopathy retinopathy Region Country Total DM UnDM Type 1 DM Type 2 DM Total DM AFR Cameroon 37.3 Ethiopia 37.8 34.1 41.0 1.7 Nigeria 15.1 0.0 South Africa 39.3 40.3 5.6 55.4 4.3 Zambia 34.0 4.0 Zimbabwe 35.9 EMME Egypt 41.5 15.7 Oman 42.4 12.8 Sudan 17.4 EUR Austria 23.0 23.3 Belgium 38.5 43.6 35.0 47.0 Croatia 59.0 Czech Republic 42.2 11.3 2.4 Denmark 35.3 4.2 Finland 54.0 10.8 France 35.0 10.6 33.5 1.4 Germany 21.0 16.1 Greece 46.7 Hungary 51.0 Ireland, Republic of 53.0 Israel 28.0 Italy 40.8 26.2 46.2 24.6 1.8 37.3 7.6 Luxembourg 30.0 Netherlands 47.0 13.5 35.0 4.0 Norway 32.8 0.0 13.8 34.4 10.1 2.4 Poland 31.4 Portugal 41.6 7.3 60.0 Russian Federation 12.0 1.1 Slovakia 17.4 Spain 29.0 44.7 5.8 Sweden 14.5 2.3 43.6 64.0 36.0 6.7 75.1 21.8 26.5 3.4 Ukraine 22.4

102 103 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Prevalence of diabetic retinopathy (%) Proliferative Total retinopathy retinopathy Region Country Total DM UnDM Type 1 DM Type 2 DM Total DM United Kingdom 42.6 2.7 52.0 4.0 51.0 33.6 36.7 36.2 1.1 NA Barbados 28.5 0.9 Mexico 49.5 5.7 USA 62.1 79.0 55.0 8.9 (incl UnDM) 36.8 10.2 68.4 1.8 USA (Mexican Americans) 33.4 5.6 USA (Non-Hispanic Blacks) 26.5 1.8 USA (Non-Hispanic Whites) 18.2 0.9 SACA Brazil 29.1 SEA Bangladesh 11.0 India 13.4 1.9 34.1 3.4 23.7 3.7 23.5 0.8 Mauritius (incl UnDM) 30.2 14.8 44.3 1.3 Sri Lanka 31.3 5.9 15.2 WP Australia 24.5 6.2 21.9 2.1 42.0 0.0 29.1 4.2 China, Hong Kong 14.0 11.4 21.9 China, People’s Republic of 28.0 31.0 2.8 47.4 Fiji 52.6 Indonesia 17.0 Japan 34.5 38.3 56.0 35.9 10.3 Korea, Republic of 33.0 35.2 8.2 Malaysia 37.0 48.6 47.3 3.6 New Zealand 37.4 Phillipines 18.0 Samoa 15.4 43.2 4.5 Singapore, Republic of 12.0 21.8 0.6 Taiwan 25.1 35.0 2.2 Thailand 21.0 32.1 6.6 Vietnam 13.0

DM diabetes mellitus Total DM previously diagnosed diabetes (both type 1 and type 2) UnDM undiagnosed diabetes

102 103 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.49 Data sources: prevalence and incidence of lower limb amputations

Region Country Data used Study type Sample size Age sample No. of amputees Lowest level of amputation AFR South Africa Levitt et al, 199760 Clinic (primary care) 243 20-85 3 N/A EMME Saudi Arabia Nielsen, 199892 Clinic (secondary care) 375 N/A 5 N/A EUR Austria Mühlhauser et al, 199218 Clinic (primary care) 375 N/A 13 below ankle Belgium Van Acker et al, 200119 Clinic (secondary care) 1,653 21-69 69 toe Czech Republic Czech Health Statistics, 2002a, 66 Population based N/A N/A N/A Denmark Ebskov et al, 1996108 Register 25-97 2,848 ray Holstein et al, 2000109 Clinical records N/A 463 ankle Finland Siitonen et al, 1993110 Operating theatre records all 254 toe Germany Trautner et al, 2001111 Operating theatre records all 39 toe Netherlands Reenders et al, 199327 Clinic (primary care) 387 mean=68 5 N/A van Houtum et al, 1996112 Hospital discharge records all 1,575 toe Norway Witso et al, 2001113 Hospital records all 74 toe Poland Nazim, 2001b, 114 Hospital records and limb fitting centre N/A 139 toe Slovakia Slovakian Diabetes Societya, 32 Clinic (secondary care) N/A N/A N/A Spain Calle-Pascual et al, 19975 Operating theatre records, hospital discharge records, medical records all 48 toe Almaraz et al, 2000b, 115 Hospital records N/A 316 N/A Sweden Lundman et al, 199835 Clinic (primary and secondary care) 4,027 >18 73 toe Larsson et al, 1995116 Amputation register all 21 toe United Kingdom Abbott et al, 2002100 Clinic (primary and secondary care) 9,710 mean=62 122 toe Deerochanawong et al, 1992117 Operation records and hospital discharge records N/A 93 toe Morris et al, 1998118 Hospital discharge records and database of rehabilitation service 7,079 all 52 toe NA Canada Lawee et al, 1992119 Hospital discharge records all 926 toe Trinidad and Tobago Gulliford et al, 2002120 Clinic (secondary care) 2,106 all 84 toe USA Humphrey et al, 199412 Hospital discharge codes 2,015 N/A 57 toe SACA Brazil Spichler et al, 2001121 Register N/A N/A N/A SEA India Ramachandran et al, 199943 Clinic (secondary care) 3,010 mean=52 21 N/A Mauritius Shaw et al, 19988 Population based 847 mean=54 2 Sri Lanka Fernando, 1996105 Clinic (secondary care) 500 30-60 24 N/A WP China, People’s Republic of Chi et al, 200147 Clinic (secondary care) 447 35-54 3 toe Japan Kuzuya et al, 199449 Clinic (secondary care) 2,115 <24-75+ 13 N/A Nauru Humphrey et al, 1996122 Operating theatre records, welfare office and health survey data 375 25+ 46 toe Taiwan Wang et al, 2000107 Population based 219 35-85 3 N/A Thailand Tandhanand et al, 200156 Clinic (secondary care) 2,378 N/A N/A N/A Thai Multicenter Group, 199455 Clinic (secondary care) 2,060 24-88 27 toe a. Unpublished data b. Abstract only c. Extra details supplied by authors

N/A not available

104 105 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

Table 1.50 Prevalence and incidence of lower limb amputations

Prevalence Incidence per 100,000 Region Country (%) diabetic population AFR South Africa 1.4 EMME Saudi Arabia (below ankle only) 1.3 EUR Austria 3.5 Belgium 4.2 Czech Republic 0.9 Denmark 156a 430b Finland 480a Germany 463a Netherlands (type 2 DM) 1.5 251b (age adjusted) Norway 440a Poland 165b Slovakia 1.3 Spain 46.1a 136b Sweden 1.8 410a United Kingdom 1.3 570b 367a NA Canada 400b Trinidad and Tobago 4.0 USA 271a SACA Brazil 181b SEA India (type 2 DM) 0.7 Mauritius (incl UnDM) 0.2 Sri Lanka (type 2 DM) 4.8 WP China, People’s Republic of 0.7 Japan 0.6 Nauru 810a Taiwan (incl UnDM) 1.4 Thailand 1.0 1.3

a. First amputation b. All amputations or not stated

DM diabetes mellitus Total DM previously diagnosed diabetes (both type 1 and type 2) UnDM undiagnosed diabetes

106 107 Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Global Burden of Diabetes The Global Burden of Diabetes Chapter 1 Chapter 1

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Ethiop Med J 2001; 39:123-131. Zimmet P. Foot Complications in Type 2 Diabetes: An 125. Erasmus RT, Alanamu RA, Bojuwoye B, Oluboyo P, Arije A. Australian Population Based Study. Diabet Med 2003; Diabetic retinopathy in Nigerians: relation to duration of 20:105-113. diabetes, type of treatment and degree of control. East Afr 107. Wang CL, Wang M, Lin MC, Chien KL, Huang YC, Lee YT. Foot Med J 1989; 66:248-254. complications in people with diabetes: a community-based 126. Rolfe M. Diabetic eye disease in Central Africa. Diabetologia study in Taiwan. J Formos Med Assoc 2000; 99:5-10. 1988; 31:88-92. 108. Ebskov B, Ebskov L. Major lower limb amputation in 127. Bartels MC, Macheka BM, Guramantunhu S, Scheenloop JJ, diabetic patients: development during 1982 to 1993. Stilma JS. Background diabetic retinopathy in Harare, Diabetologia 1996; 39:1607-1610. Zimbabwe. Trop Doct 1999; 29:189-190. 109. Holstein P, Ellitsgaard N, Olsen BB, Ellitsgaard V. Decreasing 128. el Haddad OA, Saad MK. Prevalence and risk factors for incidence of major amputations in people with diabetes. diabetic retinopathy among Omani diabetics. Diabetologia 2000; 43:844-847. Br J Ophthalmol 1998; 82:901-906. 110. Siitonen OI, Niskanen LK, Laakso M, Siitonen JT, Pyorala K. 129. Falck AA, Kaar ML, Laatikainen LT. Prevalence and Lower-extremity amputations in diabetic and nondiabetic risk factors of retinopathy in children with diabetes. patients. A population-based study in eastern Finland. A population-based study on Finnish children. Acta Diabetes Care 1993; 16:16-20. Ophthalmol Scand 1993; 71:801-809. 111. Trautner C, Haastert B, Spraul M, Giani G, Berger M. 130. Hesse L, Grusser M, Hoffstadt K, Jorgens V, Hartmann P, Unchanged incidence of lower-limb amputations in a Kroll P. [Population-based study of diabetic retinopathy in German City, 1990-1998. Diabetes Care 2001; 24:855-859. Wolfsburg]. Ophthalmologe 2001; 98:1065-1068. 112. van Houtum WH, Lavery LA, Harkless LB. The impact 131. Segato T, Midena E, Grigoletto F, Zucchetto M, Fedele D, of diabetes-related lower-extremity amputations in The Piermarocchi S, Crepaldi G. The epidemiology and Netherlands. J Diabetes Complications 1996; 10:325-330. prevalence of diabetic retinopathy in the Veneto region of 113. Witso E, Ronningen H. Lower limb amputations: registration north east Italy. Veneto Group for Diabetic Retinopathy. of all lower limb amputations performed at the University Diabet Med 1991; 8:S11-16. Hospital of Trondheim, Norway, 1994-1997. Prosthet Orthot 132. Garancini P, Micossi P, Valsania P, Radaelli G, Bandello F, Int 2001; 25:181-185. Scialdone A, Menchini U, Brancato R, Pozza G, Gallus G. 114. Nazim A. [Incidence of lower extremity amputations in Prevalence of retinopathy in diabetic subjects from out- diabetics]. Pol Arch Med Wewn 2001; 106:829-838. patient clinics in Lombardy (Italy), and associated risk 115. Almaraz MC, Soriguer F, Zamorano D, Ruiz de Adana S, factors. A multicentre epidemiologic study. Diabetes Res Gonzalez E, Esteva I, Garcia J, Lopez MJ. [Incidence of Clin Pract 1989; 6:129-138. amputaciones of the lower extremities in the population 133. Hapnes R, Bergrem H. Diabetic eye complications in a with diabetes mellitus in Malaga (1996-1997)]. Aten medium sized municipality in southwest Norway. Acta Primaria 2000; 26:677-680. Ophthalmol Scand 1996; 74:497-500. 116. Larsson J, Apelqvist J, Agardh CD, Stenstrom A. Decreasing 134. Luzniak P, Czech A, Taton J. [Prospective studies of diabetic incidence of major amputation in diabetic patients: retinopathy in a cohort of patients with type II diabetes a consequence of a multidisciplinary foot care team mellitus]. Polski Merkuriusz Lekarski 1997; 2:14-17. approach? Diabet Med 1995; 12:770-776. 135. Pinto-Figueiredo L, Moita J, Genro V, Vinagre M, Laires R, 117. Deerochanawong C, Home PD, Alberti KG. A survey of lower Rosa MJ, Cardoso C, Carreiras F. Diabetic retinopathy in a limb amputation in diabetic patients. Diabet Med 1992; population of 1,302 insulin dependent diabetics (IDDM) 9:942-946. diagnosed before 30 years of age. Int Ophthalmol 1992; 118. Morris AD, McAlpine R, Steinke D, Boyle DI, Ebrahim AR, 16:429-437. Vasudev N, Stewart CP, Jung RT, Leese GP, MacDonald TM, 136. Betts PR, Logatchov M, Volkov I, Murphy H, Newton RW. Diabetes and lower-limb amputations in the Dombrowskaya N, Borzikh S, Ivanova I, Twyman S, Vartan J. community. A retrospective cohort study. DARTS/MEMO An assessment of paediatric diabetes care in three centres Collaboration. Diabetes Audit and Research in Tayside in Russia and in Southampton, UK. The Paediatric Teams in Scotland/Medicines Monitoring Unit. Diabetes Care 1998; Moscow, Tula, Tambov, Southampton. Diabet Med 1999; 21:738-743. 16:772-778. 119. Lawee D, Csima A. Diabetes-related lower extremity 137. Fernandez-Vigo J, Sanchez Macho J, Diaz Rey A, Barros J, amputations in Ontario: 1987-88 experience. Can J Public Tome M, Bueno J. The prevalence of diabetic retinopathy Health 1992; 83:298-302. in northwest Spain. An epidemiological study of diabetic 120. Gulliford MC, Mahabir D. Diabetic foot disease and foot care retinopathy in Galicia. I. Acta Ophthalmol Scand 1993; in a Caribbean community. Diabetes Res Clin Pract 2002; 71:22-26. 56:35-40. 138. Kernell A, Dedorsson I, Johansson B, Wickstrom CP, 121. Spichler ER, Spichler D, Lessa I, Costa e Forti A, Franco LJ, Ludvigsson J, Tuvemo T, Neiderud J, Sjostrom K, LaPorte RE. Capture-recapture method to estimate lower Malmgren K, Kanulf P, Mellvig L, Gjotterberg M, Sule J, extremity amputation rates in Rio de Janeiro, Brazil. Rev Persson LA, Larsson LI, Aman J, Dahlquist G. Prevalence of Panam Salud Publica 2001; 10:334-340. diabetic retinopathy in children and adolescents with IDDM.

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A population-based multicentre study. Diabetologia 1997; in Fiji: comparison with data from an Australian diabetes 40:307-310. centre. Aust N Z J Ophthalmol 1999; 27:9-13. 139. Henricsson M, Nilsson A, Groop L, Heijl A, Janzon L. 157. Florkowski CM, Scott RS, Coope PA, Graham PJ, Moir CL. Prevalence of diabetic retinopathy in relation to age at Age at diagnosis, glycaemic control and the development of onset of the diabetes, treatment, duration and glycemic retinopathy in a population-based cohort of Type 1 diabetic control. Acta Ophthalmol Scand 1996; 74:523-527. subjects in Canterbury, New Zealand. Diabetes Res Clin 140. Larsson LI, Alm A, Bergenheim T, Lithner F, Bergstrom R. Pract 2001; 52:125-131. Retinopathy in diabetic patients aged 15-50 years in the 158. Lau HC, Voo YO, Yeo KT, Ling SL, Jap A. Mass screening for county of Umea, Sweden. Acta Ophthalmol Scand 1999; diabetic retinopathy – a report on diabetic retinal screening 77:430-436. in primary care clinics in Singapore. Singapore Med J 1995; 141. Falkenberg M, Finnstrom K. Associations with retinopathy 36:510-513. in type 2 diabetes: a population-based study in a Swedish 159. Chen MS, Kao CS, Chang CJ, Wu TJ, Fu CC, Chen CJ, Tai TY. rural area. Diabet Med 1994; 11:843-849. Prevalence and risk factors of diabetic retinopathy among 142. Sparrow JM, McLeod BK, Smith TD, Birch MK, Rosenthal AR. non insulin-dependent diabetic subjects. Am J Ophthalmol The prevalence of diabetic retinopathy and maculopathy 1992; 114:723-730. and their risk factors in the non-insulin-treated diabetic patients of an English town. Eye 1993; 7:158-163. 143. Broadbent DM, Scott JA, Vora JP, Harding SP. Prevalence of diabetic eye disease in an inner city population: the Liverpool Diabetic Eye Study. Eye 1999; 13:160-165. 144. Leske MC, Wu SY, Hyman L, Li X, Hennis A, Connell AM, Schachat AP. Diabetic retinopathy in a black population: the Barbados Eye Study. Ophthalmology 1999; 106:1893-1899. 145. Gonzalez Villalpando ME, Gonzalez Villalpando C, Arredondo Perez B, Stern MP. Diabetic retinopathy in Mexico. Prevalence and clinical characteristics. Arch Med Res 1994; 25:355-360. 146. Klein R, Klein BE, Moss SE, Linton KL. The Beaver Dam Eye Study. Retinopathy in adults with newly discovered and previously diagnosed diabetes mellitus. Ophthalmology 1992; 99:58-62. 147. Harris MI, Klein R, Cowie CC, Rowland M, Byrd-Holt DD. Is the risk of diabetic retinopathy greater in non-Hispanic blacks and Mexican Americans than in non-Hispanic whites with type 2 diabetes? A U.S. population study. Diabetes Care 1998; 21:1230-1235. 148. Rema M, Ponnaiya M, Mohan V. Prevalence of retinopathy in non insulin dependent diabetes mellitus at a diabetes centre in southern India. Diabetes Res Clin Pract 1996; 34:29-36. 149. Dandona L, Dandona R, Naduvilath TJ, McCarty CA, Rao GN. Population based assessment of diabetic retinopathy in an urban population in southern India. Br J Ophthalmol 1999; 83:937-940. 150. Fernando DJ, Siribaddana S, De S, Subasinge Z. Prevalence of retinopathy in a Sri Lankan diabetes clinic. Ceylon Med J 1993; 38:120-123. 151. Tapp R, Shaw J, Harper C, deCourten M, Balkau B, McCarty D, Taylor H, Welborn T, Zimmet P. The prevalence of and factors associated with diabetic retinopathy in the Australian population. Diabetes Care 2003; 26:1731-1737. 152. Fairchild JM, Hing SJ, Donaghue KC, Bonney MA, Fung AT, Stephens MM, Mitchell P, Howard NJ, Silink M. Prevalence and risk factors for retinopathy in adolescents with type 1 diabetes. Med J Aust 1994; 160:757-762. 153. McKay R, McCarty CA, Taylor HR. Diabetic retinopathy in Victoria, Australia: the Visual Impairment Project. Br J Ophthalmol 2000; 84:865-870. 154. Wang WQ, Ip TP, Lam KS. Changing prevalence of retinopathy in newly diagnosed non-insulin dependent diabetes mellitus patients in Hong Kong. Diabetes Res Clin Pract 1998; 39:185-191. 155. Hu YH, Pan XR, Liu PA, Li GW, Howard BV, Bennett PH. Coronary heart disease and diabetic retinopathy in newly diagnosed diabetes in Da Qing, China: the Da Qing IGT and Diabetes Study. Acta Diabetologica 1991; 28(2):169-173. 156. Brooks B, Chong R, Ho I, Capstick F, Molyneaux L, Oo TT, Tester M, Yue D. Diabetic retinopathy and nephropathy

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Diabetes in the Young: a Global Perspective Chapter 2

Diabetes in the Young: Chapter 2 a Global Perspective

iabetes is increasing in children and Dadolescents in many countries. The increase in incidence in type 1 diabetes has been shown in countries having both high and low prevalence with an indication of a steeper increase in some of the low prevalence countries. Although type 1 diabetes usually accounts for only a minority of the total burden of diabetes in a population it is the predominant form of the disease in younger age groups in most developed countries.

At the same time, there is a growing awareness that type 2 diabetes in the young is an emerging problem with potentially serious outcomes. Yet our 2.1 Global Trends in Childhood understanding of the worldwide burden Type 1 Diabetes of this disease is somewhat fractured, 2.2 Type 2 Diabetes in the Young with many studies reporting on specific communities or ethnic groups.

The purpose of this chapter is to look at the global trends in childhood type 1 diabetes and to bring together for the first time, the available epidemiological data on type 2 diabetes incidence and prevalence in the young from around the world. By the inclusion of such data it is hoped to highlight deficiencies in the knowledge of the disease and also to promote strategies to deal with it.

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2.1 Global Trends in Childhood Type 1 Diabetes

Type 1 diabetes in an adult may At a glance masquerade as type 2 diabetes at presentation with a slow deterioration Type 1 diabetes (0-14 years) 2003 in metabolic control, and subsequent progression to insulin dependency. Total child population (billion) 1.8 This form is called latent autoimmune Type 1 diabetes prevalence (%) 0.02 diabetes mellitus in adults (LADA) (9), and Number of children with type 1 diabetes 430,000 in the new WHO classification, LADA falls Annual increase of incidence (%) 3 within type 1 autoimmune diabetes but in Estimated number of newly-diagnosed cases per year 65,000 a slowly progressive form.

The predominant cause of hyperglycaemia in type 1 diabetes is an autoimmune destruction of the beta cells leading to absolute dependence on insulin treatment and a high rate Introduction of complications typically occurring at relatively young ages. Therefore type The incidence of childhood onset 1 diabetes places a particularly heavy diabetes is increasing in many countries burden on the individual, the family and in the world with an estimated overall the health services. annual increase of around 3% (1-3). There is some indication that incidence The continued mapping of global is increasing more steeply in some of trends in incidence of type 1 diabetes the low prevalence countries. Moreover, in all age groups is thus important, several European studies have suggested and in conjunction with other scientific that, in relative terms, increases are research may provide a logical basis for greatest in young children (4-6). intervention studies and future primary prevention strategies which must be the Analyses of cumulative incidence rates ultimate goal. into the fourth decade of life (7,8) suggest that incidence is not increasing Methods among young adults indicating rather a shift to a younger age at onset. The Systematic searches of bibliographic causes of these changes with time are databases were performed as explained unknown but the rapidity of the changes in Appendix 1.3 to identify studies that and the almost universally increasing provided incidence or prevalence rates of trends in younger age groups are unlikely type 1 diabetes in children. Criteria were to be due to changes in the genetic then applied to select the most suitable background of the disease. Historically, study in a given country or, if necessary, studies have tended to record incidence results from a number of studies were data only up to the age of 15 years pooled. although recently studies reporting results up to the age of 30 or 35 years For countries that had no incidence or have become more common. However, prevalence rates available the choice the distinction between type 1 and type 2 of country to use for extrapolation was diabetes becomes more difficult in these based on proximity, the state of economic older age groups since people with type 2 development measured by the gross diabetes may receive insulin therapy. domestic product (GDP) per capita and

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the ethnic composition as assessed from Figure 2.1 the Central Intelligence Agency (CIA) Estimated number of prevalent cases of type 1 diabetes World Factbook 2002 (10). The choice in children by region was also influenced by the quality rating of the studies in the various countries. ��

The majority of studies found by the �� literature search provided incidence rates rather than prevalence rates, and �� the method used to translate incidence � �

rates to prevalence rates is described in � � �

Appendix 1.3. � ��

The quality of estimates was assessed �� using the following simple rating system: A Studies from the country in question that were based on registers that �� were population based 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 (so excluding case-series studies which provided no population denominator). It is estimated that on an annual basis X Extrapolation using rates from a some 65,000 children aged under 15 different country, the identity of the years develop type 1 diabetes worldwide. chosen country being indicated. Of the estimated total of approximately 430,000 prevalent cases of type 1 Results diabetes in childhood, more than a quarter come from the South-East Asian The Tables contain information on (SEA) Region, and more than a fifth from population size in the 0-14 age group the European (EUR) Region where reliable, together with estimated numbers of up-to-date estimates of incidence were prevalent cases in 2003, organized by available for the majority of countries, region. In those countries for which rates as shown in Figure 2.1. The smallest were found in the literature search the contribution (approximately 5%) comes following information is given: from the Western Pacific (WP) Region, • geographical coverage; despite it having the largest childhood • calendar period; population. • number of cases; • estimated completeness of Africa ascertainment; and The need for extrapolation of rates • a classification of the source as either of childhood type 1 diabetes was A or B using the criteria described particularly evident in the sub-Saharan under ‘Methods’. Countries for African (AFR) Region. Published rates which no rates were found in the were found for only three of the countries literature search were assigned the in this region, and some of the studies classification X (extrapolated from a were of poor quality and based on source in another country) and the small numbers. Consequently imperfect country whose rate was used in the estimates of rates from Nigeria, Zambia extrapolation is identified. and Tanzania have had to be used for

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widespread extrapolations because of the with small populations, and therefore any dearth of published studies. error associated with the extrapolation will have little impact on the estimate of Mortality among children with diabetes the region’s total. The countries making is likely to be high in parts of this the largest contribution to the total rates region, but as numbers of cases in for childhood type 1 diabetes were United these countries were mainly derived Kingdom, Germany and Russia reflecting directly from prevalence rates rather to some degree the large childhood than indirectly from incidence rates the populations in these countries. It is worth effects of mortality are incorporated noting that the estimates for Russia were in the estimates in Table 2.2. Tropical based on a study from Novosibirsk which and malnutrition diabetes may account may not be representative of such a large for a proportion of cases in this region, country. but reliable data are lacking. For these reasons the validity of the estimates North America of numbers of children with type 1 Although no published rates were diabetes in many parts of this region available for childhood type 1 diabetes are questionable and must therefore be in many of the smaller Caribbean islands treated with considerable caution. in the North American (NA) Region, it was usually possible to extrapolate Eastern Mediterranean and rates from an island in close proximity, Middle East although such rates were often based on In contrast to the situation in sub- very small numbers of cases. The USA Saharan Africa, reliable data are available estimate, which accounts for more than for childhood type 1 diabetes rates three-quarters of the region’s total, and to in a number of the African countries a lesser extent the estimate for Canada bordering the Mediterranean Sea. In the predominate. Eastern Mediterranean and Middle East (EMME) Region as a whole about half of South and Central America the countries have published incidence Although the incidence of childhood rates. By far the largest contribution to type 1 diabetes in the South and Central the total number of estimated childhood American (SACA) Region is generally low, type 1 cases for this region comes from there are some sharp contrasts between Egypt whose estimate accounts for the rates in neighbouring countries. about a quarter of the region’s total. In This means that occasionally the choice Egypt the incidence of type I diabetes is of country to use for extrapolation can reported as 8 per 100,000 population make a considerable difference to the per year below the age of 15 years, resulting estimate (eg Bolivia, Ecuador). while in Pakistan it is only 1 per 100,000 Such estimates must therefore be population. interpreted with caution. The Brazilian estimate accounts for more than half of Europe the region’s total. Compared with other regions, the European Region has by far the most South-East Asia complete and reliable data on the rates Only two countries in the South-East of childhood type 1 diabetes with a large Asian Region have published rates proportion of countries having registries for type 1 diabetes in childhood and that are either nationwide or cover therefore extrapolation of rates was several different parts of the country. necessary. The rate from China, although outside the region, was used for some Where extrapolation for the incidence rate extrapolations, but the rate for India was was necessary it was usually for countries more frequently used and it therefore

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plays a pivotal role in the estimates for extrapolated far into the Pacific Ocean, this region. although any error induced in the region’s total by this extrapolation is likely to be Two sources of rates for India were small because of the generally low rates available, both from urban Madras and and small populations involved. therefore probably not representative of the country as a whole. The first was The rate for Thailand was used a small prevalence study (11) giving an extensively for extrapolation in the equivalent incidence rate which was Indo-China peninsula. Despite its very less than half that of the second, larger low incidence, China accounts for almost study (12), the rate from the latter study half of the region’s total. However, having needed correction for under- the Western Pacific Region makes the ascertainment. Given that even the lower smallest contribution of all to the world of these two rates far exceeds the rates total of type 1 diabetes even though it reported from other countries in the area has the largest childhood population. and that the incidence in urban Madras is likely to be higher than that for India as a Comments whole, the decision was made to use the lower of these two rates even though it The global distribution of childhood type was based on the smaller study. 1 diabetes clearly indicates large area to area variations. This variability may partly The large childhood population in be due to different distributions of risk India and the widespread use of the genes for the disease as well as different Indian data for extrapolation in this distributions of environmental exposures, region means that this decision has but part of the apparent variability both important consequences not only for between countries and regions may also the total in the region but also for the be due to methodological problems: worldwide estimate, both of which would be considerably larger had the • The available incidence data higher estimate of incidence been sometimes covers only one small part used. Notwithstanding the use of the of a large country. For example, in lower rate, the South-East Asian Region India incidence data were extrapolated contributes more than any other to the from studies performed in Madras and worldwide childhood type 1 diabetes data from Russia were extrapolated total. from a small dataset from Novosibirsk. Obviously there may be considerable Diabetes-associated mortality and tropical variability within such large countries or malnutrition diabetes are also likely in both the distribution of risk genes to play important roles in this region, and environmental exposures such but unfortunately there is inadequate as climate and lifestyle related information to address these issues. factors (13). These points reinforce the need for much more detailed data on childhood diabetes • The need for extrapolation was in this region. particularly evident in the African continent, especially in sub-Saharan Western Pacific Africa. Here rates from undesirably With the exception of Australia and New small datasets have had to be used in Zealand, the rates of childhood type 1 extrapolations because of the lack of diabetes in the Western Pacific Region published studies. appear uniformly low. Few of the Pacific islands had published data and the • Another problem was the need to rate for Papua New Guinea had to be make extrapolations involving isolated

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island populations such as in Polynesia allow for mortality was not justified. where both genetic predisposition and In sub-Saharan Africa, where mortality lifestyle habits may be very different. among children with diabetes are reported to be high (14, 15), numbers • For some extrapolations, eg in parts of cases were mainly derived from of South America, a choice had to Nigerian and Zambian prevalence rates be made between countries whose rather than indirectly from incidence reported incidence rates were very rates so that adjustment for mortality different, possibly on occasions was not necessary. In such countries because they were based on small the relationship between incidence datasets. rate and prevalence rate is difficult to predict, and consequently incidence • Another methodological problem is rates are not given for sub-Saharan the lack of data on mortality rates Africa except for Tanzania (Table 2.2). among children with diabetes in most populations. In less developed In addition to the geographical variation countries, in which mortality could in the incidence of childhood type 1 have a significant impact, the diabetes there are also well-documented disease rates were often based secular trends over time, which may on small numbers of cases or on also differ from country to country and extrapolation so that the application from region to region within a country. of an adjustment to incidence data to Such time trends have not explicitly been

Map 2.1 Published incidence rates of type 1 diabetes in children (0-14 age range) (cases per 100,000 population per year)

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incorporated in these estimates since of fat cells both leading to insulin reliable data are available for only a very resistance and thereby an overloading small number of countries, but these of the beta cell. Although autoimmune trends are of considerable importance for mechanisms are responsible for the healthcare planning. beta cell destruction leading to type 1 diabetes, overload factors may accelerate The causes of such changes over time this process (29-31). Overload through are unknown and although migration accelerated child growth and body might slowly change the genetic fat accumulation in association with a background within a population, the lifestyle with a low physical activity are rapid changes in incidence rate reported potentially preventable risk factors. to occur within comparatively short time spans are more likely to be due to changes in environmental risk factors. These environmental risk factors may initiate autoimmunity or accelerate and precipitate an already ongoing beta cell destruction (13).

Potential risk factors which may initiate the autoimmune process include early fetal events eg blood group incompatibility (16), maternal viral infections during pregnancy (17,18), early exposure to cow’s milk components and other nutritional factors such as nitrosamines (19). Population-based case-control studies have identified some protective factors, including a long duration of breast feeding (19), early vitamin D supplementation (20), pre-school day care (as a proxy measure of infections) (21) and atopic diseases (22).

Since type 1 diabetes in childhood is associated with estimates of general wealth such as GDP (23) 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.

Different estimates of child growth such as high birth weight, an increased height, weight, weight for height and body mass index (BMI) have repeatedly been shown to be risk factors for childhood onset diabetes (24-28). Rapid growth is associated with high growth hormone levels and an increased number

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Table 2.1 Data sources: estimates of type 1 diabetes in children – African Region

Country Data used Period Geography No. of cases Completeness Classification Angola Zambia (Rolfe et al, 1989)a, 32 X Benin Nigeria (Afoke et al, 1992)b, 33 X Botswana Zambia (Rolfe et al, 1989)a, 32 X Burkina Faso Nigeria (Afoke et al, 1992)b, 33 X Burundi Tanzania (Swai et al, 1993)34 X Cameroon Nigeria (Afoke et al, 1992)b, 33 X Cape Verde Nigeria (Afoke et al, 1992)b, 33 X Central African Republic Nigeria (Afoke et al, 1992)b, 33 X Chad Nigeria (Afoke et al, 1992)b, 33 X Comoros Tanzania (Swai et al, 1993)34 X Congo, Democratic Republic of Zambia (Rolfe et al, 1989)a, 32 X Congo, Republic of Zambia (Rolfe et al, 1989)a, 32 X Côte d’Ivoire Nigeria (Afoke et al, 1992)b, 33 X Djibouti Sudan (Elamin et al, 1992)35 X Equatorial Guinea Nigeria (Afoke et al, 1992)b, 33 X Eritrea Tanzania (Swai et al, 1993)34 X Ethiopia Tanzania (Swai et al, 1993)34 X Gabon Nigeria (Afoke et al, 1992)b, 33 X Gambia Nigeria (Afoke et al, 1992)b, 33 X Ghana Nigeria (Afoke et al, 1992)b, 33 X Guinea Nigeria (Afoke et al, 1992)b, 33 X Guinea-Bissau Nigeria (Afoke et al, 1992)b, 33 X Kenya Tanzania (Swai et al, 1993)34 X Lesotho Zambia (Rolfe et al, 1989)a, 32 X Liberia Nigeria (Afoke et al, 1992)b, 33 X Madagascar Mauritius (Karvonen et al, 2000)36 X Malawi Zambia (Rolfe et al, 1989)a, 32 X Mali Nigeria (Afoke et al, 1992)b, 33 X Mauritania Nigeria (Afoke et al, 1992)b, 33 X Mozambique Tanzania (Swai et al, 1993)34 X Namibia Zambia (Rolfe et al, 1989)a, 32 X Niger Nigeria (Afoke et al, 1992)b, 33 X Nigeria Nigeria (Afoke et al, 1992)b, 33 1990 Anambra 14 N/A B Reunion Mauritius (Karvonen et al, 2000)36 X Rwanda Tanzania (Swai et al, 1993)34 X Sao Tome and Principe Nigeria (Afoke et al, 1992)b, 33 X Senegal Nigeria (Afoke et al, 1992)b, 33 X Seychelles Mauritius (Karvonen et al, 2000)36 X Sierra Leone Nigeria (Afoke et al, 1992)b, 33 X Somalia Tanzania (Swai et al, 1993)34 X South Africa Zambia (Rolfe et al, 1989)a, 32 X Swaziland Zambia (Rolfe et al, 1989)a, 32 X Tanzania Tanzania (Swai et al, 1993)34 1982-91 Dar es Salaam 36 100% A Togo Nigeria (Afoke et al, 1992)b, 33 X Uganda Tanzania (Swai et al, 1993)34 X Western Sahara Algeria (Karvonen et al, 2000)36 X Zambia Zambia (Rolfe et al, 1989)a, 32 pre-1989 Copperbelt 37 90% B Zimbabwe Zambia (Rolfe et al, 1989)a, 32 X a. Gives prevalence for <20 years b. Gives prevalence for 5-17 years

N/A not available

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Table 2.2 Estimates of type 1 diabetes in children – African Region

Incidence rates Population size (cases per 100,000 Estimated no. (000’s) population per year)b of prevalent cases Country 0-14 yrsa 0-14 yrs (000’s) Angola 6,951 0.3 Benin 3,095 0.6 Botswana 648 0.0 Burkina Faso 6,102 1.1 Burundi 3,162 0.2 Cameroon 6,703 1.2 Cape Verde 174 0.0 Central African Republic 1,677 0.3 Chad 4,043 0.7 Comoros 327 0.0 Congo, Democratic Republic of 27,527 1.4 Congo, Republic of 1,540 0.1 Côte d’Ivoire 6,939 1.2 Djibouti 284 0.1 Equatorial Guinea 218 0.0 Eritrea 1,813 0.1 Ethiopia 30,596 1.7 Gabon 541 0.1 Gambia 560 0.1 Ghana 8,184 1.5 Guinea 3,704 0.7 Guinea-Bissau 564 0.1 Kenya 13,615 0.8 Lesotho 814 0.0 Liberia 1,510 0.3 Madagascar 7,745 0.7 Malawi 5,559 0.3 Mali 5,725 1.0 Mauritania 1,289 0.2 Mozambique 8,493 0.5 Namibia 800 0.0 Niger 6,046 1.1 Nigeria 54,789 9.9 Reunion 204 0.0 Rwanda 3,607 0.2 Sao Tome and Principec 81 0.0 Senegal 4,431 0.8 Seychellesc 22 0.0 Sierra Leone 2,263 0.4 Somalia 4,815 0.3 South Africad 14,818 4.9 Swaziland 393 0.0 Tanzania 16,670 0.9 0.5 Togo 2,144 0.4 Uganda 12,679 0.7 Western Sahara 101 0.0 Zambia 5,168 0.3 Zimbabwe 5,905 0.3

AFR Total 295,037 § 35.1

a. UN population projections – medium variant 2003 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 200210 d. Adjusted to take account of the higher rates in those of European origin

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Table 2.3 Data sources: estimates of type 1 diabetes in children – Eastern Mediterranean and Middle East Region

Country Data used Period Geography No. of cases Completeness Classification Afghanistan Uzbekistan (Rakhimova et al, 2002)37 X Algeria Algeria (Karvonen et al, 2000)36 1990 Oran 23 N/A B Armenia Ukraine (Timchenko et al, 1996)38 X Bahrain Oman (Soliman et al, 1996)39 X Egypt Egypt (Arab et al, 1992)40 pre-1992 Alexandria, N/A N/A B Damahour Iran Pakistan (Staines et al, 1997)41 X Iraq Jordan (Ajlouni et al, 1999)42 X Jordan Jordan (Ajlouni et al, 1999)42 1992-96 Whole country 275 96% A Kuwait Kuwait (Shaltout et al, 2002)43 1992-97 Whole country 364 90-96% A Lebanon Jordan (Ajlouni et al, 1999)42 X Libya Libya (Kadiki, 1998)44 1991-95 Benghazi 126 100% A Morocco Algeria (Karvonen et al, 2000)36 X Occupied Palestinian Jordan (Ajlouni et al, 1999)42 X Territories Oman Oman (Soliman et al, 1996)39 1993-94 Whole country 31 96% A Pakistan Pakistan (Staines et al, 1997)41 1989-93 Karachi 240 N/A B Qatar Qatar (Al-Zyoud et al, 1997)a, 45 1992-96 Whole country 80 N/A B Saudi Arabia Saudi Arabia (Kulaylat et al, 2000)46 1986-97 Eastern Province 46 100% A Sudan Sudan (Elamin et al, 1992)35 1987-90 Khartoum 311 95% A Syria Jordan (Ajlouni et al, 1999)42 X Tunisia Tunisia (Karvonen et al, 2000)36 1990-94 Beja, Gafsa, 168 N/A B Kairoan, Monastir United Arab Emirates Oman (Soliman et al, 1996)39 X Yemen Oman (Soliman et al, 1996)39 X a. Only to 12 years

N/A not available

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Table 2.4 Estimates of type 1 diabetes in children – Eastern Mediterranean and Middle East Region

Incidence rates Population size (cases per 100,000 Estimated no. (000’s) population per year) of prevalent cases Country 0-14 yrsa 0-14 yrs (000’s) Afghanistan 10,501 1.2 0.8 Algeria 10,530 5.7 3.9 Armenia 768 8.1 0.4 Bahrain 178 2.5 0.0 Egypt 23,775 8.0 11.8 Iran 24,940 1.0 1.5 Iraq 10,085 3.2 2.0 Jordan 2,117 3.2 0.3 Kuwait 540 20.9 0.8 Lebanon 1,078 3.2 0.2 Libya 1,842 9.3 0.7 Morocco 10,515 5.7 3.7 Occupied Palestinian Territories 1,634 3.2 0.3 Oman 1,198 2.5 0.2 Pakistan 62,839 1.0 3.4 Qatar 154 11.4 0.1 Saudi Arabia 9,338 12.3 5.7 Sudan 13,182 8.0 6.5 Syria 6,704 3.2 1.3 Tunisia 2,693 6.6 1.1 United Arab Emirates 653 2.5 0.1 Yemen 10,557 2.5 1.6

EMME Total 205,822 § 46.6

a. UN population projections – medium variant 2003

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Table 2.5 Data sources: estimates of type 1 diabetes in children – European Region

Country Data used Period Geography No. of cases Completeness Classification Albania Macedonia (Green et al, 2001)3 X Andorra Spain (Green et al, 2001)3 X Austria Austria (Green et al, 2001)3 1989-98 Whole country 1,314 98% A Azerbaijan Republic Uzbekistan (Rakhimova et al, 2002)37 X Belarus Belarus (Martinucci et al, 2002)47 1986-99 Gomel approx 280 100% A Belgium Belgium (Green et al, 2001)3 1989-98 Antwerp 191 96% A Bosnia and Herzegovina Bosnia and Herzegovina (Bratina et al, 1990-98 Tuzla 43 100% A 2001)48 Bulgaria Bulgaria (Green et al, 2001)3 1989-98 Whole country 885 100% A Croatia Croatia (Green et al, 2001)3 1989-98 Zagreb A Cyprus Cyprus (Skordis et al, 1997)49 1990-94 Greek population 81 N/A B Czech Republic Czech Republic (Green et al, 2001)3 1989-98 Whole country A Denmark Denmark (Svensson et al, 2002)50 1996-2000 Whole country 839 99% A Estonia Estonia (Green et al, 2001)3 1989-98 Whole country 365 100% A Finland Finland (Tuomilehto et al, 1999)51 1987-96 Whole country 3,613 100% A France France (EURODIAB ACE, 2000)2 1989-94 Four regions 837 99% A Georgia, Republic of Ukraine (Timchenko et al, 1996)38 X Germany Germany (Green et al, 2001)3 1989-98 Dusseldorf, Baden 2,535 90-97% A Wurttemberg Greece Greece (Green et al, 2001)3 1989-98 Attica, five northern 623 100% A regions Hungary Hungary (Green et al, 2001)3 1989-98 Eighteen counties 1,385 100% A Iceland Iceland (Green et al, 2001)3 1989-98 Whole country 89 100% A Ireland, Republic of Ireland (Roche et al, 2002)52 1997 Whole country 140 91% A Israel Israel (EURODIAB ACE, 2000)2 1989-94 Whole country 433 100% A Italy Italy (Green et al, 2001)3 1989-98 Lazio, eastern Sicily 255 86-99% A/B Kazakhstan Uzbekistan (Rakhimova et al, 2002)37 X Kyrgyzstan Uzbekistan (Rakhimova et al, 2002)37 X Latvia Latvia (Green et al, 2001)3 1989-98 Whole country 386 100% A Lithuania Lithuania (Green et al, 2001)3 1989-98 Whole country 638 100% A Luxembourg Luxembourg (Green et al, 2001)3 1989-98 Whole country 84 100% A Macedonia Macedonia (Green et al, 2001)3 1989-98 Whole country 175 98% A Malta Malta (Schranz, 1998)53 1990-96 Whole country 90 N/A B Moldova, Republic of Romania (Green et al, 2001)3 X Monaco France (EURODIAB ACE, 2000)2 X Netherlands Netherlands (EURODIAB ACE, 2000)2 1989-94 Five regions 421 96% A Norway Norway (Joner et al, 2000)54 1989-98 Whole country 1,866 100% A Poland Poland (Green et al, 2001)3 1989-98 Gliwice, three cities 1,175 100% A Portugal Portugal (Green et al, 2001)3 1989-98 Algarve, Madeira 136 85-100% A/B Romania Romania (Green et al, 2001)3 1989-98 Bucharest 227 100% A Russian Federation Russia (Shubnikov et al, 1999)55 1992-97 Novosibirsk N/A N/A B San Marino Italy (Green et al, 2001)3 X Serbia and Montenegro Serbia and Montenegro (Vlajinac et al, 1982-92 Belgrade 259 90% A 1995)56 Slovakia Slovakia (Green et al, 2001)3 1989-98 Whole country 1,156 100% A Slovenia Slovenia (Green et al, 2001)3 1989-98 Whole country 327 100% A Spain Spain (Green et al, 2001)3 1989-98 Catalonia 1,336 94% A Sweden Sweden (Pundziute-Lycka et al, 2002)7 1995-98 Whole country approx 1,800 96-99% A Switzerland Switzerland (EURODIAB ACE, 2000)2 1991-94 Whole country 353 N/A B Tajikistan Uzbekistan (Rakhimova et al, 2002)37 X Turkey Jordan (Ajlouni et al, 1999)42 X Turkmenistan Uzbekistan (Rakhimova et al, 2002)37 X Ukraine Ukraine (Timchenko et al, 1996)38 1985-92 Whole country N/A N/A B United Kingdom United Kingdom (Green et al, 2001)3 1989-98 Leeds, Oxford, Northern 3,419 95-100% A Ireland, Leicester Uzbekistan Uzbekistan (Rakhimova et al, 2002)37 2000 Whole country N/A N/A B

N/A not available

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

Incidence rates Population size (cases per 100,000 Estimated no. (000’s) population per year) of prevalent cases Country 0-14 yrsa 0-14 yrs (000’s) Albania 905 3.6 0.2 Andorrab 10 12.8 0.0 Austria 1,275 9.5 0.8 Azerbaijan Republic 2,112 1.2 0.2 Belarus 1,668 5.7 0.6 Belgium 1,713 11.8 1.3 Bosnia and Herzegovina 706 3.5 0.1 Bulgaria 1,108 8.8 0.7 Croatia 815 6.6 0.3 Cyprus 175 10.5 0.1 Czech Republic 1,567 9.8 1.0 Denmark 982 19.4 1.2 Estonia 210 11.4 0.2 Finland 899 37.4 2.5 France 10,970 8.3 5.6 Georgia, Republic of 963 8.1 0.5 Germany 12,028 12.2 10.1 Greece 1,537 9.1 0.9 Hungary 1,581 9.6 1.1 Iceland 64 13.9 0.1 Ireland, Republic of 817 16.3 0.9 Israel 1,783 5.9 0.6 Italy 8,033 9.5 5.6 Kazakhstan 3,968 1.2 0.3 Kyrgyzstan 1,603 1.2 0.1 Latvia 359 7.1 0.2 Lithuania 641 7.8 0.3 Luxembourg 84 11.9 0.1 Macedonia 434 3.6 0.1 Malta 75 15.6 0.1 Moldova, Republic of 879 5.0 0.3 Monacob 5 8.3 0.0 Netherlands 2,864 13 2.5 Norway 876 22.5 1.3 Poland 6,662 6.7 3.0 Portugal 1,674 11.5 1.3 Romania 3,694 5.0 1.2 Russian Federation 22,389 7.2 12.4 San Marinob 4 9.5 0.0 Serbia and Montenegro 1,976 8.1 1.0 Slovakia 970 9.2 0.6 Slovenia 288 8.5 0.2 Spain 5,664 12.8 4.4 Sweden 1,498 28.0 3.1 Switzerland 1,139 7.9 0.6 Tajikistan 2,244 1.2 0.2 Turkey 20,561 3.2 4.1 Turkmenistan 1,793 1.2 0.1 Ukraine 7,651 8.1 3.8 United Kingdom 10,923 18.9 13.7 Uzbekistan 8,623 1.2 0.6

EUR Total 161,460 § 90.1

a. UN population projections – medium variant 2003 b. Population estimates extracted from CIA World Factbook 200210 124 125

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Table 2.7 Data sources: estimates of type 1 diabetes in children – North American Region

Country Data used Period Geography No. of cases Completeness Classification Anguilla Antigua and Barbuda (Tull et al, 1997)a, 57 X Antigua and Barbuda Antigua and Barbuda (Tull et al, 1997)a, 57 1989-93 Antigua 4 100 A Aruba Venezuela (Karvonen et al, 2000)36 X Bahamas Cuba (Karvonen et al, 2000)36 X Barbados Barbados (Karvonen et al, 2000)36 1990-93 Whole country 5 N/A B Belize Mexico (Karvonen et al, 2000)36 X Bermuda Cuba (Karvonen et al, 2000)36 X British Virgin Islands Antigua and Barbuda (Tull et al, 1997)a, 57 X Canada Canada (Karvonen et al, 2000)36 1990-94 Alberta, Prince 204 75-100% A/B Edward Island Cayman Islands Cuba (Karvonen et al, 2000)36 X Dominica, Dominica (Karvonen et al, 2000)36 1990-93 Whole country 5 N/A B Commonwealth of Grenada Barbados (Karvonen et al, 2000)36 X Guadeloupe Dominica (Karvonen et al, 2000)36 X Guyana Venezuela (Karvonen et al, 2000)36 X Haiti Puerto Rico (Karvonen et al, 2000)36 X Jamaica Cuba (Karvonen et al, 2000)36 X Martinique Barbados (Karvonen et al, 2000)36 X Mexico Mexico (Karvonen et al, 2000)36 1990-93 Veracruz 9 100% B St Kitts and Nevis Antigua and Barbuda (Tull et al, 1997)a, 57 X St Lucia Barbados (Karvonen et al, 2000)36 X St Vincent and the Barbados (Karvonen et al, 2000)36 X Grenadines Trinidad and Tobago Barbados (Karvonen et al, 2000)36 X USA USA (Karvonen et al, 2000)36 1990-94 Allegheny, 607 51-100% A/B Jefferson, Chicago a. Relates to 0-19 years age range

N/A not available

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

Incidence rates Population size (cases per 100,000 Estimated no. (000’s) population per year) of prevalent cases Country 0-14 yrsa 0-14 yrs (000’s) Anguillab 3 3.5 0.0 Antigua and Barbudab 19 3.5 0.0 Arubab 15 0.1 0.0 Bahamas 91 2.9 0.0 Barbados 53 2.0 0.0 Belize 87 1.5 0.0 Bermudab 12 2.9 0.0 British Virgin Islandsb 5 3.5 0.0 Canada 5,759 24.1 9.1 Cayman Islandsb 8 2.9 0.0 Dominica, Commonwealth of b 20 5.7 0.0 Grenadab 32 2.0 0.0 Guadeloupe 105 5.7 0.0 Guyana 228 0.1 0.0 Haiti 3,305 17.4 3.6 Jamaica 798 2.9 0.1 Martinique 84 2.0 0.0 Mexico 32,799 1.5 2.6 St Kitts and Nevisb 11 3.5 0.0 St Lucia 48 2.0 0.0 St Vincent and the Grenadinesb 34 2.0 0.0 Trinidad and Tobago 293 2.0 0.0 USA 61,383 13.8 49.2

NA Total 105,192 § 64.7

a. UN population projections – medium variant 2003 b. Population estimates extracted from CIA World Factbook 200210

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Table 2.9 Data sources: estimates of type 1 diabetes in children – South and Central American Region

Country Data used Period Geography No. of cases Completeness Classification Argentina Argentina (Karvonen et al, 2000)36 1990-94 Avellaneda, Cordoba, 89 88-100% A/B Corrientes, Tierra del Fuego Bolivia Peru (Karvonen et al, 2000)36 X Brazil Brazil (Karvonen et al, 2000)36 1990-92 Sao Paulo 34 70-95% B Chile Chile (Santos et al, 2001)58 1997-98 Santiago 61 100% A Colombia Colombia (Karvonen et al, 2000)36 1990 Santa Fé de Bogotá 56 97% A Costa Rica Colombia (Karvonen et al, 2000)36 X Cuba Cuba (Karvonen et al, 2000)36 1990-94 Whole country 349 75-100% A Dominican Republic Puerto Rico (Karvonen et al, 2000)36 X Ecuador Colombia (Karvonen et al, 2000)36 X El Salvador Mexico (Karvonen et al, 2000)36 X French Guiana Venezuela (Karvonen et al, 2000)36 X Guatemala Mexico (Karvonen et al, 2000)36 X Honduras Mexico (Karvonen et al, 2000)36 X Netherlands Antilles Venezuela (Karvonen et al, 2000)36 X Nicaragua Mexico (Karvonen et al, 2000)36 X Panama Colombia (Karvonen et al, 2000)36 X Paraguay Paraguay (Karvonen et al, 2000)36 1990-94 Whole country 79 N/A B Peru Peru (Karvonen et al, 2000)36 1990-91 Lima 16 88% B Puerto Rico Puerto Rico (Karvonen et al, 2000)36 1990-94 Whole country 844 90-97% A Suriname Venezuela (Karvonen et al, 2000)36 X Uruguay Uruguay (Karvonen et al, 2000)36 1992 Montevideo 26 97% A Venezuela Venezuela (Karvonen et al, 2000)36 1992 Caracas 43 N/A B

N/A not available

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

Incidence rates Population size (cases per 100,000 Estimated no. (000’s) population per year) of prevalent cases Country 0-14 yrsa 0-14 yrs (000’s) Argentina 10,408 6.4 4.1 Bolivia 3,454 0.4 0.1 Brazil 48,424 8.0 23.8 Chile 4,322 4.1 1.1 Colombia 14,048 3.8 3.3 Costa Rica 1,326 3.8 0.3 Cuba 2,240 2.9 0.4 Dominican Republic 2,806 17.4 3.0 Ecuador 4,323 3.8 1.0 El Salvador 2,304 1.5 0.2 French Guiana 65 0.1 0.0 Guatemala 5,252 1.5 0.5 Honduras 2,782 1.5 0.3 Netherlands Antilles 52 0.1 0.0 Nicaragua 2,283 1.5 0.2 Panama 892 3.8 0.2 Paraguay 2,266 0.9 0.1 Peru 8,578 0.4 0.2 Puerto Rico 934 17.4 1.1 Suriname 121 0.1 0.0 Uruguay 837 8.3 0.4 Venezuela 8,322 0.1 0.1

SACA Total 126,041 § 40.4

a. UN population projections – medium variant 2003

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Table 2.11 Data sources: estimates of type 1 diabetes in children – South-East Asian Region

Country Data used Period Geography No. of cases Completeness Classification Bangladesh India (Ramachandran et al, 1992)59 X Bhutan People’s Republic of China (Karvonen X et al, 2000)36 India India (Ramachandran et al, 1992)59 1991 Madras 30 N/A B Maldives India (Ramachandran et al, 1992)59 X Mauritius Mauritius (Karvonen et al, 2000)36 1990-94 Whole country 21 35-100% B Nepal People’s Republic of China (Karvonen X et al, 2000)36 Sri Lanka India (Ramachandran et al, 1992)59 X

N/A not available

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

Incidence rates Population size (cases per 100,000 Estimated no. (000’s) population per year) of prevalent cases Country 0-14 yrsa 0-14 yrs (000’s) Bangladesh 54,846 4.2 14.3 Bhutan 941 0.6 0.0 India 341,094 4.2 88.8 Maldives 135 4.2 0.0 Mauritius 296 1.4 0.0 Nepal 10,048 0.6 0.4 Sri Lanka 4,877 4.2 1.3

SEA Total 412,236 § 104.8

a. UN population projections – medium variant 2003

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Table 2.13 Data sources: estimates of type 1 diabetes in children – Western Pacific Region

Country Data used Period Geography No. of cases Completeness Classification Australia Australia (Craig et al, 2000)60 1990-96 New South Wales 1,591 99% A Brunei Darussalam Thailand (Tuchinda et al, 2002)61 X Cambodia Thailand (Tuchinda et al, 2002)61 X China, Hong Kong Hong Kong (Huen et al, 2000)62 1984-96 Whole country 227 N/A B China, Macau Hong Kong (Huen et al, 2000)62 X China, People’s Republic of People’s Republic of China (Karvonen 1990-94 Twenty-one 462 69-100% A/B et al, 2000)36 regions Cook Islands Papua New Guinea (Ogle et al, 2001)63 X East Timor Thailand (Tuchinda et al, 2002)61 X Fiji Papua New Guinea (Ogle et al, 2001)63 X French Polynesia Papua New Guinea (Ogle et al, 2001)63 X Guam Papua New Guinea (Ogle et al, 2001)63 X Indonesia Thailand (Tuchinda et al, 2002)61 X Japan Japan (Karvonen et al, 2000)36 1990-93 Chiba, Hokkaido, 167 77-100% A/B Okinawa Kiribati Papua New Guinea (Ogle et al, 2001)63 X Korea, Democratic People’s Republic of Korea (Ko et al, 1994)64 X Republic of Korea, Republic of Republic of Korea (Ko et al, 1994)64 1985-88 Seoul 71 N/A B Lao People’s Democratic Thailand (Tuchinda et al, 2002)61 X Republic Malaysia Thailand (Tuchinda et al, 2002)61 X Marshall Islands Papua New Guinea (Ogle et al, 2001)63 X Micronesia Papua New Guinea (Ogle et al, 2001)63 X Mongolia People’s Republic of China (Karvonen X et al, 2000)36 Myanmar Thailand (Tuchinda et al, 2002)61 X Nauru Papua New Guinea (Ogle et al, 2001)63 X New Caledonia Papua New Guinea (Ogle et al, 2001)63 X New Zealand New Zealand (Karvonen et al, 2000)36 1990-94 Auckland, 213 100% A Canterbury Niue Papua New Guinea (Ogle et al, 2001)63 X Palau Papua New Guinea (Ogle et al, 2001)63 X Papua New Guinea Papua New Guinea (Ogle et al, 2001)63 1996-2000 Whole country 8 N/A B Philippines People’s Republic of China (Karvonen X et al, 2000)36 Samoa Papua New Guinea (Ogle et al, 2001)63 X Singapore, Republic of Singapore (Lee et al, 1998)a, 65 1992-94 Whole country 40 92% A Solomon Islands Papua New Guinea (Ogle et al, 2001)63 X Taiwan Hong Kong (Huen et al, 2000)62 X Thailand Thailand (Tuchinda et al, 2002)61 1991-95 North, north- 191 N/A B east, south and central regions Tokelau Papua New Guinea (Ogle et al, 2001)63 X Tonga Papua New Guinea (Ogle et al, 2001)63 X Tuvalu Papua New Guinea (Ogle et al, 2001)63 X Vanuatu Papua New Guinea (Ogle et al, 2001)63 X Vietnam Thailand (Tuchinda et al, 2002)61 X

a. Only to age 12 years

N/A not available

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

Incidence rates Population size (cases per 100,000 Estimated no. (000’s) population per year) of prevalent cases Country 0-14 yrsa 0-14 yrs (000’s) Australia 3,931 17.8 4.4 Brunei Darussalam 105 0.3 0.0 Cambodia 5,979 0.3 0.1 China, Hong Kong 1,093 1.4 0.1 China, Macau 86 1.4 0.0 China, People’s Republic of 299,371 0.6 9.3 Cook Islandsb 8 0.1 0.0 East Timor 298 0.3 0.0 Fiji 273 0.1 0.0 French Polynesia 71 0.1 0.0 Guam 59 0.1 0.0 Indonesia 64,466 0.3 1.2 Japan 18,228 1.7 1.9 Kiribatib 39 0.1 0.0 Korea, Democratic People’s Republic of 5,858 0.7 0.3 Korea, Republic of 9,576 0.7 0.4 Lao People’s Democratic Republic 2,355 0.3 0.0 Malaysia 7,785 0.3 0.1 Marshall Islandsb 36 0.1 0.0 Micronesiab 48 0.1 0.0 Mongolia 840 0.6 0.0 Myanmar 15,782 0.3 0.3 Naurub 5 0.1 0.0 New Caledonia 66 0.1 0.0 New Zealand 864 15.2 0.9 Niueb 1 0.1 0.0 Palaub 5 0.1 0.0 Papua New Guinea 2,049 0.1 0.0 Philippines 29,012 0.6 1.1 Samoa 65 0.1 0.0 Singapore, Republic of 892 2.5 0.2 Solomon Islands 221 0.1 0.0 Taiwanb 4,733 1.4 0.4 Thailand 16,775 0.3 0.3 Tokelaub 1 0.1 0.0 Tongab 42 0.1 0.0 Tuvalub 4 0.1 0.0 Vanuatu 86 0.1 0.0 Vietnam 25,090 0.3 0.5

WP Total 516,194 § 21.6

a. UN population projections – medium variant 2003 b. Population estimates extracted from CIA World Factbook 200210

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Decreased prevalence onset diabetes in Europe 1989-1998. Diabetologia 2001; of atopic diseases in children with diabetes. J Pediatr 2000; 44 Suppl 3:B3-B8. 137(4):470-474. 4. Tuomilehto J, Virtala E, Karvonen M, et al. Increase in 23. Patterson CC, Dahlquist G, Soltesz G, Green A. Is incidence of insulin-dependent diabetes mellitus among childhood-onset type I diabetes a wealth-related disease? children in Finland. Int J Epidemiol 1995; 24(5):984-992. An ecological analysis of European incidence rates. 5. Gardner SG, Bingley PJ, Sawtell PA, Weeks S, Gale EA. Rising Diabetologia 2001; 44 Suppl 3:B9-16. incidence of insulin dependent diabetes in children aged 24. Blom L, Persson LA, Dahlquist G. A high linear growth is under 5 years in the Oxford region: time trend analysis. The associated with an increased risk of childhood diabetes Bart’s-Oxford Study Group. BMJ 1997; 315(7110):713-717. mellitus. Diabetologia 1992; 35(6):528-533. 6. Dahlquist G, Mustonen L. Analysis of 20 years of 25. 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Joseph TA, Viswanathan M. Prevalence of childhood 31. Pipeleers D, Hoorens A, Marichal-Pipeleers M, et al. Role diabetes in an urban population in South India. Diabetes of pancreatic beta-cells in the process of beta-cell death. Res Clin Pract 1992; 17:227-231. Diabetes 2001; 50 Suppl 1:S52-S57. 12. Ramachandran A, Snehalatha C, Krishnaswamy CV. 32. Rolfe M, Armstrong JR. Diabetes mellitus on the Zambian Incidence of IDDM in children in urban population in Copperbelt. J R Coll Physicians Lond 1989; 23:255-259. southern India. Madras IDDM Registry Group Madras, South 33. Afoke AO, Ejeh NM, Nwonu EN, Okafor CO, Udeh NJ, India. Diabetes Res Clin Pract 1996; 34:79-82. Ludvigsson J. Prevalence and clinical picture of IDDM in 13. Dahlquist G. Diabetes in children: The etiology in an Nigerian Igbo schoolchildren. Diabetes Care 1992; 15:1310- epidemiological perspective. In The Diabetes Annual WHO 1312. vol 8, eds Home PD, Marshall SM. Amsterdam:Elsevier, 34. Swai AB, Lutale JL, McLarty DG. Prospective study of 1994. incidence of juvenile diabetes mellitus over 10 years in 14. Castle WM, Wicks ACB. A follow-up of 93 newly-diagnosed Dar es Salaam, Tanzania. BMJ 1993; 306:1570-1572. African diabetics for 6 years. Diabetologia 1980; 35. Elamin A, Omer MI, Zein K, Tuvemo T. Epidemiology of 18:121-123. childhood type I diabetes in Sudan, 1987-1990. Diabetes 15. Makame MH. Childhood diabetes, insulin, and Africa. Care 1992; 15:1556-1559. Diabet Med 1992; 9:571-573. 36. Karvonen M, Viik-Kajander M, Moltchanova E, Libman I, 16. Dahlquist G, Kallen B. Maternal-child blood group LaPorte R, Tuomilehto J. Incidence of childhood type 1 incompatibility and other perinatal events increase the risk diabetes worldwide. Diabetes Mondiale (DiaMond) Project for early-onset type 1 (insulin-dependent) diabetes mellitus. Group. Diabetes Care 2000; 23:1516-1526. Diabetologia 1992; 35(7):671-675. 37. Rakhimova GGN, Ismailov S. Prevalence of Type 1 diabetes 17. Dahlquist GG, Ivarsson S, Lindberg B, Forsgren M. Maternal mellitus and its vascular complications in childhood enteroviral infection during pregnancy as a risk factor for population in the Republic of Uzbekistan according to a childhood IDDM. A population-based case-control study. national register (Abstract). Diabetologia 2002; Diabetes 1995; 44(4):408-413. 45 Suppl 2:A107. 18. Hyoty H, Hiltunen M, Knip M, et al. A prospective study of 38. Timchenko OI, Kozachok GS, Turos EI, Omel’chenko EM. the role of coxsackie B and other enterovirus infections in [The prevalence of diabetes mellitus in children of different the pathogenesis of IDDM. Childhood Diabetes in Finland regions of Ukraine]. Tsitol Genet 1996; 30:70-73. (DiMe) Study Group. Diabetes 1995; 44(6):652-657.

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39. Soliman AT, al Salmi IS, Asfour MG. Epidemiology of The Caribbean African Heritage IDDM Study (CAHIS) Group. childhood insulin-dependent diabetes mellitus in the Diabetes Care 1997; 20:309-310. Sultanate of Oman. Diabet Med 1996; 13:582-586. 58. Santos J, Carrasco E, Moore A, Perez-Bravo F, Albala C. 40. Arab M. Diabetes mellitus in Egypt. World Health Stat Q Incidence rate and spatio-temporal clustering of type 1 1992; 45:334-337. diabetes in Santiago, Chile, from 1997 to 1998. Rev Saude 41. Staines A, Hanif S, Ahmed S, McKinney PA, Shera S, Publica 2001; 35:96-100. Bodansky HJ. Incidence of insulin dependent diabetes 59. Ramachandran A, Snehalatha C, Abdul Khader OM, mellitus in Karachi, Pakistan. Arch Dis Child 1997; Joseph TA, Viswanathan M. Prevalence of childhood 76:121-123. diabetes in an urban population in south India. Diabetes 42. Ajlouni K, Qusous Y, Khawaldeh AK, Jaddou H, Batiehah A, Res Clin Pract 1992; 17:227-231. Ammari F, Zaheri M, Mashal A. Incidence of insulin- 60. Craig ME, Howard NJ, Silink M, Chan A. The rising incidence dependent diabetes mellitus in Jordanian children aged of childhood type 1 diabetes in New South Wales, Australia. 0-14 y during 1992-1996. Acta Paediatr Suppl 1999; J Pediatr Endocrinol Metab 2000; 13:363-372. 88:11-13. 61. Tuchinda C, Likitmaskul S, Unachak K, Panamonta O, 43. Shaltout AA, Moussa MA, Qabazard M, Abdella N, Patarakijavanich N, Chetthakul T. The epidemiology of Karvonen M, Al Khawari M, Al Arouj M, Al Nakhi A, type 1 diabetes in Thai children. J Med Assoc Thai 2002; Tuomilehto J, El Gammal A. Further evidence for the rising 85:648-652. incidence of childhood Type 1 diabetes in Kuwait. Diabet 62. Huen KF, Low LC, Wong GW, Tse WW, Yu AC, Lam YY, Med 2002; 19:522-525. Cheung PC, Wong LM, Yeung WK, But BW, Cheung PT, 44. Kadiki OA, Roaeid RB, Bhairi AM, Elamari IM. Incidence of Kwan EY, Karlberg JP, Lee C. Epidemiology of diabetes insulin-dependent diabetes mellitus in Benghazi, Libya mellitus in children in Hong Kong: the Hong Kong childhood (1991-1995). Diabetes Metab 1998; 4:424-427. diabetes register. J Pediatr Endocrinol Metab 2000; 45. Al-Zyoud M, Al Ali M, Rahim A, Ibrahim M. Insulin 13:297-302. dependant diabetes mellitus (IDDM) in children below 63. Ogle GD, Lesley J, Sine P, McMaster P. Type 1 diabetes 13 years of age in Qatar. Diabetes Insights 1997; 4-10. mellitus in children in Papua New Guinea. PNG Med J 2001; 46. Kulaylat NA, Narchi H. A twelve year study of the incidence 44:96-100. of childhood type 1 diabetes mellitus in the Eastern 64. Ko KW, Yang SW, Cho NH. The incidence of IDDM in Seoul Province of Saudi Arabia. J Pediatr Endocrinol Metab 2000; from 1985 to 1988. Diabetes Care 1994; 17:1473-1475. 13:135-140. 65. Lee WW, Ooi BC, Thai AC, Loke KY, Tan YT, Rajan U, Tan CL. 47. Martinucci ME, Curradi G, Fasulo A, Medici A, Toni S, The incidence of IDDM in Singapore children. Singapore Osovik G, Lapistkaya E, Sherbitskaya E. Incidence of Med J 1998; 39:359-362. childhood type 1 diabetes mellitus in Gomel, Belarus. J Pediatr Endocrinol Metab 2002; 15:53-57. 48. Bratina NU, Tahirovic H, Battelino T, Krzisnik C. Incidence of childhood-onset Type I diabetes in Slovenia and the Tuzia region (Bosnia and Herzegovina) in the period 1990-1998. Diabetologia 2001; 44 Suppl 3:B27-B31. 49. Skordis N, Hadjiloizou S. Incidence of insulin dependent diabetes mellitus in Greek Cypriot children and adolescents, 1990-1994. J Pediatr Endocrinol Metab 1997; 10:203-207. 50. Svensson J, Carstensen B, Molbak A, Christau B, Mortensen HB, Nerup J, Borch-Johnsen K. Increased risk of childhood type 1 diabetes in children born after 1985. Diabetes Care 2002; 25:2197-2201. 51. Tuomilehto J, Karvonen M, Pitkaniemi J, Virtala E, Kohtamaki K, Toivanen L, Tuomilehto-Wolf E. Record-high incidence of Type I (insulin-dependent) diabetes mellitus in Finnish children. The Finnish Childhood Type I Diabetes Registry Group. Diabetologia 1999; 42:655-660. 52. Roche EF, Menon A, Gill D, Hoey HM. Incidence of type 1 diabetes mellitis in children aged under 15 years in the Republic of Ireland. J Pediatr Endocrinol Metab 2002; 15:1191-1194. 53. Schranz AG. Trends in incidence of childhood type 1 diabetes in Malta. Diabetes Care 1998; 21:194-195. 54. Joner G, Stene LC, Sovik O. No increase in incidence of type 1 diabetes in young children in Norway 1989-98 (Abstract). Diabetologia 2000; 43 Suppl 1:A27. 55. Shubnikov E, Choubnikova J. The incidence of insulin- dependent diabetes mellitus in the age-group 0-9 years in Siberia is increasing (Abstract). Diabetologia 1999; 42 Suppl 1:A86. 56. Vlajinac HD, Bojovic BM, Sipetic SB, Adanja BJ, Jarebinski MS, Radmanovic SZ, Zdravkovic DS. Insulin dependent diabetes mellitus: incidence in childhood in Belgrade 1982-92. J Epidemiol Community Health 1995; 49:107-108. 57. Tull ES, Jordan OW, Simon L, Laws M, Smith DO, Vanterpool H, Butler C. Incidence of childhood-onset IDDM in black African-heritage populations in the Caribbean. 134 135

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2.2 Type 2 Diabetes in the Young

type 2 diabetes. However, there are now Introduction At a glance also reports of type 2 diabetes occurring It is well recognized that the global amongst Europid (White Caucasoid) • Type 2 diabetes in burden of type 2 diabetes is both teenagers (7). In Japan, the prevalence the young is a global significant and rising, with most of of type 2 diabetes amongst junior high phenomenon, which is the increase registered in the last school children has almost doubled from on the increase. two decades. From 2003 to 2025 the 7.3 per 100,000 in 1976-80 to 13.9 per • The risk of type 2 worldwide prevalence of diabetes in 100,000 in 1991-5, with type 2 diabetes diabetes is clearly adults is expected to rise from 5.1% now outnumbering type 1 diabetes in linked to an increasing to 6.3% of the adult population, or Japanese children (8). prevalence of obesity, 194 million to 333 million people. which is associated Compared to adults, there is little with changing dietary The largest proportional and absolute information on type 2 diabetes incidence and lifestyle patterns. increase will occur in developing and prevalence in the young with many countries, where the prevalence will surveys being clinic based or case series • Studies have shown rise from 4.2% to 5.6% (see Chapter 1). with a paucity of population-based that youth with type In India and China the adult diabetic surveys, particularly outside North 2 diabetes will also population is expected to double by America (4) and Japan (8). Similarly, unlike develop diabetes- 2025 to about 73 million in India and 46 adults, information on the natural history related micro- and million in China. By 2025, type 2 diabetes and aetiology of type 2 diabetes in the macrovascular prevalence is expected to reach 2.8% of paediatric age range is also sparse. Other complications, the adult population in Africa and 7.2% in deficiencies include a lack of uniformity as with adults. South and Central America. in case definition, data collection and • The increasing follow-up, with the diagnosis often made prevalence of type 2 In 1990 it was estimated that 0.2% of retrospectively (9). diabetes in the young the total global diabetic population may be blunted by of 118 million was under 15 years Despite these weaknesses, it is now encouraging more of age (1). The prevalence of type 2 becoming recognized that type 2 diabetes physical activity, and diabetes increases with age and affects in children is becoming a global public changing dietary some 17% of all 65-74 year olds in the health issue with potentially serious habits. US, and a similar proportion in other health outcomes (10). In response to this countries, such as Australia (2-4). the American Diabetes Association (ADA) Amongst the young, type 2 diabetes is has issued a consensus statement on the thought to account for 2-3% of all types screening, diagnosis and treatment of of diabetes. This, however, is likely to children with type 2 diabetes (5). be an underestimate as, depending on the study, 8-45% of recently diagnosed The impact of misclassification diabetes in the young in the US is due There may be underestimation in type 2 to type 2 diabetes (5). Data from the diabetes rates due to a misclassification third National Health and Nutrition of the type of diabetes at initial Examination Survey (NHANES III) in the presentation. The presence of diabetic USA indicates that 16 million Americans ketoacidosis (DKA), or diabetic coma, have type 2 diabetes (2). is classically a manifestation of type 1 diabetes. However, a number of reports There are ever increasing reports of type have shown that DKA may occur at 2 diabetes in children worldwide, with initial presentation in patients who are some as young as eight years of age eventually found to have type 2 diabetes. being affected (6). These are mostly in That is, they have elevated C-peptide ethnic groups known to be at high risk of and an absence of islet cell or anti GAD

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antibodies (4). This type of presentation reported in Asians, Hispanics, indigenous has also been termed Flatbush (11,12), or peoples (USA, Canada, Australia) and atypical diabetes mellitus (ADM) (13). African Americans, with some of the highest rates in the world being Unlike type 1 diabetes, most children observed amongst Pima Indians (19,20). with type 2 diabetes are asymptomatic, For instance from the period 1967-76 however, approximately a third present to 1987-96 the prevalence of type 2 with ketonuria (an excess of ketones in diabetes in Pimas increased four to the urine) (14). One study found DKA six-fold, reaching a prevalence of occurred in 4.2% of all patients attending 22.3 per 1,000 for 10-14 year olds and a paediatric clinic, all of whom were 50.9 per 1,000 for 15-19 year olds by of Canadian aboriginal descent (15). A 1992-96 (14). case series examining African American adolescents found that up to 42% Obesity, diet and inactivity presented with ketonuria and 25% with On a global basis the rise in type 2 DKA (16). Similarly another report has diabetes rates seems to mirror the shown that some 30% of Hispanic youth growth in urbanization and economic with type 2 diabetes can present with development and may be due to ketosis (17). Why type 2 diabetes can maladaptation to a rapidly changing present with ketosis and in particular why environment (21,22). Closely associated this presentation is more likely to occur with this is the increase in overweight in African Americans or Hispanics is not and obesity. clear (18). Obesity has been linked to changing Possible factors in type 2 patterns in diet and physical activity diabetes development levels (23,24). Allied to this are studies from Japan which have demonstrated a Ethnicity parallel rise in type 2 diabetes incidence Ethnicity is an important factor in type 2 in children and levels of obesity from diabetes development in both adults 1975 to 1995 (8) as shown in Figure and children with higher rates being 2.2. Of note is that over this time period there have also been significant increases in fat and animal protein intake among Figure 2.2 Japanese youth, now mirroring the Annual incidence of type 2 diabetes and prevalence kind of westernized diets consumed by of obesity among Japanese school children Japanese-Americans (25). (from Kitagawa T et al, 1998 (8)) Dietary changes are not only confined

� ��

� to the home environment. A survey of � ��

� Californian public schools found that 85%

� �� sold fast food, which in turn accounted � � � � �� for 70% of all food sales (26). Of concern � � �

� is that almost 70% of school districts � �� allowed advertising on campus, with 24% � � �

� �� allowing advertising in exchange for cash � � �

� or equipment. � � ��

� ��

� � � � � � � The prevalence of obesity among � � ��

� Japanese children has increased from � � � �� 5% in 1976 to 8% in 1992 and is similar to data reported from the United States �� (27). In the USA, the National Longitudinal

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Survey of Youth, which is a prospective well as the adoption of a more sedentary cohort study conducted from 1986 to life with a westernized diet are thought 1998, showed that over this time period to contribute to rising obesity levels (34). the overweight prevalence increased Currently some 85% of children with type annually by 3.2% in non-Hispanic whites, 2 diabetes are either overweight or obese 5.8% in African Americans and 4.3% at diagnosis (5). in Hispanics. Thus by 1998, 21.5% of African Americans, 21.8% of Hispanics Inactivity is one of the major contributors and 12.3% of non-Hispanic whites were to being overweight. In the developed overweight (28). world, use of computers and increasing time spent in front of the television A more recent study of nearly 5,000 are some of the factors impacting on children in the USA has shown that activity (24, 29). during 1999-2000, 15% of 6-19 year olds were overweight, compared to A recent longitudinal study showed a 11% in 1994-98. The biggest rises marked decline in physical activity in were recorded in African American and adolescent girls with 56% of black and Mexican American adolescents (29). This 31% of white girls aged 16-17 years study also showed that the prevalence having no habitual leisure-time physical of being overweight (BMI ≥25) reached a activity (35). Pregnancy, cigarette staggering 65% in US adults. Increasing smoking, higher BMI and lower parental obesity is also a problem elsewhere, with education at baseline were all associated a recent study from Australia examining with a subsequent decline in physical children aged 7-15 years, reporting that activity. Another study highlighting racial the prevalence of obesity has increased differences in physical activity levels two to four-fold from 1985 to 1997 (30). found that white students in the USA have generally higher physical activity The problem of obesity also extends to levels than other ethnic groups, with developing nations, particularly in the boys usually more active than girls, more affluent urban areas. In India, a whatever the race (36). recent study found that the age adjusted prevalence of being overweight among A lifestyle predisposing to obesity and 13-18 year olds was around 18%. type 2 diabetes seems to characterize Prevalence rates increased with age and families with adolescents who have decreasing physical activity and with type 2 diabetes, according to a study by higher socio-economic status (31). Other Pinhas-Hamiel et al. Specifically the study factors also thought to be important showed that members of such families amongst Indian Asians are low birth tend to be overweight, inactive and have weight and insulin resistance (22). a tendency to high fat intake and even binge eating (37). Overall in the USA, only Obesity is also being increasingly 50% of young people aged 12-21 years observed in indigenous populations, are regularly involved in physical activity, such as the Objiwa-Cree community in with some 25% admitting to no physical Canada, where a study found that 48-51% activity at all. Even in schools there is of children aged 4-19 years have a weight a decline in physical education, with more than the 90th percentile (32). participation rates down from 41.6% in Similar reports have come from other 1991 to 24.5% in 1995 (38). communities such as indigenous Australians, with obesity rates of up to Insulin resistance 86% (33). Changes in traditional lifestyles The onset of type 2 diabetes is frequently among indigenous communities such as reported around puberty and is thought a reduction in hunting and gathering as to coincide with the physiological rise

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in insulin resistance (IR) associated with resistance and is reported to occur in puberty, where insulin sensitivity may be up to 60-90% of young people with reduced by as much as 30% (9). Healthy type 2 diabetes (19). This seems to be young adolescents compensate for the especially true for African Americans peri-pubertal rise in IR by increasing and some Native Americans, but so far insulin secretion as they have normal not demonstrated in other populations pancreatic beta cell function. This is not such as in Japan (25). However, despite the case with adolescents with type 2 its ubiquitous occurrence in some diabetes, where both insulin action populations with type 2 diabetes, it and eventually beta cell function are should not exclusively be used as a impaired (5). reliable marker of hyperinsulinaemia and insulin resistance. There appear to be ethnic differences in insulin resistance, with African American In a study conducted by Nguyen children being more hyperinsulinaemic et al, only 35% of obese children with (having high levels of insulin in the hyperinsulinaemia had AN, whether black blood) and insulin resistant than Europids or white (44). Similarly a recent survey (39). Similarly, the Bogalusa Heart Study of obese Hispanic children (BMI ≥95th has shown that compared to Europids, percentile) found that there was no African Americans (especially girls) had association between AN and markers of higher insulin levels and insulin:glucose insulin resistance. In contrast, acanthosis ratios (40). nigricans was associated with BMI but negatively with birth weight (45). Further, a recent study has shown that compared to Europids, African Polycystic ovary syndrome American children have a combination Polycystic ovary syndrome (PCOS) is of both lower insulin clearance and associated with menstrual irregularities, higher insulin secretion (41). Using a infertility and a state of insulin resistance frequently sampled intravenous glucose (46). It is also said to affect up to 5-10% tolerance test, both African American of females in their reproductive years (47) and Hispanic children demonstrated and is thought to predispose to glucose greater insulin resistance than Europid intolerance, with studies showing up children (42). Further analysis showed to 30-40% being affected by impaired no ethnic differences in the first phase glucose tolerance (IGT) and up to 7-10% insulin secretion. However, second with type 2 diabetes (46, 48, 49). phase secretion was significantly higher It may explain why there are more among Hispanics compared to African females with type 2 diabetes amongst Americans, due to lower hepatic insulin adolescents (9, 46). clearance among African Americans. Family history Insulin resistance may be lowered by Many studies show a strong family simple means such as increasing activity history among affected youth with levels. This has been demonstrated in 45-80% having at least one parent with obese children and more recently in non- diabetes and 74-100% having a first diabetic, normal weight children (43), or second degree relative with type 2 where the more active children had diabetes (5, 50). Children with diabetes lower fasting insulin and greater insulin are also more likely to have a family sensitivity. history of cardiovascular disease (CVD), with one study showing that up to Acanthosis nigricans 28% have a positive family history of Acanthosis nigricans (AN) is thought CVD (51). to be a physical marker of insulin

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The Bogalusa Heart Study (52) has shown size, leading to low birth weight and that children of individuals with type 2 hence later development of insulin diabetes were more likely to be obese resistance (61-64). and have higher blood pressures, fasting insulin, glucose and triglycerides. In a Two recent studies challenge this. First, study among Pima Indians, it was shown a study examining 300 five-year old that the cumulative incidence of type 2 British children found that girls were more diabetes was highest in offspring if both insulin resistant than boys, and insulin parents had diabetes (53). resistance was not related to birth weight (65). The second is a study from Belgium Intrauterine environment (66), which examined twins aged 18-35 Apart from genes, the intrauterine years and found that among twin pairs environment may be important as there discordant for birth weight, there was is evidence of higher rates of type 2 little evidence that the lighter twin had diabetes in offspring of mothers who abnormal glucose-insulin metabolism in develop gestational diabetes (GDM) adult life. Low pre-pregnancy maternal BMI (54). A prospective study by Silverman and older maternal age at delivery were et al found that the prevalence of IGT in independently associated with insulin the children of mothers with a diabetic resistance in the offspring. These findings pregnancy increased with time from 1.2% suggest that maternal factors may be at less than five years of age to 19.3% at more important than feto-placental factors 10-16 years of age. This was compared to in determining glucose-insulin metabolism 2.5% in control subjects. in the offspring.

In addition, higher levels of amniotic fluid Methods insulin (AFI) measured at 33-38 weeks gestation was a strong predictor of later A Medline search was conducted using IGT (55). AFI is also thought to correlate Ovid (medical information service) of with later childhood obesity (56), which papers written in the English language in turn may lead to later type 2 diabetes from 1965-2002. development. Key words used were: Diabetes, diabetics, Birth weight is strongly influenced by non-insulin dependent diabetes, type II the intrauterine environment, particularly diabetes, impaired glucose tolerance, in diabetic pregnancies, which can be insulin resistance, child, childhood, associated with high birth weight (57). young, adolescence, overweight, obesity Conversely there is also evidence that and polycystic ovary syndrome. low birth weight can result in later adult type 2 diabetes development (58). The keywords related to diabetes were This is most likely due to poor maternal combined with those related to children nutrition leading to impaired islet cell and then further combined with terms development (57, 59), but may also related to obesity and then finally with occur in a number of other conditions polycystic ovary syndrome. such as pregnancies complicated by hypertension/pre-eclampsia, which is not All available studies with relevant data an uncommon condition complicating up have been included and have been to 3-5% of all pregnancies (60). grouped by study type (population based, case reports, case series and There is a hypothesis that insulin clinic based). These have further resistance is a product of fetal been divided into the IDF regions of programming and that gestational Africa (AFR), Eastern Mediterranean and metabolic perturbations affect fetal Middle East (EMME), Europe (EUR), North

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America (NA), South and Central America of Africa (79-82), studies found are few (SACA), South-East Asia (SEA) and Western and in most examples conducted some Pacific (WP). 15 years ago.

Studies which include subjects 20 years Africa of age and under have been selected. Five studies were found and included However, data are presented for studies two from west Africa (79, 81) and three which have given higher age ranges but from east Africa (80, 82, 83). All but which include subjects less than 20 years one, which looked only at Indians (83), of age within those ranges. In these cases showed a zero or low prevalence of it has not been possible to separate those diabetes. Apart from the study examining under 20 from the information given. Indians, all the others were conducted in the 1980s. Therefore taking into Most papers have been published in account the current information on peer review journals but a number are in type 2 diabetes rates around the world, abstract form. These are no more than the results for Africa are probably an three years old. underestimate and may not represent the contemporary situation. Results Eastern Mediterranean and Results are reported as presented in Middle East the original papers, unlike in the adult A large study of some 25,377 individuals diabetes and childhood type 1 diabetes aged 2-77 years was conducted in Saudi sections (see Chapters 1.1 and 2.1 Arabia by el-Hazmi et al (78). The figures respectively) in which figures have been for those less than 29 years of age have calculated for the national population. been selected. In the under-14 year age group, IGT prevalence was double that In some of the studies used, the of type 2 diabetes (0.25% versus 0.12%). prevalence of type 2 diabetes in the The opposite was true for the 14-29 general population (child and adolescent) year age group, where type 2 diabetes was determined from a representative outnumbered IGT almost 3:1 (0.79% for population-based sample (67). However, type 2 diabetes versus 0.21% for IGT). many studies have simply reported a series of cases, sometimes supplemented North America by a calculation of the prevalence in Unlike other regions, data from North the general population, using estimated America on type 2 diabetes and IGT figures for the size of the population prevalence are more extensive and from which the cases were drawn (68), or recent. The ethnicity of the study examined only a specific sub-population, subjects is diverse with many including such as from a diabetes registry (69-72) African Americans, Mexican Americans or an obesity clinic (73-77). and non-Hispanic white Americans in the same study. Population-based studies In general, it is very difficult to compare A study from Texas in 1981 examining the studies due to wide differences 15-24 year old Mexican Americans found in study design. Population-based no type 2 diabetes in males and only a studies were found from all regions low prevalence of 0.4% in females (84). except Europe, and South and Central By 2002, a study surveying Mexican America. Apart from studies from Japan American fourth graders found not only (8) and Saudi Arabia (78), many of the an overall type 2 diabetes prevalence other papers only examined relatively of 0.3%, but also cases of IGT (0.14%) small numbers of people. In the case and impaired fasting glucose (IFG)

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(0.14%) (85). In contrast another study A study from Chenai in south India (90), has reported relatively high rates of conducted eight years ago, found a zero type 2 diabetes (1.5%) and IFG (10.8%) prevalence rate for type 2 diabetes. in a population of Europids and African This may, however, be an underestimate Americans (86). This study, however, given the recent worldwide rise in type 2 is ongoing with some 50% of recruited diabetes in children. subjects still to have an oral glucose tolerance test (OGTT). The true rates of Western Pacific IFG and type 2 diabetes may change once Studies from Japan (8) and Taiwan (93) the full picture is known. were identified in the Western Pacific area. The largest study reported is from North America: Japan (8), with some seven million youth Indigenous/First Nation being studied between 1976 and 1997. A study, which examined Pima Indians Over this time type 2 diabetes incidence since 1967, demonstrated rising rates increased 10-fold in primary school of glucose intolerance over time, as well children: 0.2 per 100,000 per year from as a female preponderance (87). From 1976 to 1980 versus 2.0 per 100,000 per 1967-76 to 1987-96 the prevalence of year from 1991 to 1995. Similarly over type 2 diabetes markedly increased from the same time period, type 2 diabetes 2.4% in males and 2.7% in females to incidence doubled among junior high 3.8% in males and 5.3% in females. A school children: 7.3 versus 13.9 per female preponderance of type 2 diabetes 100,000 per year. of almost 4:1 among Navajo subjects was also found in another study (88). A cohort of indigenous Australian children aged 7-18 years was surveyed A study of American Indian and Alaskan in 1989 and again in 1994. Over the five Native adolescents reported that the years, the prevalence of type 2 diabetes prevalence of type 2 diabetes increased almost doubled to 1.3%, while that by 68% from 1990 to 1998 among those for IGT increased almost seven-fold to aged 15-19 years (0.32% to 0.54%) (20). 8.1% (94). At the follow-up, 18% of the In addition although the prevalence population were overweight or obese. of type 2 diabetes was higher among In addition one-third of the children had females, the relative increase over this elevated cholesterol levels, with almost time period was greater among males half reporting alcohol use and smoking. (0.23% to 0.41% for males versus 0.42% to 0.68% for females). Even though the In contrast to the Australian study, the overall prevalence among under-15 Tongan study (95) examining 15-19 year year olds remained the same at 0.12%, olds found no glucose intolerance in that there was regional variation, and Alaska population. recorded the biggest rise of 114% (0.04% to 0.09%). Case reports Although there are case reports of type 2 From Canada, greater rates for IFG (2.6%) diabetes in the young from a number compared to type 2 diabetes (1.1%) were of countries (96), only two (both from found among Cree-Objiway subjects, but the UK) have been included. These were no female preponderance (89). included for two reasons. First, there has so far been little available data from South-East Asia the UK and secondly, one of the reports Studies in the South-East Asian Region includes Europids (7), who until now were identified from India (90) and have been thought to be at low risk of Bangladesh (91, 92). developing childhood type 2 diabetes.

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In the other report (97), all the subjects These studies have also shown an were female and of Indian/Pakistani Asian increase in incidence rates. One or Arab origin. They were all obese and study (69) found that type 2 diabetes with a strong family history of diabetes. incidence rates rose by 9% per year from Three out of the eight children had 1985 to 1994, reaching 3.8 per 100,000 polycystic ovary syndrome. The finding per year by 1990-94, while another of being overweight and having a strong study (101) found a 10-fold increase in family history is also a feature in the type 2 diabetes incidence rates from 0.7 report by Drake et al (7). However, here per 100,000 per year in 1982 to 7.2 per the subjects are all Europid, with only one 100,000 per year in 1994. Yet another having PCOS. study (102) reported that in 1994, 9.4% of new cases of diabetes were due to Clinic/register-based studies type 2 diabetes, rising to 20% by 1998. Clinic and register-based studies make up Similarly, Likitmaskul et al (67) reported the largest group of studies conducted a rise from 5% to 17% from 1997 to 1999 on youth IGT and type 2 diabetes. They in the proportion with type 2 diabetes reveal type 2 diabetes occurring in referred to a diabetic clinic. children as young as under the age of five years (98). In addition, they have A study from 1989 to 2001 from a clinic demonstrated a female preponderance in Hungary (103) also reported rising (33, 70, 71, 99), strong family history incidence rates over time with 57% of (70, 100, 101), obesity (6,67,70,99-101) all type 2 diabetes and 77% of all IGT and acanthosis nigricans (6,67,99,101).

Profile: Chul Hee Han

Chul Hee Han, 15, was born in Seoul, South Korea and moved to Australia in 1994 when he was seven years old. James, as his friends call him, was diagnosed with type 2 diabetes at 14 when his mother noticed that he was gaining weight, especially around his middle.

His only medical problem had been an operation at the age of five months for a twisted bowel but apart from this, his childhood had been a healthy one. James’ father died when he was only four years old and he has little memory of his father. James’ mother tells of her husband who was a big man and who developed type 2 diabetes at the age of 28. Little treatment was given and he died of a heart attack at 32 years of age. The family then moved to Australia to be with relatives, and became Australian citizens.

On noticing his weight gain, James’ mother wanted to have him checked out for diabetes because of the family history. This led to an oral glucose tolerance test being done and the two-hour blood glucose level of 17.2mmol/l was diagnostic of diabetes. Other tests ruled out the possibility of this being type 1 diabetes and James was started on treatment for

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diagnosed in the last six years of the IGT prevalence of 23% in subjects 13-year study. pre-selected for obesity. More recently, Sinha et al (76) selected subjects whose Incidence rates also rise with age, with weight was more than the 95th percentile one study (98) demonstrating that 15-19 for age and sex attending an obesity year olds with rates of 5.9 per 100,000 clinic and found similar rates of IGT: 25% per year have three times the rate in 4-10 year olds and 21% in 11-18 year compared to 10-14 year olds with rates olds. of 1.8 per 100,000 per year. A study by Ciampalini et al (77) from Italy Although a population-based study have reported similar rates of 24%, but from south India eight years ago (90) others have not been able to reproduce found no cases of diabetes, a very these results from their study population recent clinic-based study (99), also from of obese youth, with Uwaifo et al (75) Chenai, diagnosed 18 cases of type 2 from USA and Invitti et al (104) from diabetes among children aged 9-15 years. Italy reporting much lower rates of 4.1% Common factors noted in this group were and 4.5% respectively for IGT. Another female preponderance, family history and study from Western Pacific also found obesity. lower rates of IGT (4.3%) in young obese subjects (73). A number of studies have pre-selected subjects for obesity, AN or PCOS. The cause for the discrepancy in results One study (74) in 1965 found an is unknown but has been suggested to

type 2 diabetes. He now does three blood tests a day and takes a tablet to control his blood glucose levels. He goes to the clinic every three months for a check-up. Says James: “I worry that my diabetes may get worse and that complications may occur. The blood glucose tests are not much of a bother and I have learnt to take my tablets every day before breakfast.”

James has continued life as before as far as school and sport is concerned, he does everything that his friends do. But he has become very careful when it comes to eating. His mother packs his lunch and he does not buy food from the tuck shop. He only rarely has fast food and avoids any junk food. “I don’t do any special sports nor do I weigh myself at home but I look after myself,” says James. “I think about my diabetes almost every time I eat and try not to eat too much. My teachers don’t know that I have diabetes and I have only told my two best friends.”

James, who is in year 10 of high school, attends a selective school for high achievers in an outer suburb of Sydney. He has known that he wants to become a dentist all his life. His mother and his relatives worry about James. “We are careful with food and stick to a Korean diet. We only choose the low fat recipes and use olive oil for cooking,” says his mother. “We pray for the diabetes to go away.”

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be due to referral bias in the study by with type 2 and 20.2% of those with Sinha et al (76) in favour of children who type 1 had nephropathy. are extremely obese (75). Another reason could be the contribution of PCOS. Of Yet another study (109) looked at note is that 40% of the subjects with IGT incidence of retinopathy and nephropathy in Sinha et al’s (76) study had PCOS. In among Pima Indians diagnosed with addition Sinha et al reported a type 2 type 2 diabetes at under 20 years of age diabetes prevalence of 3.6%, all of whom (youth), 20-39 years (young adults) and were non-Hispanic Black or Hispanic, 40-59 years of age (older). At less than while Invitti et al noted a much lower five years duration of type 2 diabetes, prevalence of 0.1%, among Europids. nephropathy was present in all age groups (incidence/1,000 person years: Studies pre-selecting for PCOS have 13/1,000 youth, 8/1,000 young adults demonstrated significant rates of glucose and 7/1,000 older). However, retinopathy intolerance. One study (47) reported an only appeared among those with youth IGT prevalence of 26.9% while another onset diabetes after 5 to 10 years (105) found a rate of 13%. However, both duration (incidence/1,000 person years: studies report lower prevalences of type 10/1,000 youth, 29/1,000 young adults 2 diabetes of 3.7% and 0.0% respectively. and 35/1,000 older).

Brickman et al (106) have conducted These studies have important one of the few studies pre-selecting for implications in that they highlight the risk the presence of AN and report an IGT of complications occurring at a relatively prevalence of 24% in subjects with AN. young age and as in the case of the Pima They suggest that children with AN may Indian study, that these complications benefit from diabetes screening and can occur relatively soon after diagnosis. early intervention. However, AN is not a This will place a significant burden on universal phenomenon in children with health budgets as well as society as a type 2 diabetes, and has so far not been whole. This is particularly so because noted to any degree among the large these people would be entering their studies surveying Japanese youth (8). peak working and earning capacity. Early detection and intervention is therefore Diabetic complications essential to reduce the risk of future complications. As with adults it is expected that youth with type 2 diabetes will also Discussion develop diabetes-related micro- and macrovascular complications. This was Compared to adults there is a paucity of reported recently in a study from Canada information on both the epidemiology (107), where subjects who developed and natural history of type 2 diabetes type 2 diabetes as children were then in the young. This needs to be urgently surveyed as young adults, aged between addressed given the potential threat of an 18 and 33 years. Of the 51 subjects, 9% explosion in childhood type 2 diabetes. had died, 6% were on dialysis while one had a toe amputation and one was blind. There are only a few large scale population-based studies focusing on Another follow-up study from Japan (108) youth with type 2 diabetes. Most of the compared those with type 1 and type 2 information available comes from case diabetes diagnosed at under 30 years series or clinic-based studies, together of age for development of nephropathy. with some case reports. On a global After 30 years of diabetes, 44% of those basis, the majority of data come from

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developed countries, particularly North and it is possible that it may partly America and Japan, with a distinct lack explain the female preponderance of information from many regions in the in youth onset type 2 diabetes. world, particularly from Africa and South Future work may need to address the America. issue of PCOS, especially since it is amenable to treatment. Notably, there is also a lack of 6 Studies have shown that youth standardization in study methods, with with type 2 diabetes will also many surveys only examining small develop diabetes-related micro- and numbers of subjects, as well as using macrovascular complications, as with different diagnostic methods and criteria. adults. These studies have important In addition some studies have only implications in that they highlight looked at very high risk subjects, such the risk of complications occurring as those with PCOS (47), presence of AN at a relatively young age, which will (106), or obesity (76). This can make place a significant burden on health comparisons between studies difficult. budgets as well as society as a whole. 7 The increasing prevalence of type 2 Conclusion diabetes in the young may be blunted by encouraging more physical activity Despite apparent deficiencies in research, and changing dietary habits. we can still make some valid conclusions 8 Interventional programmes should regarding type 2 diabetes in the young: be implemented to address the underlying cause, with an emphasis 1 It is a global phenomenon, which is on diet, weight, exercise and lifestyle on the increase. issues. 2 Children are being affected in both developed and developing nations. It is recognized that in an ideal world 3 Reports are appearing that show its it would be possible to implement the existence in populations hitherto proposed recommendations. In reality thought not to be at risk, such as this may be difficult given the poor British Europids. economic condition that many have 4 The risk of type 2 diabetes is clearly to endure and the already tight health linked to an increasing prevalence of budgets governments have to deal with. obesity, which is in turn associated However, many regions of the world are with changing dietary and lifestyle progressing economically and hence patterns. In particular an increase in becoming more urbanized. fatty foods as well as a reduction in activity levels both at home and in A consequence of urbanization is the the school. The change in lifestyle is parallel emergence of cardiovascular a worldwide phenomenon, occurring disease and diabetes, which hitherto, in both developed and emerging was mainly a problem of the developed nations, where it is most prevalent in world (see Chapter 3). Governments, urban areas. In these nations as well therefore, will be forced to deal with the as among indigenous communities problem of type 2 diabetes in children. residing in developed nations, there As such, it would be better to address seems to be a gradual abandonment the problem as a public health issue of traditional ways of living in favour under the heading of primary care and of a ‘westernized’ lifestyle. prevention, rather than dealing with the 5 A number of studies have noted an consequences of an entrenched condition association between type 2 diabetes and its complications in a young and polycystic ovary syndrome. Not population. all studies look for this condition

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Table 2.15 Type 2 diabetes and impaired glucose tolerance in the young – population-based studies

Prevalence (%) DM incidence Region Country Author Year of study Ethnicity Age (yrs) Diagnostic method Sample size DM IGT per 100,000 per year AFR Mali Fisch et al, 198781 1984-1985 Mixed tribal 15-24 FCG 2,558 0.39 Tanzania McLarty et al, 198982 1988 African 15-24 OGTT 1,178 0.4 6.7 Ahren et al, 198480 1982-1983 African ≤19 OGTT 1,327 0.15 Ramaiya et al, 199183 Indian 15-24 OGTT 156 Male 0.0 Male 2.3 Female 0.0 Female 4.2 Togo Teuscher et al, 198779 1987 Mixed tribal <20 OGTT 864 0.0 EMME Saudi Arabia el-Hazmi et al, 200078 1998 Arab 2-29 OGTT 9,917 (<14) <14 = 0.12 <14 = 0.25 14-29 = 0.79 14-29 = 0.21 NA Canada Dean et al, 199889 1996-1997 Cree-Ojibway 4-19 FBG 717 1.1 2.6 Delisle et al, 1993110 1989 Algonquin 15-20 OGTT 106 1.9 Harris et al, 1997111 1996 Cree-Ojibway 10-19 OGTT 244 3.0 10.0 USA Harrell et al, 200286 2001-2002 Caucasian 69% 10-15 FPG 668 1.5 10.8 African American 24% Hale et al, 200285 2002 Mostly Mexican 4th grade OGTT 1,417 0.3 0.14 American Hanis et al, 199684 1981-2002 Mexican American 15-24 OGTT 729 Male 0.0 Female 0.4 Chavez et al, 2002112 2002 N/A 15-19 RBG 778 0.13 Freedman et al, 199788 1991-1992 Navajo 12-19 OGTT 160 Male 3.0 Male 3.0 Female 13.0 Female 13.0 Dabelea et al, 199887 1987-1996 Pimas 5-19 OGTT 3,098 5-9 years: Male 0.0 Female 0.0 10-14 years: Male 1.5 Female 2.9 15-19 years: Male 3.8 Female 5.3 Acton et al, 200220 1990-1998 American Indian and ≤19 Chart review <15 years: 0.12 Alaskan native 15-19 years: 0.54 Male: 0.41 Female: 0.68 Kim et al, 1999113 1999 Navajo 13-20 OGTT 234 0.42 3.4 SEA Bangladesh Sayeed et al, 199592 1995 South Asian rural 15-29 OGTT 371 0.5 5.7 Sayeed et al, 199791 1997 South Asian urban 15-19 OGTT 271 0.06 0.04 India Bai et al, 199590 1994 South Asian 5-19 OGTT 3,515 0.0 WP Australia Braun et al, 199694 1989 Indigenous 7-18 OGTT 74 1.3 8.1 Australia Daniel et al, 1999114 1987-1995 Indigenous 15-24 OGTT 1,070 Japan Kitagawa et al, 19988 1991-1995 Japanese <15 Annual urinalysis. 386,000 Primary school 2 If glycosuria x2, then OGTT Junior high school +13.9 Taiwan Chuang et al, 200293 1993-1999 South-East Asian 6-18 Semi-annual urinalysis. 3x106 Male 0.009 If glycosuria, then OGTT Female 0.01 Tonga Colagiuri et al, 200295 1998-2000 Polynesian 15-19 OGTT 59 0.0

DM type 2 diabetes FBG fasting blood glucose FCG fasting capillary glucose FPG fasting plasma glucose IGT impaired glucose tolerance N/A not available OGTT oral glucose tolerance test RBG random blood glucose

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Table 2.16 Type 2 diabetes in the young – case reports

Year of Diagnostic Type 2 cases Region Country Author study Ethnicity Age (yrs) method (No.) EUR United Kingdom Ehtisham et al, 200097 2000 South Asian/Arab 9-16 Chart review Female 8.0 United Kingdom Drake et al, 20027 2002 Caucasian 13-15 Chart review Male 3.0 Female 1.0

Table 2.17 Type 2 diabetes in the young – case series

Type 2 cases Prevalence * DM incidence * Region Country Author Year of study Ethnicity Age (yrs) Diagnostic method Source of cases (No.) (%) per 100,000 per year EMME Libya Kadiki et al, 199698 1981-1990 Arab ≤19 Chart review Diabetes register and hospital 0-4 years: 0 N/A 5-9 years: 0.1 clinic 5-9 years: 1 10-14 years: 1.8 10-14 years: 11 15-19 years: 5.9 15-19 years: 30 United Arab Emirates Punnose et al, 2002115 1990-1998 Arab ≤18 Chart review Hospital clinic Male 1 N/A Female 4 EUR United Kingdom Ehtisham et al, 200171 1993 Mixed <18 Chart review Paediatric clinics Male 2 0.004 N/A Female 15 Ehtisham et al, 200171 1999-2000 Mixed <18 Chart review Paediatric clinics 4 N/A DM 1.52 NA Canada Harris et al, 199670 1978-1994 Cree-Ojibway <16 Chart review Diabetes register Male 1 Male 0.07 N/A Female 14 Female 0.42 Total 0.25 Dean, 1998116 1996 First Nation 5-14 Chart review Diabetes register 15 0.77 N/A USA Jones, 1998117 1993-1998 Mexican American 67% 5-17 OGTT or Sustacal challenge test Medical centre and clinics 18 N/A N/A Lipton et al, 200269 1985-1994 African American ≤17 Chart review Diabetes register N/A N/A DM 3.8 Latino Pihoker et al, 19986 1998-1995 African American 8-21 Chart review Diabetes clinic 37 N/A N/A Caucasian 12 Hispanic 1 Macaluso et al, 2002102 1994-1998 Hispanic 5-19 Chart review Diabetes clinic 92 14 N/A African American WP Australia Davis et al, 200233 1990-2002 Mixed <15 Chart review Paediatric centre Male 12 N/A N/A Female 25 Sinha et al, 200050 1999-2000 Indigenous 6-16 Chart review/OGTT Diabetes clinic 20 N/A N/A

* Calculated using an estimate of the total at-risk population.

DM type 2 diabetes N/A not available OGTT oral glucose tolerance test

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Table 2.18 Type 2 diabetes and impaired glucose tolerance in the young – clinic-based studies

Prevalence (%) DM incidence Region Country Author Year of study Ethnicity Age (yrs) Population Diagnostic method Sample size DM IGT per 100,000 per year EUR Hungary Korner, 2002103 1989-2001 Caucasian ≤19 Diabetic clinic Chart review 524 10.7 N/A Italy Invitti et al, 2003104 1994-2001 Caucasian 6-18 Obese OGTT 710 0.1 4.5 N/A Ciampalini et al, 200277 N/A Caucasian 3-19 Obese OGTT 191 0.5 12.6 N/A United Kingdom Barrett et al, 2002118 2000 Mixed <16 Paediatric diabetes centres Questionnaire of 15,255 0.2 N/A paediatric centres in UK NA USA Paulsen et al, 196874 1965 Mixed 4-16 Obese OGTT 66 0.0 23.0 N/A Legro et al, 1999105 1983-1991 Mixed 14-20 PCOS – all female OGTT 16 0.0 13.0 N/A Pinhas-Hamiel et al, 1996101 1984-1994 African American 68% ≤19 N/A N/A N/A 7.2 White 32% Neufeld et al, 199817 1990-1994 Mexican American <17 Diabetic clinic Chart review 55 31.0 N/A Uwaifo et al, 200275 1996-2002 Caucasian 6-11 Overweight BMI at ≤95th OGTT Overweight 121 0.0 4.1 N/A African American percentile Not overweight 104 0.0 0.0 Sinha et al, 200276 1999-2001 Caucasian 58% 4-18 Obesity clinic OGTT 4-10 years: 55 0.0 24.0 N/A Hispanic 19% 11-18 years: 112 3.6 23.0 African American 23% Brickman et al, 2002106 1999-2002 Mixed Mean 11.9 Presence of AN OGTT 33 3.0 24.0 N/A Palmert et al, 200247 2001 Mixed 13-19 PCOS – all female OGTT 27 3.7 26.9 N/A SEA India Ramachandran et al, 200399 2002-2003 Indian Asian 9-15 Diabetes clinic Chart review 18 0.0 WP Singapore, Republic of Lee et al, 199973 1999 Malay 42% ≤15 Obese children in a OGTT 23 17.0 4.3 N/A Indian 28% paediatric clinic Chinese 33% Thailand Likitmaskul et al, in press67 1997-1999 South-East Asian <15 Diabetic clinic Chart review 39 17.9 N/A New Zealand McGrath et al, 199972 1978-1998 Maori DM onset before 30 Diabetes register Chart review 51 55.0 N/A

AN acanthosis nigricans BMI body mass index (kg/m²) DM type 2 diabetes IGT impaired glucose tolerance N/A not available PCOS polycystic ovary syndrome OGTT oral glucose tolerance test

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39. Gutin B, Islam S, Manos T, Cucuzzo N, Smith C, Stachura ME. 56. Metzger BE, Silverman BL, Freinkel N, Dooley SL, Ogata ES, Relation of percentage of body fat and maximal aerobic Green OC. Amniotic fluid insulin concentration as a capacity to risk factors for atherosclerosis and diabetes in predictor of obesity. Arch Dis Child 1990; 65:1050-1052. black and white seven- to eleven-year-old children. J Pediatr 57. Casey BM, Lucas MJ, McIntire DD, Leveno KJ. Pregnancy 1994; 125:847-852. outcomes in women with gestational diabetes compared 40. Svec F, Nastasi K, Hilton C, Bao W, Srinivasan SR, with the general obstetric population. Obstet Gynecol 1997; Berenson GS. Black-white contrasts in insulin levels during 90:869-873. pubertal development. The Bogalusa Heart Study. Diabetes 58. Barker DJ, Hales CN, Fall CH, Osmond C, Phipps K, 1992; 1:313-317. Clark PM. Type 2 (non-insulin-dependent) diabetes mellitus, 41. Arslanian SA, Saad R, Lewy V, Danadian K, Janosky J. hypertension and hyperlipidaemia (syndrome X): relation to Hyperinsulinemia in african-american children: decreased reduced fetal growth. Diabetologia 1993; 36:62-67. insulin clearance and increased insulin secretion and its 59. Hales CN, Barker DJ. Type 2 (non-insulin-dependent) relationship to insulin sensitivity. Diabetes 2002; diabetes mellitus: the thrifty phenotype hypothesis. 51:3014-3019. Diabetologia 1992; 35:595-601. 42. Goran MI, Bergman RN, Cruz ML, Watanabe R. Insulin 60. Sibai BM, Caritis S, Hauth J, Lindheimer M, VanDorsten JP, resistance and associated compensatory responses in MacPherson C, Klebanoff M, Landon M, Miodovnik M, african-american and Hispanic children. Diabetes Care Paul R, Meis P, Dombrowski M, Thurnau G, Roberts J, 2002; 25:2184-2190. McNellis D. Risks of preeclampsia and adverse neonatal 43. Schmitz KH, Jacobs DR, Jr, Hong CP, Steinberger J, Moran A, outcomes among women with pregestational diabetes Sinaiko AR. Association of physical activity with insulin mellitus. National Institute of Child Health and Human sensitivity in children. Int J Obes Relat Metab Disord 2002; Development Network of Maternal-Fetal Medicine Units. 26:1310-1316. Am J Obstet Gynecol 2000; 182:364-369. 44. Nguyen TT, Keil MF, Russell DL, Pathomvanich A, 61. Barker DJ. Mothers, Babies and Health in Later Life. Uwaifo GI, Sebring NG, Reynolds JC, Yanovski JA. Relation Edinburgh: Churchill Livingston, 1998. of acanthosis nigricans to hyperinsulinemia and insulin 62. Ravelli AC, van der Meulen JH, Michels RP, Osmond C, sensitivity in overweight African American and white Barker DJ, Hales CN, Bleker OP. Glucose tolerance in children. J Pediatr 2001; 138:474-480. adults after prenatal exposure to famine. Lancet 1998; 45. Hirschler V, Aranda C, Oneto A, Gonzalez C, Jadzinsky M. 351:173-177. Is acanthosis nigricans a marker of insulin resistance in 63. Phillips DI, Barker DJ, Hales CN, Hirst S, Osmond C. obese children? Diabetes Care 2002; 25:2353. Thinness at birth and insulin resistance in adult life. 46. Lewy VD, Danadian K, Witchel SF, Arslanian S. Early Diabetologia 1994; 37:150-154. metabolic abnormalities in adolescent girls with polycystic 64. Flanagan DE, Moore VM, Godsland IF, Cockington RA, ovarian syndrome. J Pediatr 2001; 138:38-44. Robinson JS, Phillips DI. Fetal growth and the physiological 47. Palmert MR, Gordon CM, Kartashov AI, Legro RS, Emans SJ, control of glucose tolerance in adults: a minimal model Dunaif A. Screening for abnormal glucose tolerance analysis. Am J Physiol Endocrinol Metab 2000; in adolescents with polycystic ovary syndrome. J Clin 278:E700-706. Endocrinol Metab 2002; 87:1017-1023. 65. Wilkin TJ, Metcalf BS, Murphy MJ, Kirkby J, Jeffery AN, 48. Ehrmann DA, Barnes RB, Rosenfield RL, Cavaghan MK, Voss LD. The relative contributions of birth weight, Imperial J. Prevalence of impaired glucose tolerance and weight change, and current weight to insulin resistance diabetes in women with polycystic ovary syndrome. in contemporary 5-year-olds: the EarlyBird Study. Diabetes Diabetes Care 1999; 22:141-146. 2002; 51:3468-3472. 49. Dowling HJ, Pi-Sunyer FX. Race-dependent health risks of 66. Loos RJ, Phillips DI, Fagard R, Beunen G, Derom C, upper body obesity. Diabetes 1993; 42:537-543. Mathieu C, Verhaeghe J, Vlietinck R. The influence of 50. Sinha AK, O’Rourke S, Leonard D, Yarker J. Early onset maternal BMI and age in twin pregnancies on insulin Type 2 diabetes (T2DM) in the indigenous communities of resistance in the offspring. Diabetes Care 2002; far north Queensland (FNQ). In Australian Diabetes Society 25:2191-2196. Annual Scientific Meeting Cairns, Australia, 2000, p. 90. 67. Likitmaskul SKP, Chaichanwatanakul K, Punnakanta L, 51. Glowinska B, Urban M, Koput A. Cardiovascular risk factors Angsusingha K, Tuchinda C. An increasing prevalence of in children with obesity, hypertension and diabetes: type 2 diabetes in Thai children and adolescents associated lipoprotein(a) levels and body mass index correlate with with the increasing prevalence of obesity. J Pediatr family history of cardiovascular disease. Eur J Pediatr 2002; Endocrinol Metab, in press. 161:511-518. 68. Kadiki OA, Roaeid RB, Bhairi AM, Elamari IM. Incidence of 52. Berenson GS, Radhakrishnamurthy B, Bao W, Srinivasan SR. insulin-dependent diabetes mellitus in Benghazi, Libya Does adult-onset diabetes mellitus begin in childhood?: (1991-1995). Diabetes Metab 1998; 24:424-427. the Bogalusa Heart Study. Am J Med Sci 1995; 69. Lipton R, Keenan H, Onyemere KU, Freels S. Incidence and 310 Suppl 1:S77-82. onset features of diabetes in African-American and Latino 53. McCance DR, Pettitt DJ, Hanson RL, Jacobsson LT, children in Chicago, 1985-1994. Diabetes Metab Res Rev Bennett PH, Knowler WC. Glucose, insulin concentrations 2002; 18:135-142. and obesity in childhood and adolescence as predictors of 70. Harris SB, Perkins BA, Whalen-Brough E. Non-insulin- NIDDM. Diabetologia 1994; 37:617-623. dependent diabetes mellitus among First Nations children. 54. Dyck RF, Klomp H, Tan L. From “thrifty genotype” to “hefty New entity among First Nations people of north western fetal phenotype”: the relationship between high birthweight Ontario. Can Fam Physician 1996; 42:869-876. and diabetes in Saskatchewan Registered Indians. Can J 71. Ehtisham S, Kirk J, McEvilly A, Shaw N, Jones S, Rose S, Public Health 2001; 92:340-344. Matyka K, Lee T, Britton SB, Barrett T. Prevalence of type 2 55. Silverman BL, Metzger BE, Cho NH, Loeb CA. Impaired diabetes in children in Birmingham. BMJ 2001; 322:1428. glucose tolerance in adolescent offspring of diabetic 72. McGrath NM, Parker GN, Dawson P. Early presentation of mothers. Relationship to fetal hyperinsulinism. Diabetes type 2 diabetes mellitus in young New Zealand Maori. Care 1995; 18:611-617. Diabetes Res Clin Pract 1999; 43:205-209.

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73. Lee WY, KPF Chia, YY Tan CL. Looking for NIDDM and insulin 92. Sayeed MA, Banu A, Khan AR, Hussain MZ. Prevalence resistance in obese Singaporean children – when should we of diabetes and hypertension in a rural population of investigate? Diabetes Res Clin Pract 1999; 44:S25. Bangladesh. Diabetes Care 1995; 18:555-558. 74. Paulsen EP, Richenderfer L, Ginsberg-Fellner F. Plasma 93. Chuang LM, Sung FC, Lee CY, Lin RR, Lin CC, Chiang CC. glucose, free fatty acids, and immunoreactive insulin in Incidence and prevalence of childhood diabetes in Taiwan sixty-six obese children. Studies in reference to a family – an experience with nation-wide screening. Diabetes Res history of diabetes mellitus. Diabetes 1968; 17:261-269. Clin Pract 2002; 56:S16. 75. Uwaifo GI, Elberg J, Yanovski JA. Impaired glucose tolerance 94. Braun B, Zimmermann MB, Kretchmer N, Spargo RM, in obese children and adolescents. N Engl J Med 2002; Smith RM, Gracey M. Risk factors for diabetes and 347 (4):290-292; author reply 290-292. cardiovascular disease in young Australian aborigines. A 76. Sinha R, Fisch G, Teague B, Tamborlane WV, Banyas B, 5-year follow-up study. Diabetes Care 1996; 19:472-479. Allen K, Savoye M, Rieger V, Taksali S, Barbetta G, 95. Colagiuri S, Colagiuri R, Na’ati S, Muimuiheata S, Hussain Z, Sherwin RS, Caprio S. Prevalence of impaired glucose Palu T. The prevalence of diabetes in the kingdom of Tonga. tolerance among children and adolescents with marked Diabetes Care 2002; 25:1378-1383. obesity. N Engl J Med 2002; 346:802-810. 96. Fagot-Campagna A. Emergence of type 2 diabetes mellitus 77. Ciampalini P, Spera S, Bottazzo GF, Barbetti F, Crino A. in children: epidemiological evidence. J Pediatr Endocrinol Glucose intolerance in Italian obese children and Metab 2000; 13 Suppl 6:1395-1402. adolescents. Diabetologia 2002; 45:A91. 97. Ehtisham S, Barrett TG, Shaw NJ. Type 2 diabetes mellitus 78. el-Hazmi MA, Warsy AS. Prevalence of overweight and in UK children – an emerging problem. Diabet Med 2000; obesity in diabetic and non-diabetic Saudis. East Mediterr 17:867-871. Health J 2000; 6:276-282. 98. Kadiki OA, Reddy MR, Marzouk AA. Incidence of insulin- 79. Teuscher T, Baillod P, Rosman JB, Teuscher A. Absence of dependent diabetes (IDDM) and non-insulin-dependent diabetes in a rural West African population with a high diabetes (NIDDM) (0-34 years at onset) in Benghazi, Libya. carbohydrate/cassava diet. Lancet 1987; 1:765-768. Diabetes Res Clin Pract 1996; 32:165-173. 80. Ahren B, Corrigan CB. Prevalence of diabetes mellitus in 99. Ramachandran A, Snehalatha C, Satyavani K, Sivasankari S, north-western Tanzania. Diabetologia 1984; 26:333-336. Vijay V. Type 2 diabetes in Asian-Indian urban children. 81. Fisch A, Pichard E, Prazuck T, Leblanc H, Sidibe Y, Brucker G. Diabetes Care 2003; 26:1022-1025. Prevalence and risk factors of diabetes mellitus in the 100. Glaser NS, Jones KL. Non-insulin dependent diabetes rural region of Mali (West Africa): a practical approach. mellitus in Mexican-American children. West J Med 1998; Diabetologia 1987; 30:859-862. 168:11-16. 82. McLarty DG, Swai AB, Kitange HM, Masuki G, Mtinangi BL, 101. Pinhas-Hamiel O, Dolan LM, Daniels SR, Standiford D, Kilima PM, Makene WJ, Chuwa LM, Alberti KG. Prevalence of Khoury PR, Zeitler P. Increased incidence of non-insulin- diabetes and impaired glucose tolerance in rural Tanzania. dependent diabetes mellitus among adolescents. J Pediatr Lancet 1989; 1:871-875. 1996; 128:608-615. 83. Ramaiya KL, Swai AB, McLarty DG, Alberti KG. Impaired 102. Macaluso CJ, Bauer UE, Deeb LC, Malone JI, Chaudhari M, glucose tolerance and diabetes mellitus in Hindu Indian Silverstein J, Eidson M, Goldberg RB, Gaughan-Bailey B, immigrants in Dar es Salaam. Diabet Med 1991; 8:738-744. Brooks RG, Rosenbloom AL. Type 2 Diabetes Mellitus 84. Hanis CL, Boerwinkle E, Chakraborty R, Ellsworth DL, Among Florida Children and Adolescents, 1994 through Concannon P, Stirling B, Morrison VA, Wapelhorst B, 1998. Public Health Rep 2002; 117:373-379. Spielman RS, Gogolin-Ewens KJ, Shepard JM, Williams SR, 103. Korner AM, MD. Rising tide of type 2 diabetes mellitus and Risch N, Hinds D, Iwasaki N, Ogata M, Omori Y, Petzold C, impaired glucose tolerance among Hungarian children and Rietzch H, Schroder HE, Schulze J, Cox NJ, Menzel S, adolescents. Diabetologica Hungarica 2002;10:22-27. Boriraj VV, Chen X, et al. A genome-wide search for human 104. Invitti C, Guzzaloni G, Gilardini L, Morabito F, Viberti G. non-insulin-dependent (type 2) diabetes genes reveals a Prevalence and concomitants of glucose intolerance in major susceptibility locus on chromosome 2. Nat Genet European obese children and adolescents. Diabetes Care 1996; 13:161-166. 2003; 26:118-124. 85. Hale DE, Danney MM, Caballero M, Garcia O, Trevino RP. 105. Legro RS, Kunselman AR, Dodson WC, Dunaif A. Prevalence Prevalence of type 2 diabetes mellitus in urban, Mexican and predictors of risk for type 2 diabetes mellitus and American 4th graders. Diabetes 2002; 51:A25. impaired glucose tolerance in polycystic ovary syndrome: a 86. Harrell JS, McMurray RG, Davenport M, Amorim L, Buse J. prospective, controlled study in 254 affected women. J Clin Type 2 diabetes in southern middle school students. Endocrinol Metab 1999; 84:165-169. Diabetes 2002; 51:A26. 106. Brickman WJ, Howard JC, Metzger BE. Abnormal glucose 87. Dabelea D, Hanson RL, Bennett PH, Roumain J, Knowler WC, tolerance in children with acanthosis nigricans: a chart Pettitt DJ. Increasing prevalence of Type II diabetes in review. Diabetes 2002; 51:A429. American Indian children. Diabetologia 1998; 41:904-910. 107. Dean H FB. Natural history of type 2 diabetes diagnosed 88. Freedman DS, Serdula MK, Percy CA, Ballew C, White L. in childhood: long term follow-up in young adult years. Obesity, levels of lipids and glucose, and smoking among Diabetes 2002; 51:A24. Navajo adolescents. J Nutr 1997; 127:2120S-2127S. 108. Yokoyama H, Okudaira M, Otani T, Sato A, Miura J, 89. Dean HJ, Young TK, Flett B, Wood-Steiman P. Screening for Takaike H, Yamada H, Muto K, Uchigata Y, Ohashi Y, type-2 diabetes in aboriginal children in northern Canada. Iwamoto Y. Higher incidence of diabetic nephropathy in Lancet 1998; 352:1523-1524. type 2 than in type 1 diabetes in early-onset diabetes in 90. Bai PV, Krishnaswami CV, Chellamarippan M, Kumar GV, Japan. Kidney Int 2000; 58:302-311. Subramaniam JR, Srivatwa A, Subramanyam B, Rao MB. 109. Krakoff J, Lindsay RS, Looker HC, Nelson RG, Hanson RL, Prevalence of diabetes in the young in south India. Indian Knowler WC. Incidence of retinopathy and nephropathy in Pediatr 1995; 32:1173-1176. youth-onset compared with adult-onset type 2 diabetes. 91. Sayeed MA, Hussain MZ, Banu A, Rumi MA, Azad Khan AK. Diabetes Care 2003; 26:76-81. Prevalence of diabetes in a suburban population of 110. Delisle HF, Ekoe JM. Prevalence of non-insulin-dependent Bangladesh. Diabetes Res Clin Pract 1997; 34:149-155. diabetes mellitus and impaired glucose tolerance in two Algonquin communities in Quebec. CMAJ 1993; 148:41-47. 154 155

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111. Harris SB, Gittelsohn J, Hanley A, Barnie A, Wolever TM, Gao J, Logan A, Zinman B. The prevalence of NIDDM and associated risk factors in native Canadians. Diabetes Care 1997; 20:185-187. 112. Chavez RA, Strazdas LA, Lebowitz MD, Arriaga YE, Caruso Y, Dixit NM. Prevalence of type 2 diabetes in adolescents in Douglas, Arizona: is it significant. Diabetes 2002; 51:A429. 113. Kim C, McHugh C, Kwok Y, Smith A. Type 2 diabetes mellitus in Navajo adolescents. West J Med 1999; 170:210-213. 114. Daniel M, Rowley KG, McDermott R, Mylvaganam A, O’Dea K. Diabetes incidence in an Australian aboriginal population. An 8-year follow-up study. Diabetes Care 1999; 22:1993-1998. 115. Punnose J, Agarwal MM, El Khadir A, Devadas K, Mugamer IT. Childhood and adolescent diabetes mellitus in Arabs residing in the United Arab Emirates. Diabetes Res Clin Pract 2002; 55:29-33. 116. Dean H. NIDDM-Y in First Nation children in Canada. Clin Pediatr (Phila) 1998; 37:89-96. 117. Jones KL. Non-insulin dependent diabetes in children and adolescents: the therapeutic challenge. Clin Pediatr (Phila) 1998; 37:103-110. 118. Barrett TG, Ehtisham S, Smith A, Hattersley AT. UK Diabetes Survey shows type 2 diabetes present in 0.4% of newly diagnosed children, associated with overweight, female and ethnic minorities. Diabetes 2002; 51:A25.

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very disturbing feature of diabetes A has been the clustering of diabetes with other well-known cardiovascular risk factors, in particular central (abdominal) obesity. It is for this reason that a chapter on obesity and cardiovascular disease (CVD) appears in this edition of the Diabetes Atlas.

With globalization, there have been dramatic changes in the human environment, behaviour and way-of- life which have resulted in escalating rates of both diabetes and obesity. This explains the recent popularity of the term ‘diabesity’. The frequency of central obesity, hypertension and elevated 3.1 Obesity blood lipids are dramatically increased in 3.2 Cardiovascular Disease and persons with diabetes and this has been Diabetes: Double Jeopardy called the ‘Deadly Quartet’.

The concern regarding the associated increase in cardiovascular risk becomes even greater when one considers that people with impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) also have a substantial increase in cardiovascular risk factors and, like persons with diabetes, higher cardiovascular risk. Coronary artery disease and cerebrovascular disease are two to three times more common in people with diabetes than in people without diabetes.

Cardiovascular disease is the major cause of death in people with type 2 diabetes. A key strategy in reducing macro-vascular disease lies in the better understanding of the metabolic syndrome: glucose

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intolerance (type 2 diabetes, IGT or IFG), hyperinsulinaemia, hypertension, dyslipidaemia and central obesity. This clustering of CVD risk factors represents a time bomb for both individuals with diabetes and the nations faced with the public health burden as it provides the driving force for a cardiovascular disease epidemic.

It is now very clear that management of diabetes should focus not only on tight blood glucose control but also on strategies for reducing the other important cardiovascular risk factors such as central obesity, hypertension, and dyslipidaemia in order to reduce cardiovascular disease complications.

It is also clear from a number of epidemiological studies that the clock starts ticking for cardiovascular disease many years before the clinical diagnosis of diabetes. This highlights the rationale for early intervention in the IGT phase. The potential for IGT and, indeed, the metabolic syndrome to be prevented is now well documented with lifestyle interventions and pharmacotherapy.

Reducing obesity through healthy nutrition along with exercise provides the logical means of prevention of both diabetes and associated cardiovascular morbidity and mortality. This is supported by three major type 2 diabetes intervention studies – the DaQing Study in China, the Diabetes Prevention Study (DPS) in Finland and the Diabetes Prevention Program (DPP) in USA. An integrated approach to preventing both diabetes and obesity can hopefully reduce the global burden.

The report on obesity was compiled by the International Obesity Task Force while the data on CVD mortality rates were compiled by the WHO Collaborating Centre at the Menzies Centre, University of Tasmania, Australia.

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3.1 Obesity

Introduction be obese. The International Obesity A new generation is Task Force (IOTF) estimates that up to entering adulthood with Obesity is the principal risk factor for 1.7 billion people may be exposed to unprecedented levels type 2 diabetes. An excess of body fat, weight-related health risks, taking into of obesity. This, in especially when concentrated within account varied Asian populations with a addition to the existing the abdomen, has a range of potentially BMI of 23 or more. burden of adult obesity, harmful consequences. Classified as a reinforces the concern disease, obesity diminishes both quality Average BMI levels across Africa and Asia that weight-related of life and life expectancy, but it is also a have been estimated at between 20-23 chronic diseases will common risk factor for a number of other kg/m2, but in Europe and North America be the most significant diseases from osteo-arthritis to heart mean levels are much higher at 25-27 public health concern disease and some types of cancer (see kg/m2, indicating that a substantial part throughout the Box 3.1). of the population may be exposed to 21st century. the health risks of higher BMIs (3). More The World Health Organization (WHO) than 2.5 million deaths each year are definesoverweight as a body mass attributed to higher BMI, a figure that is index (BMI) of at least 25 kg/m2 and expected to double by 2030. obesity as a BMI of at least 30 kg/m2 (see Box 3.2). However, the health risks Regional trends rise progressively above BMI levels of 20-22 kg/m2 in all populations (1). The Across the world the epidemic of conclusions of a WHO expert group, obesity has been gathering momentum which considered the evidence for lower affecting both developed and developing BMI action points around BMI 23 in countries. different Asian populations, are at present under review.

Box 3.1 WHO recommends a general limit for waist circumference of 102 cm and 88 Obesity – a risk factor cm in men and women respectively, but more appropriate waist circumference verweight and obesity lead to adverse metabolic action levels are now being sought to effects on blood pressure, cholesterol, triglycerides specify risk levels relating to diabetes and O and insulin resistance. Risks of coronary heart disease, other co-morbidities in Asian countries to ischaemic stroke and type 2 diabetes mellitus increase help alert those with lower BMIs to their steadily with increasing body mass index (BMI). increased risks (2). Type 2 diabetes mellitus - confined to older adults for Over recent years rates of overweight most of the 20th century - now affects obese children even and obesity have escalated rapidly in before puberty. Modest weight reduction reduces blood many parts of the world to epidemic pressure and abnormal blood cholesterol and substantially lowers risk of type 2 diabetes. proportions, reflecting increased consumption of energy dense diets high Raised BMI also increases the risks of cancer of the breast, in fats and sugars, compounded by colon, prostate, endometrium, kidney and gallbladder. declining levels of physical activity. Although the mechanisms that trigger these increased cancer risks are not fully understood, they may relate to Using the standard classification, more obesity-induced hormonal changes. Chronic overweight than 1.1 billion people are estimated and obesity contribute significantly to osteo-arthritis, a to be overweight, of whom around major cause of disability in adults. 320 million are now calculated to

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rates of 50.9% in Tunisia and 51.3% in Box 3.2 Morocco, and obesity rates (BMI≥30) in women of 23% in Tunisia and 18% Defining body mass index (1) in Morocco, representing a three-fold Body mass index (BMI) is calculated by dividing weight in increase over 20 years (6). kilogrammes (kg) by the square of height in metres (m). Europe BMI ≥25 = overweight Few countries in the European Region BMI 25-29.9 = pre-obesity report obesity rates below 10%. BMI ≥30 = obesity Prevalence rates, particularly among women, rise to more than 20% in The sub-categories of obesity: countries such as the United Kingdom, Obesity class I 30.0-34.9 = moderate Germany, Finland and Greece. The most Obesity class II 35.0-39.9 = severe rapid increase is noted in England where Obesity class III 40+ = very severe obesity rates have risen three-fold from 1980 to 2001, with levels of morbid obesity (BMI≥40) also increasing three- fold among men and almost doubling among women during the 1990s (7).

Africa North America Wide disparities in levels of obesity are In the United States obesity affects found in this region with the highest one in three adults overall, more than rates in South Africa, where mean BMI double the rate of 20 years ago. Ethnic values for men and women are 22.9 minorities, particularly women, are even kg/m2 and 27.1 kg/m2 respectively, but more adversely affected with 40% of levels of central obesity among women Mexican American women and 50% of have been assessed at 42% (4). The South black American women having a body Africa Health Review 2000 indicated mass index above 30 kg/m2 compared obesity rates from 8% among black men to 30.6% of white women. Extreme to 20% among white men, but among obesity rates, classified as morbid or women the rates range from 20% for very severe obesity of BMI≥40, are as Indian/Asians to 30.5% for black women. high as 15% among black American In parts of sub-Saharan Africa obesity women (8). Neighbouring Canada often exists alongside under-nutrition (5). experienced an increase of 150% in its overall adult obesity rate from 1985 to Eastern Mediterranean 1998 reaching 14.8%, but 40% of men and Middle East and 25% of women fell into the pre-obese High levels of overweight and obesity category (9). exist particularly among women, in countries as diverse as Egypt and the In the Caribbean, obesity is a significant Gulf states including Saudi Arabia. problem, particularly among women, Obesity rates of 25-30% and even higher with correspondingly high rates of type 2 are not untypical in Kuwait, the United diabetes. Abdominal obesity, using WHO Arab Emirates and Bahrain. In Iran, waist circumference limits, ranged from obesity rates vary from rural to urban 3% of men in St Lucia to 8% in Barbados, populations rising to 30% among women but among women was found to be as in Tehran. high as 34% in Jamaica, 41% in St Lucia and 45% in Barbados (10). Diabetes In northern Africa the prevalence of studies in Jamaica have demonstrated obesity among women is high. Half of markedly high risks associated with all women are overweight (BMI≥25) with overweight and central obesity (11).

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South and Central America this apply in the Asian region. Using this Evidence of the impact of the ‘nutrition standard, adult obesity in Japan would transition’ is clear in the growing levels of average 20%, rising to 30% in men over obesity throughout this region. Obesity 30 years old and women over 40 years rates are reported to vary for men from old, representing a three to four-fold 7% in Peru and Brazil to more than 20% in increase over the last 40 years (15,16). Paraguay, where the rates in women rise to as high as 36% (12). China has adopted its own standards defining overweight at a BMI of 24 or Western Pacific more, and obesity at a BMI of 28 or more. Various Asian populations may be However abdominal obesity is defined by particularly susceptible to the health risks a waist circumference of 85 cm in men of central obesity, regardless of BMI (13). and 80 cm in women (17). Figure 3.1 Consequently there is an increasing focus shows the prevalence of obesity, using on measuring waist circumferences, BMI ≥25 as a criterion, in selected which can predict individual risk more countries in the Western Pacific. accurately than body mass index (14). However, Japanese experts have agreed The link between obesity and type 2 independently to redefine the criteria diabetes is most manifest in the Pacific for obesity as a disease, with a cut-off at area which has some of the highest levels BMI≥25. It has also been suggested that of adult obesity. Obesity prevalence rates

Figure 3.1 Prevalence of obesity using BMI ≥25 as criterion in selected countries – Western Pacific Region

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(BMI ≥30) of between 60% and 80% can as fat cells expand, particularly in the be found among men and women in abdomen. Physical inactivity, both a some islands including Samoa and Nauru. cause and consequence of weight gain, In Tonga, 60% of the adult population also contributes to insulin resistance. is obese and recently 12% of men and nearly 18% of women were identified with The IOTF analyses, undertaken for the type 2 diabetes, a doubling of the rate World Health Report 2002 and associated over 25 years. A further 20% were found WHO Global Burden of Disease research, to be at risk due to elevated blood sugar indicate that approximately 58% of levels (18). diabetes mellitus globally (as well as 21% of ischaemic heart disease and 8-42% of Obesity and diabetes certain cancers) can be attributed to BMI above 21 kg/m2. However in western Obesity and type 2 diabetes are causally countries, around 90% of type 2 diabetes linked. Weight gain leads to insulin cases are attributable to weight gain (see resistance through several mechanisms. Figure 3.2), and childhood overweight Insulin resistance places a greater and obesity are now leading to an demand on the pancreatic capacity to unusual pattern of premature type 2 produce insulin, which also declines diabetes, which is particularly difficult to with age, leading to the development of manage once established (19). clinical diabetes. Among adults, clear evidence exists that Fat accumulation induces insulin surprisingly modest weight reductions resistance through changes in its can markedly reduce the development hormonal and other secretions. Protective of type 2 diabetes, if not prevent it hormones such as adiponectin decline completely, in susceptible individuals,

Figure 3.2 Proportion of diabetes (%) attributable to weight gain by region (30+ years)

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and that weight loss can reverse the Figure 3.3 type 2 diabetic state. The remarkable Overweight and obesity among school-age children effect of weight loss through diet and (5-17 years) increased activity has been demonstrated �� in the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Diabetes Prevention Program in the USA �� to benefit particularly the over-60s, in whom nearly three-quarters of new cases ��

of diabetes were prevented. � � �

� �� This and other studies provide hope to � � �

� �� those with impaired glucose tolerance � � and a susceptibility to diabetes. Dietary and activity changes to produce a 5-7% �� weight loss can successfully reduce the incidence of type 2 diabetes; reductions � in fat and calorie intake accompanied by half an hour’s extra walking or � other exercise each day have been �� demonstrated to lower the incidence by �� 58%. Great success has been achieved �� Source: © IOTF (25) among people over 60 years, reducing the development of diabetes in that high- risk age group by 71% (20). Similar data have emerged from China, Scandinavia reduce the quality of life as well as and other European studies. lowering life expectancy. Higher body mass index has been shown to account Costs of obesity for up to 16% of the global burden of disease, expressed as a percentage of The cost of obesity in economic terms disability-adjusted life years (DALYs) has been estimated to account for 2-7% (see Map 3.1) (24). of total healthcare costs (1). Recently the combined direct and indirect costs Childhood obesity to the USA have been re-assessed at US$123 billion in 2001 (21). This Childhood obesity is a relatively recent expenditure may overshadow the costs phenomenon, which poses a critical in smaller countries such as England threat to health. Significant prevalences where the Parliamentary National Audit exist in developing countries as well as Office assessed the cost at around £2.5 in industrially developed economies. An billion (£3 billion when adjusted to IOTF analysis (see Figure 3.3) has shown 2003 figures) (22). In the Pacific islands, that overweight and obesity affects one the economic consequences of non- in 10 children worldwide, but the rate communicable diseases, chiefly obesity is double in Europe and three times as and type 2 diabetes, have been dramatic, great across the entire Americas (25). consuming US$1.95 million, almost 60% The emergence of type 2 diabetes in of the health budget of Tonga, and in Fiji childhood is a serious development. In absorbing US$13.6 million, 39% of the the USA it has been noted that up to health budget (23). 45% of children with newly diagnosed diabetes have type 2 diabetes and The human cost can be measured in most are overweight or obese at terms of years of disability, which can diagnosis (26).

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Conclusion weight-related chronic diseases will be the most significant public health concern The most recent WHO recommendations throughout the 21st century. for dietary improvements and increased levels of exercise across entire The provision of effective obesity populations provide the basis for the treatment, which can prevent or delay development of global strategies to the onset of type 2 diabetes, and the challenge the rise in obesity along development of coherent strategies with other diet and activity related to halt the progressive weight gain chronic diseases, including type 2 in evidence in most populations, is diabetes (27). However even if the WHO lacking. Weighing the clear benefit of recommendations, including those to interventions against the significant costs reduce fat, sugar and salt consumption, in both human and financial terms of were to be implemented, it would be inaction, it is surprising, if not alarming, some considerable time before the that so little has been done worldwide benefits were reflected in a reduction of to attack the root causes of the twin obesity and co-morbidity rates. epidemics of obesity and type 2 diabetes.

A new generation is entering adulthood with unprecedented levels of obesity. This, in addition to the existing burden of adult obesity, reinforces the concern that

Map 3.1 Proportion of DALYs attributable to overweight (high body mass index)

�� Source: World Health Report 2002, WHO �� 164 �� 165 ��

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Map 3.2 Global prevalence of obesity (BMI ≥30) in males

�� Source: © IOTF, 2003 � �� Map 3.3 �� Global prevalence of obesity (BMI ≥30) in females �� Source: © IOTF, 2003 �� 164 165 �� Diabetes Atlas Second Edition Diabetes Atlas Second Edition �� The Widening Circle The Widening Circle Chapter 3 Chapter 3

20. Knowler WC, Barrett-Connor E, Fowler SE, Hamman References RF, Lachin JM, Walker EA, Nathan DM. Reduction in the incidence of type 2 diabetes with lifestyle intervention or 1. World Health Organization. Obesity: Preventing and metformin. N Engl J Med 2002; 346:393-403. Managing the Global Epidemic. Technical Report Series no. 21. Wolf AM, Manson JE, Colditz GA. The Economic Impact of 894. WHO, Geneva, 2000. Overweight, Obesity and Weight Loss. Ed Eckel R in Obesity. 2. Choo V. WHO reassesses appropriate body mass index for Lippincott, Williams and Wilkins, 2002. Asian populations. Lancet 2002; 360:234. 22. National Audit Office. Tackling Obesity. National Audit 3. IOTF analysis of data gathered for the WHO Global Burden Office, London 2001. of Disease 2003. 23. Dalton A and Crowley S. Economic Impact of NCD in the 4. Puoane T, Steyn K, Bradshaw D, Laubscher R, Fourie J, Pacific Islands in Obesity in the Pacific: Too Big to Ignore. Lambert V, Mbananga N. Obesity in South Africa: the South Secretariat of the Pacific Community 2002. African demographic and health survey. Obesity Research 24. World Health Organization. The World Health Report 2002; 10:1038-1048. 2002. Reducing Risks, Promoting Healthy Life. IOTF 5. Maire B, Delpeuch F, Cornu A, Tchibindat F, Simondon F, research for the WHO Global Burden of Disease programme. Massamba JP, Salem G, Chevassus-Agnes S. Urbanization 25. IOTF. Childhood Obesity – The New Crisis in Public Health. and nutritional transition in sub-saharan Africa: exemplified International Obesity Task Force, London, 2003; in press. by Congo and Senegal. Rev Epidemiol Santé Publique 1992; 26. American Diabetes Association. Type 2 diabetes in children 40:252-258 (article in French). and adolescents. Diabetes Care 2000; 3:381-389. 6. Mokhtar N, Elati J, Chabir R, Bour A, Elkari K, Schlossman 27. WHO/FAO. Diet, Nutrition and the Prevention of Chronic NP, Caballero B, Aguenaou H. Diet culture and obesity in Diseases. Technical Report Series no. 916. WHO, Geneva, northern Africa. J Nutrition 2001; 131:887S-892S. 2003. (www.who.int/hpr/NPH/docs/who_fao_expert_ 7. Department of Health 2001. Health Survey for England. report.pdf) www.doh.gov.uk/. 8. NHANES 1999-2000. www.cdc.gov/. 9. Katzmarzky PT. The Canadian obesity epidemic, 1985-1998. CMAJ 2002; 166(8):1039-1040. 10. Okosun IS, Forrester TE, Rotimi CN, Osotimehin BO, Muna WF, Cooper RS. Abdominal adiposity in six populations of West African descent: prevalence and population attributable fraction of hypertension. Obes Res 1999; 7:453-462. 11. Wilks R, Rotimi C, Bennett F, McFarlane-Anderson N, Kaufman JS, Anderson SG, Cooper RS, Cruickshank JK, Forrester T. Diabetes in the Caribbean: results of a population survey from Spanish Town, Jamaica. Diabetic Medicine 1999; 16:875-883. 12. Filozof C, Gonzales C, Sereday M, Mazza C, Braguinsky J. Obesity prevalence and trends in Latin American countries. Obesity Reviews 2001; 2:99-196. 13. James WPT, Chunming C, Inoue S. Appropriate Asian body mass indices? Obesity Reviews 2002; 3:139. 14. Lean ME, Han TS, Deurenberg P. Body composition by densitometry from simple anthropometric measurements. Am J Clinical Nutrition 1996; 63:4-14. 15. The Examination Committee of Criteria for ‘Obesity Disease’ in Japan, Japan Society for the Study of Obesity. New Criteria for ‘Obesity Disease’ in Japan. Circulation Journal 2002; 66(11):987-992. 16. Kanazawa M, Yoshiike N, Osaka T, Numba Y, Zimmet P, Inoue S. Criteria and classification of obesity in Japan and Asia-Oceania. Asia Pac J Clin Nutr 2002 Dec; 11 Suppl 8:S732-S737. 17. Zhou BF, Cooperative Meta-Analysis Group of the Working group on Obesity in China. Predictive values of body mass index and waist circumference for risk factors of certain related diseases in Chinese adults - study on optimal cut- off points of body mass index and waist circumference in Chinese adults. Biomed Environ Sci 2002; 15:83-95. 18. Colagiuri S, Colagiuri R, Na’ati S, Muimuiheata S, Hussain Z, Palu T. The prevalence of diabetes in the kingdom of Tonga. Diabetes Care 2002; 25:1378-1383. 19. James WPT, Jackson-Leach R, Mhurdu CN, Kalamara E, Shayeghi M, Rigby N, Nishida C and Rodgers A. Overweight and Obesity. In Comparative Quantification of Health Risks: Global and Regional Burden of Disease Attributable to Selected Major Risk Factors, eds. Ezzati M, Lopez AD, Rodgers A, Murray CJL. WHO, Geneva, 2003; in press.

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3.2 Cardiovascular Disease and Diabetes: Double Jeopardy

Introduction Major cardiovascular complications Cardiovascular disease (CVD) is a major worldwide health problem and the The most important cardiovascular leading cause of death in industrialized complications of diabetes are: countries. Cardiovascular disease is also the major complication of type 2 diabetes • coronary heart disease (CHD); and is responsible for more than 50% • cerebrovascular disease (CBVD); and and up to 80% of deaths in people with • peripheral vascular disease (PVD). diabetes as well as for very substantial morbidity and loss of quality of life (see Given the global epidemic of diabetes, Chapter 1.2). the double threat of diabetes and CVD is set to explode unless preventative action Diabetes can lead to cardiovascular is taken. It is noteworthy for example damage in a number of ways. The that, in some Western populations, processes do not develop independently, CHD rates have declined in the overall and each may accelerate or worsen the population but no consistent decline is others. Thus, as diabetes progresses, the seen in people with diabetes (1). heart and blood vessels are exposed to multiple attacks. The cardiovascular disease triad Cardiovascular death rates are either high or appear to be climbing in countries �� where diabetes is prevalent. The outlook for cardiovascular diseases is alarming when one considers the number of people with diabetes worldwide and that �� this is set to more than double by 2025. ��

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

Many cardiovascular deaths are potentially preventable in both people with and without diabetes if action is �� taken to systematically address the �� known risk factors. While some risk factors are fixed, such as age, gender and genetic background, many others are modifiable, such as high blood pressure, lipid abnormalities, obesity and smoking.

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Figure 3.7 Diabetes as a risk factor Heart attacks in people with and without diabetes over a period of seven years (adapted from Haffner SM et al (2)) The impact of cardiovascular disease in diabetes is exacerbated even further by �� the earlier age of onset of type 2 diabetes �� which is now reaching down even to children and adolescents, and carries �� the threat of early onset of CVD. In �� addition advances in insulin therapy have

� improved the life expectancy of people

� ��

� with type 1 diabetes and each year of � �

� �� prolonged life increases the likelihood of � � �

� cardiovascular complications. � ��

�� Diabetes leads to cardiovascular damage

�� by a number of mechanisms, each of which in turn may accelerate or worsen � the others. It belongs to a special risk � category as it has so marked an effect �� on cardiovascular risk. As well as being

�� a risk factor in its own right, diabetes

�� is associated with a higher prevalence of other common risk factors such Source: Diabetes and Cardiovascular Disease: Time to Act, IDF 2001 (3) as hypertension and dyslipidaemia, and, these risk factors, in turn, have a more harmful effect in the presence of Figure 3.8 diabetes. For each risk factor present, the Deaths in people with and without diabetes in the year risk of cardiovascular death is about three following a first heart attack(adapted from Miettinen et al (4)) times greater in people with diabetes compared to those without diabetes. ��

�� The end result is that people with diabetes are two to four times more �� likely to develop CVD than the general �� population (see Figure 3.7). In the case

� of CVD, silent myocardial infarction is

� ��

� common and the risks of sudden death � �

� �� and heart failure are also increased. In � � �

� the case of stroke, transient ischaemic � �� attacks are two to six times more �� common in the diabetic population and

�� vascular dementia is also more common. In the case of PVD people with diabetes � have a 15-40 times increase in the risk of � lower limb amputation compared to the �� general population.

��

�� These figures also conceal additional problems. For a given major vascular Source: Diabetes and Cardiovascular Disease: Time to Act, IDF 2001 (3) event such as myocardial infarction or stroke, the outcome is worse in people with diabetes compared to the

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general population (see Figure 3.8). The use of mortality data, obtained This results from both the severity and principally from the Global Cardiovascular widespread nature of atherosclerosis in Infobase, does however serve to indicate diabetes, combined with other causes the magnitude of the problem and to of vascular disease in diabetes apart highlight regional differences and trends. from atherosclerosis, such as arterial stiffness, microangiopathy and autonomic It should be noted that considerable The link between neuropathy*. differences exist in the degree of diabetes and CVD is completeness of the vital registration so strong that the It is important to note also that even at data submitted by countries. In some prevention agenda for the stage of impaired glucose tolerance countries, the vital registration data both diseases can be (IGT), before full-blown diabetes has system covers only a part of the country linked and integrated developed, the risk of cardiovascular (for example urban areas, or some at many levels of disease is already increased by about two provinces only). In some other countries, the system. The high times compared to people with normal although the vital registration data CVD risk in people glucose tolerance. system covers the whole country, not all with IGT and newly- deaths are registered. Further details on diagnosed diabetes A costly combination data sources and methodology can be also emphasizes both found in Appendix 1.4. the importance of About half of all the money spent on primary prevention of diabetes care goes towards the costs It should be emphasized also that these diabetes in the context of managing diabetic complications. data provide the overall picture of total of overall prevention Cardiovascular complications frequently CVD mortality and are not limited to CVD of CVD and the account for the bulk of the costs as in the context of diabetes. significance of diabetes reflected in the patterns of hospital as an ‘entry point’ for admissions for the treatment of Regional and national trends overall, comprehensive complications (see Figure 3.9). The As well as differences in total trends cardiovascular risk trend of escalating diabetes prevalence in different parts of the world, there management. with its impact on CVD will no doubt may also be differences in disease lead to an immense financial burden patterns which are not revealed by these in many countries unless action is figures. For example, in the case of taken to prevent both diabetes and its cerebrovascular disease, the proportion complications. of deaths resulting from haemorrhagic stroke compared to thrombotic stroke is The global burden of higher in Japan, China and many African cardiovascular disease countries, compared to Europe or North America. This may reflect differences in The data which follow summarize the the relative importance of individual risk global burden of cardiovascular disease factors, such as hypertension. by using mortality data for coronary heart disease and cerebrovascular disease Africa from individual countries. It needs to Available data from Africa are very be emphasized that these are mortality limited but show marked contrasts data and do not therefore indicate levels between countries. Botswana reports of morbidity in survivors. They also do zero deaths from CHD and a low not include information about peripheral mortality from cerebrovascular disease vascular disease. whereas Zimbabwe occupies an intermediate position. In South Africa the mortality from cerebrovascular disease in females stands out as being equal to * For further details readers are referred to Diabetes and Cardiovascular Disease: Time to Act, that of males and double that of CHD in International Diabetes Federation, 2001 (3). females.

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Figure 3.9 Proportion of hospital bed days used for the treatment of diabetic complications

United Kingdom Argentina

��

Source: International Diabetes Federation, 1999 (5)

Eastern Mediterranean North America and Middle East CHD mortality rates have shown recent Limited reports from the Middle East falls in both Canada and USA and are indicate cerebrovascular disease mortality broadly similar to western European rates similar to those of western countries such as Germany, Sweden and European countries with the lowest rates, Austria although still much higher than for example France. Rates in Egypt are other European countries such as France however higher and appear to be rising and Portugal. Rates of cerebrovascular quite rapidly. By contrast CHD rates disease in USA and Canada are broadly are relatively low in Egypt compared to similar to those in lower prevalence Bahrain, and, particularly, Kuwait. western European countries such as France, Netherlands and Spain. Europe In many western European countries South and Central America CHD mortality rates have dropped and the Caribbean appreciably in the last two decades. CHD mortality rates vary greatly from However the eastern European countries country to country but are generally from the previous Soviet bloc have some similar to or below those for North of the highest rates in the world for America, with the exception of Trinidad both CHD and cerebrovascular disease. and Cuba and a few other countries Thus Estonia has double the rate of which have a relatively high mortality Finland, and Georgia makes interesting rate in females. Mortality rates from comparison with France, with a five cerebrovascular disease are relatively times higher rate in males and ten times much higher and approach or exceed higher rate in females. The Russian those from CHD, a notable example Federation and Ukraine also have very being Brazil. high rates. Similar trends are seen with cerebrovascular disease.

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South-East Asia be linked and integrated at many levels of Data are available only from Sri Lanka the system. The high CVD risk in people and Mauritius. The absence of data from with IGT and newly-diagnosed diabetes India, Pakistan and Bangladesh makes also emphasizes both the importance detailed analysis difficult. This lack of primary prevention of diabetes in the of data also causes concern given the context of overall prevention of CVD numbers of people with diabetes in India and the significance of diabetes as an and relatively high reported rates for CHD ‘entry point’ for overall, comprehensive in migrant Indian populations. cardiovascular risk management. An effective prevention strategy should The reported rates from Sri Lanka indicate therefore include each of the following that both CHD and cerebrovascular components: disease mortality rates are approximately similar to those of France, a western • Primary prevention of diabetes, European country with relatively low preferably integrated with other non- rates. Mauritius has very high rates for communicable disease prevention both CHD and cerebrovascular disease, programmes. A carefully balanced and is also well known for high diabetes combination of population-wide and prevalence rates. targeted high-risk strategies should be employed. Western Pacific • Secondary prevention of diabetes This is a huge and diverse region and complications by optimal diabetes this diversity is reflected in the ranges care. of reported mortality rates. The reported • Overall risk factor management in mortality rates for CHD in males range people with diabetes. This requires from 7.9 in China to 235 in Singapore and intensive treatment of the whole in females range from 5.5 in China to 116 range of involved risk factors and in New Zealand and 109 in Singapore. metabolic abnormalities and not just hyperglycaemia. In several countries cerebrovascular • Provision of targeted medical and mortality is higher than CHD mortality revascularisation treatments to reduce with China and Japan providing the death and disability in people who clearest examples of this. This is likely have already developed CVD. to reflect the importance of hypertension • Careful design of healthcare systems as a risk factor in these countries to overcome barriers, ensure flexibility and, as commented upon above, also and provide adequate facilities for the coincides with a relatively high ratio of overall management of CVD risk. haemorrhagic stroke to ischaemic stroke in these two countries.

Prevention

As stated earlier CVD is the cause of most of the deaths and much of the disability seen in people with diabetes. Good evidence now exists that much of this disease burden can be prevented or, at the very least, delayed by appropriate preventative measures. The link between diabetes and CVD is so strong that the prevention agenda for both diseases can

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Map 3.4 Coronary heart disease in males (35-74 years): mortality rates per 100,000 population per year

�� Map 3.5 �� Coronary heart disease in females (35-74 years): mortality rates per 100,000 population per year ��

�� 172 �� 173 �� Diabetes Atlas Second Edition ��Diabetes�� Atlas Second Edition�� The Widening Circle The Widening Circle Chapter 3 Chapter 3

Map 3.6 Cerebrovascular disease in males (35-74 years): mortality rates per 100,000 population per year

�� Map 3.7 �� Cerebrovascular disease in females (35-74 years): mortality rates per 100,000 population per year ��

�� 172 173 �� Diabetes Atlas Second Edition Diabetes Atlas Second Edition �� The Widening Circle Chapter 3

References

1. Gu K, Cowie CC, Harris MI. Diabetes and decline in heart disease mortality in US adults. J Am Med Assoc 1999; 281:1291-1297. 2. Haffner SM, Lehto S, Rönnemaa T, Pyörälä K, Laakso M. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without previous myocardial infarction. N Engl J Med 1998; 339:229-234. 3. International Diabetes Federation. Diabetes and Cardiovascular Disease: Time to Act. International Diabetes Federation, Brussels, 2001. 4. Miettinen H, Lehto S, Salomaa VV, et al. Impact of diabetes on mortality after the first myocardial infarction. Diabetes Care 1998; 21:69-75. 5. International Diabetes Federation. Diabetes Health Economics: Facts, Figures and Forecasts. International Diabetes Federation, Brussels, 1999.

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The Economic Impact of Diabetes Chapter 4

he economic impact of diabetes is Tconsiderable. Its costs affect health services, national productivity as well as individuals and families. Hospital in-patient costs for the treatment of complications are the largest single contributor to direct healthcare costs. Many of these complications and, therefore, their costs are preventable. Intensive therapy, directed at the control of blood glucose, blood pressure etc, has been shown to be cost-effective in that, although initial costs are increased, it decreases longer term costs as a result of delayed or prevented complications.

The annual direct healthcare costs of diabetes worldwide, for people in the 20- 79 age bracket, is estimated to be at least 153 billion international dollars* and may be as much as 286 billion, or even more.

If predictions of diabetes prevalence are fulfilled, total direct healthcare expenditure on diabetes worldwide will be between 213 billion and 396 billion international dollars in 2025. This would mean that the proportion of the world’s healthcare budget being spent, in 2025, on diabetes care will be between 7% and 13% with high prevalence countries, such as Nauru, spending up to 40% of their budget.

In many countries a substantial proportion of healthcare costs are borne by the individual and the family. Estimates of the indirect cost of diabetes ie the cost of lost production are as high as direct costs or even higher than those for direct costs. * see footnote a, page 183.

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Calculated costs for by increasing the effectiveness of all countries surveillance and treatment for those who already have diabetes, by implementing The future predictions The first edition ofDiabetes Atlas primary prevention measures for those of cost are as looked at published empirical estimates who are at high risk of developing type 2 alarming as the of the current direct healthcare costs diabetes and reducing the risk profile for future predictions of of diabetes (1). While continuing to type 2 diabetes in the population as a diabetes prevalence. emphasize the importance of such whole. They suggest that, estimates, this chapter in the second unless effective edition is wider in scope. Economic information is an important prevention measures component in making decisions about are introduced, It puts forward, for the first time, diabetes and diabetes healthcare. expenditure devoted calculated estimates of the current Decision makers are asking, or should be to diabetes and its direct cost of diabetes care worldwide. asking, such questions as: complications will It also uses the same method, together dominate the health with predictions of the future burden of • What is the economic impact of economies of many diabetes in these countries, to estimate diabetes? countries by the end of the likely future direct cost burden of the • How does this impact compare with the first quarter of the disease in 2025. This widening of scope that of other current health problems? current century. reflects the inclusion, in this edition of • What information is available on the the Atlas, of diabetes prevalence data for cost-effectiveness of different methods all countries. for the prevention of diabetes? • What do we know about the cost- These future predictions of cost are effectiveness of delivering diabetes as alarming as the future predictions care in different ways? of prevalence. They suggest that, unless effective prevention measures IDF’s Task Force on Diabetes Health are introduced, expenditure devoted Economics has recently completed to diabetes and its complications will a review of currently available dominate the health economies of many information on the cost-effectiveness countries by the end of the first quarter of interventions relevant to diabetes of the current century. prevention and care (2). A large number of interventions – intensive blood glucose Importance of economics and blood pressure control, the use of lipid lowering agents, screening for and Economic aspects of diabetes and treatment of diabetic retinopathy and diabetes care continue to attract active care of the feet, for example – are attention as the world diabetes epidemic known to be effective. Evidence is progresses and the healthcare sectors accumulating that many of these are of countries remain under pressure also cost-effective, or even cost-saving. to accomplish more and more within Many of the costs of diabetes and its constrained resources. complications are, therefore, potentially preventable. Governments, diabetes associations, health professionals and people with Availability of up-to-date diabetes themselves need to be aware of information the current and future economic impact of the disease on the healthcare sector, Most of the estimates in the following the individual and family, and society. sections are those that have appeared in the literature since the previous edition of They also need to be aware of the Diabetes Atlas. potential for reducing this cost burden

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Considerable caution is required Total cost of care for when considering these estimates and people with diabetes comparisons between them can only The second cost estimate includes all validly be made when they have been episodes of care for people with diabetes assembled using the same methods and – diabetes-related healthcare and also the same assumptions. As with all cost those of care in which the main reason of illness studies, the methods used are for the encounter is apparently unrelated either ‘top down’ or ‘bottom up’. to diabetes. The latter would include, for example, surgery for appendicitis In the ‘top down’ approach, aggregate or hip replacement or treatment for data at national or local level of breast cancer in people with co-existing treatments, healthcare utilization etc diabetes. are used together with unit costs for the appropriate item. This second estimate has at least two advantages. First, it sidesteps the need In the ‘bottom up’ approach, affected to decide whether, or to what extent, a individuals are identified, their treatments condition is or is not related to diabetes and healthcare utilization events recorded and, second, it incorporates the impact and unit costs used to calculate the totals which diabetes may have on the costs required. of care even for such conditions as Each method has its own advantages appendicitis, hip replacement or breast and disadvantages. A third method – the cancer in people with co-existing calculation of direct costs by means of diabetes. formulae – has been suggested and is described here with empirically derived Lengths of hospital stay may be longer estimates in sections which follow. if diabetes co-exists. Drug bills are likely to be larger, care in general will be more Direct costs intense and rehabilitation more complex and thus more costly. If such overall cost It is important to distinguish between two estimates are used then the incremental estimates of direct healthcare costs: (or ‘extra’) cost of diabetes is calculated by subtracting the average costs of care 1 Cost of diabetes healthcare for a person without diabetes from those 2 Total cost of care for people with of a person with diabetes, preferably diabetes. using age, sex and ethnicity matched estimates. Cost of diabetes healthcare This is the cost element that is Costs may be calculated from the point attributable to diabetes itself or to the of view of the state or the individual and complications of diabetes. It clearly family. These latter costs are sometimes includes the costs of hospital admissions termed ‘out-of-pocket’ expenditures. and other healthcare episodes for diabetic More and more studies are focusing on ketoacidosis, hypoglycaemia and other these personal costs of care and on the direct results of diabetes or its therapy. potential for economic issues to influence the quality of care which people receive. The healthcare costs of diabetic neuropathy, retinopathy and nephropathy Direct costs: are also usually included. It is less clear, calculations using formulae however, how much of the costs of care for such things as a myocardial infarction Formulae have been proposed by or stroke in a person with diabetes Jönsson (3) which can enable countries should be attributed to diabetes per se. or regions to estimate direct healthcare

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prevalence estimates for the 20-79 year Box 4.1 age group for 2003, and data on per capita health expenditure (in international Formulae for calculating direct healthcare costs dollars) as presented in the World Health of diabetes (3) Report 2002 (5). By multiplying the 20-79 year population figures by the per capita 1. Cost of diabetes care: health expenditures, the total healthcare P(R – 1) budget for that age group is derived. × THCB P(R – 1) + 1 Calculations are then presented for values of R of 2 and 3. Figure 4.1 shows the 2. Cost of care for people with diabetes: values of R of 2 and 3 by region. P × R × THCB P(R – 1) + 1 All countries are represented except for 22 countries or areas for which no value P = prevalence of diabetes of per capita health expenditure is given R = ratio of the cost of care for people with diabetes/ in the WHO Report*. These represent 1% cost of care for people without diabetes of the world’s population. THCB = total healthcare budget The calculated estimates for some countries can be validated against the empirically derived estimates listed below. For example, the American costs of diabetes, or any other disease, Diabetes Association’s latest estimate without the need for costly and time for the direct cost of diabetes over all consuming empirical studies (see age groups in the USA is US$91.8 billion Box 4.1). in 2002 (6). This is within the range of calculated costs, by formula, using the Of the three variables needed to make diabetes prevalence and total healthcare these calculations, estimates of the budget figures for the USA which is 66.7 prevalence of diabetes (P) are now billion international dollars for R = 2 to available for every country and the 124.2 billion international dollars for total healthcare budget (THCB) for most R = 3 (Table 4.5). The empirically derived countries is available from published figure of US$91.8 billion corresponds to a sources. However, R, the ratio of the value of R lying between 2.5 and 2.6. cost of care for people with diabetes compared with the cost of care of Empirically derived people without diabetes, is not widely cost estimates available in various countries and some assumptions need to be made in order to Africa use these formulae. There is a growing interest in the economics of diabetes in Africa. However, The data to hand suggest that, at least no recent country specific estimates for countries with high or moderate have been published since the work of incomes, the value of R lies between 2 Chale and her colleagues in Tanzania in and 3, eg Rubin et al’s (4) estimate of 2.6 1992 (7). Cost of illness data from African for the United States. countries is badly needed.

Tables 4.1-4.8 give estimates of the cost * Anguilla, Antigua and Barbuda, Aruba, Bermuda, of diabetes care for persons aged 20-79 British Virgin Islands, Cayman Islands, China Hong using the first formula in Box 4.1. The Kong, China Macau, East Timor, French Guiana, French Polynesia, Guadeloupe, Guam, Martinique, Occupied tables use, from the data in Chapter 1, Palestinian Territories, Puerto Rico, Reunion, Saint population estimates and diabetes Lucia, Taiwan, Tanzania, Tokelau and Western Sahara.

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Eastern Mediterranean Figure 4.1 and Middle East Estimates of the costs of diabetes care by region Data are also extremely sparse for the �� countries in the Eastern Mediterranean and Middle East Region. There appears to be nothing published since the study by ��

Arab (8) in Egypt and by Rekik et al (9) � � � �

� ��

in Tunisia. It is worth noting that, in the � � �

Tunisian study, the total annual cost of � � �

� ��

medication and outpatient care for people � � �

with diabetes was 2.6 times that for � � � � people without diabetes (US$179 versus � ��

US$68) and that a clear relationship was � � �

found between higher costs and the � �� presence of ‘degenerative complications’. � �� Europe Diabetes healthcare costs in Sweden � �� have been extensively studied since

the early estimates by Jönsson and ��

others. Recently, Norlund et al (10) have �� estimated that 28% of the extra cost of diabetes is attributable to the costs of healthcare (the remainder are indirect From France (13) comes the observation costs). This amounts to an estimated that medical care costs for people with SEK9,548 (US$1,118) per person per year. diabetes are around 3,048 (US$3,265) per person per year (twice the average Björk (11) has estimated that three times medical care consumption in the French the healthcare resources are being spent population) while in the Netherlands, on diabetes complications compared van Os et al (14) have estimated diabetes with that spent on diabetes control healthcare costs to be a modest 2.5% of while Jönsson et al (12) have made the the total healthcare budget. important observation that excess costs in the first year after the diagnosis of Using a number of complementary diabetes in young adults (15-34 years data sources, Currie and colleagues at diagnosis) are considerably greater have published several cost estimates than those incurred seven years later for diabetes and its complications in ie eight years after diagnosis. Annual the same defined United Kingdom (UK) excess costs at these two time points population. In 1997 they published one for men were US$4,743 and US$2,010 of the few estimates of future costs of respectively while, for women, the diabetes (15). More recently, they have equivalent figures were US$4,976 and been involved with others in developing US$2,734. The cost profile during a computer-based model for testing the the natural history of the condition in effects of demographic, epidemiological any one person with diabetes seems, and therapeutic changes on these future therefore, to be ‘U’ or ‘J’ shaped, with, costs (16), thus linking descriptive immediately after diagnosis, relatively estimates of the cost of diabetes with high costs which subsequently fall cost-effectiveness information from and then rise again with the onset of studies such as the UK Prospective complications. Diabetes Study (UKPDS).

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The findings of theCODE-2 (Cost of End-stage renal failure had the effect of Diabetes in Europe – Type 2) and T2ARDIS increasing costs by 771%. (Type 2 Diabetes Accounting for a Major Resource Demand In Society) studies Recent work in Canada suggests that the agree that the financial burden of type 2 total direct healthcare cost of diabetes diabetes in the United Kingdom is just is US$3.5 billion in 1998 prices (21). under 5% of the nation’s healthcare Comparison with the estimates in Table budget in 1998, that there is a strong 4.5 of 4.7 billion international dollars relationship between hospital costs and (R=2) and 8.7 billion international dollars the presence of complications, and that (R=3) suggests that this may be an the economic and psychosocial burden underestimate (or the calculated figures of diabetes extends not only to affected an overestimate). individuals but also to their carers (17). The empirical Canadian work North America emphasized the dominant contribution The most recent peer-reviewed of cardiovascular disease in people with estimate of the annual direct cost of diabetes (35% of direct and indirect costs) diabetes in the USA is the American and declared that “the cost of preventive Diabetes Association’s 2002 estimate treatment is insignificant compared of US$91.8 billion (6). This compares with the downstream costs of failure to with the previous estimate for 1997 of adequately treat the disease”. US$44 billion (18). This is a total figure covering all aspects of diabetes and its South and Central America complications. Of considerable interest, given the range of countries studied, is the work of The US literature also has a number of Barceló et al (22). The direct healthcare estimates which break down the total costs were estimated as US$10.69 billion cost figure into estimates for specific, for 25 countries in 2000 (Table 4.9). The individual complications. For example, contributions of the various items to the O’Brien et al (19) estimated the ‘event direct cost total are shown in Figure 4.2, cost’ of a single myocardial infarction in while the specific contributors to the a person with diabetes to be US$27,630 cost of diabetic complications are shown (1996 prices). This leads on to a ‘state in Figure 4.3. Indirect costs were also cost’ (ie the annual additional cost of care calculated and were around five times the following such an event) of US$2,185 per direct cost total. annum. They point out that some early complications, such as the presence of The method employed by Barceló et al microalbuminuria (the presence of small is the ‘top down method’ (22). They traces of protein in the urine), are low used population prevalence estimates cost, estimated as a US$14 per annum for diabetes, treatment and healthcare ‘state cost’, but, if left undetected and utilization figures taken both from untreated, lead to extremely high later individual studies and routinely collected costs, in this case the US$53,660 per data (see Table 4.9). These were then annum ‘state cost’ of end-stage renal multiplied by unit costs for insulin, oral failure. hypoglycaemics and other items. Like all top-down studies, the accuracy of the In a similar fashion, for people with results is dependent on the validity of the diabetes receiving their healthcare from assumptions made. Nevertheless, this one health maintenance organization, a work represents a considerable advance major cardiovascular disease event eg in pulling together comparable data from myocardial infarction was estimated to Latin American and Caribbean countries increase the cost of care by 360% (20). not previously studied (see Map 4.1).

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South-East Asia Figure 4.2 In India, estimates have been made of the Contributions to total direct healthcare cost in 25 Latin out-of-pocket expenses resulting from American and Caribbean countries, 2000 (adapted from diabetes. This is the direct healthcare Barceló et al (22)) impact on the person with diabetes who may need to spend a considerable proportion of the family income in order �� to receive treatment at a chosen location

eg outside the public sector. In a diabetes �� centre in Chenai, families in the poorest section of the population may have to spend as much as 25% of their income in order to obtain the care of their �� choice (23).

Western Pacific

A similar theme, of the personal direct �� costs, is developed by Simmons et al (24) for patients resident in an inner OHA oral hypoglycaemic agents suburb of Auckland, New Zealand. Not only were these patients spending a significant proportion of their income on diabetes care but between a fifth and a Figure 4.3 half (depending on income and ethnic Specific contributors to the cost of diabetic complications, origin) of those taking part reported that 2000 (adapted from Barceló et al (22)) personal costs had an inhibitory effect on self-monitoring of blood glucose, self-medication and even on insulin �� therapy amongst those who needed it. �� Taiwan has been estimated to spend 11.5% of its healthcare budget on the treatment of people with diabetes. This comes from a national extrapolation of Bureau of National Health Insurance claims between July 1997 and July 1998 (25). The average cost of care for someone with diabetes in this system was 4.3 times higher than that for a person without diabetes. ��

Indirect costs and intangible costs

There is much less information on the indirect costs of diabetes, ie cost of American Diabetes Association 2002 lost production, partly because of the study mentioned above, indirect costs methodological difficulties involved in its were estimated to be US$39.8 billion collection. When indirect costs have been compared with direct costs of US$91.8 calculated, they have been estimated billion and compared with a previous as around the same, sometimes more estimate of indirect costs of US$54 than direct costs. For example, in the billion (6).

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In a study of 30,000 people in Manitoba, been no predictions of the likely future Canada, the 600 individuals who had costs of diabetes. As the prevalence diabetes were twice as likely not to be in of diabetes increases, the likelihood is the work force as those without diabetes that costs will also rise although the (26). Predicted increases in the prevalence magnitude will depend on a number of of diabetes worldwide emphasize the things, particularly, the extent to which fact that the economically productive age complications will be prevented or groups within society will be particularly delayed. affected. Given these predictions, the effects on lost production are likely to be The ratio of the cost of care of people considerable and need to be quantified with diabetes to the cost of care of more extensively. those without (R in Jönsson’s formulae – Box 4.1) may well rise initially, as Considerable interest is currently being the increased costs of more intensive shown in information of intangible costs treatment assert themselves. However, (quality of life) and standardized methods this ratio of costs is likely then to fall to obtain this are becoming available. as the preventive effect of this more Again, however, the data available are intensive therapy becomes manifest. sparse and none are shown in this edition of the Diabetes Atlas. Using, again, the first formula listed in Box 4.1 together with the predictions Predictions of the future costs of prevalence in 2025 in Chapter 1, of diabetes the future costs of diabetes can be calculated given certain assumptions. Apart from the Bagust et al study (16) If it is assumed that per capita health and the predictions, for Australia, expenditure of the countries listed in included in McCarty et al (27), there have Tables 4.2 to 4.8 will not increase in real terms, then each country’s total health expenditure in 2025 for people aged Figure 4.4 20–79 years can be calculated using Predictions of the future costs of diabetes (as % of total this per capita figure and the predicted healthcare expenditure) by region, 2025 population for that year.

�� Table 4.10 lists the overall predictions �� by region (see Figure 4.4) and, for each region, the predicted costs for the �� country with the highest diabetes care ��

� expenditure expressed as a percentage � �

� of total health expenditure. The predicted

� ��

� diabetes costs for all other countries � � � �� are available from the author or can be � �

� calculated using the first formula given in

� � �

� Box 4.1 and the appropriate data for that � country given in Chapter 1.

�

� ��

��

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Diabetes Atlas Second Edition Diabetes Atlas Second Edition The Economic Impact of Diabetes The Economic Impact of Diabetes �� Chapter 4 Chapter 4 �� Map 4.1 �� Estimated total direct healthcare costs of diabetes per person (USD) in 25 �� Latin American and Caribbean countries (adapted from Barceló et al (22)) ��

Table 4.1 Calculated estimates of the costs of diabetes care by region

Cost of diabetes care per year (’000 international dollarsa) given values for Rb of: Region R=2 R=3 AFR 784,539 1,522,237 EMME 3,594,864 6,677,924 EUR 42,768,723 80,520,020 NA 73,526,777 136,815,507 SACA 7,086,861 13,465,503 SEA 2,602,742 4,937,200 WP 22,635,907 42,906,055

Worldwide Total 153,000,412 286,844,446

a. The international dollar is a common currency unit that takes into account differences in the relative purchasing power of various currencies. Figures expressed in international dollars are calculated using purchasing power parities (PPP), which are rates of currency conversion constructed to account for differences in price level between countries. b. R = Ratio of cost of care for people with diabetes/cost of care for people without diabetes

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Table 4.2 Calculated estimates of the costs of diabetes care – African Region

Per capita health Cost of diabetes care per year expenditure (’000 international dollarsa) (international dollarsa) given values for Rb of: Country R=2 R=3 Angola 52 7,940.6 15,477.0 Benin 27 1,652.0 3,236.0 Botswana 358 8,815.1 17,044.0 Burkina Faso 37 4,873.4 9,495.1 Burundi 16 600.0 1,184.5 Cameroon 55 3,186.4 6,322.5 Cape Verde 92 476.5 932.0 Central African Republic 37 1,493.4 2,920.6 Chad 19 1,860.5 3,624.3 Comoros 35 303.9 593.3 Congo, Democratic Republic of 21 11,313.6 22,096.7 Congo, Republic of 25 875.1 1,707.6 Côte d’Ivoire 45 8,170.3 15,976.1 Djibouti 63 888.6 1,697.4 Equatorial Guinea 103 562.8 1,099.1 Eritrea 25 888.1 1,743.8 Ethiopia 17 9,182.5 18,035.5 Gabon 171 3,140.2 6,107.1 Gambia 46 693.2 1,357.4 Ghana 51 16,482.7 31,932.0 Guinea 56 4,329.8 8,489.3 Guinea-Bissau 28 323.9 635.3 Kenya 115 40,360.2 78,826.2 Lesotho 100 3,113.9 6,046.6 Liberia 3 93.5 183.4 Madagascar 33 6,180.3 12,070.1 Malawi 38 3,258.2 6,409.4 Mali 32 3,352.3 6,573.0 Mauritania 52 2,310.8 4,469.9 Mozambique 30 7,756.9 15,065.0 Namibia 366 9,055.1 17,586.6 Niger 22 3,130.3 6,077.7 Nigeria 20 23,838.5 46,651.9 Reunion N/A Rwanda 40 1,637.4 3,238.4 Sao Tome and Principe 23 64.9 126.5 Senegal 56 5,679.4 11,114.1 Seychelles 758 4,049.6 7,299.4 Sierra Leone 28 1,340.3 2,625.2 Somalia 7 629.8 1,232.5 South Africa 663 539,377.0 1,044,412.1 Swaziland 210 2,732.7 5,311.9 Tanzania N/A Togo 36 1,590.9 3,119.1 Uganda 36 5,491.5 10,818.3 Western Sahara N/A Zambia 49 6,663.1 12,945.5 Zimbabwe 171 24,779.6 48,327.5

AFR Total 784,539 1,522,237

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Table 4.3 Calculated estimates of the costs of diabetes care – Eastern Mediterranean and Middle East Region

Per capita health Cost of diabetes care per year expenditure (’000 international dollarsa) (international dollarsa) given values for Rb of: Country R=2 R=3 Afghanistan 9 7,627.1 14,174.9 Algeria 142 99,274.1 191,019.1 Armenia 192 37,478.6 69,735.7 Bahrain 641 36,532.9 64,667.7 Egypt 138 486,102.3 892,230.6 Iran 336 450,956.0 871,535.0 Iraq 573 487,336.9 909,974.6 Jordan 325 56,198.5 105,506.7 Kuwait 542 76,044.3 136,631.8 Lebanon 696 91,739.2 173,117.5 Libya 392 43,299.1 83,644.5 Morocco 166 116,582.9 224,217.7 Occupied Palestinian Territories N/A Oman 448 58,322.1 105,830.0 Pakistan 76 432,936.1 803,003.8 Qatar 849 46,040.1 80,924.1 Saudi Arabia 684 620,292.9 1,142,333.8 Sudan 51 25,824.0 50,117.8 Syria 51 25,364.9 47,930.4 Tunisia 472 123,476.7 236,579.9 United Arab Emirates 761 232,769.2 398,837.1 Yemen 70 40,665.5 75,911.4

EMME Total 3,594,864 6,677,924

N/A not available

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Table 4.4 Calculated estimates of the costs of diabetes care – European Region

Per capita health Cost of diabetes care per year expenditure (’000 international dollarsa) (international dollarsa) given values for Rb of: Country R=2 R=3 Albania 129 9,319.4 17,978.1 Andorra 1,639 5,929.6 11,059.0 Austria 2,171 498,962.5 961,054.0 Azerbaijan Republic 57 19,055.6 35,789.7 Belarus 430 268,819.5 495,419.9 Belgium 2,269 686,248.6 1,319,504.9 Bosnia and Herzegovina 319 85,970.0 158,079.0 Bulgaria 198 106,386.3 194,996.3 Croatia 638 120,022.6 227,502.4 Cyprus 1,415 37,285.6 71,106.4 Czech Republic 1,031 691,931.6 1,273,362.9 Denmark 2,428 601,903.8 1,131,216.2 Estonia 556 48,799.6 89,656.9 Finland 1,667 425,125.2 796,447.7 France 2,335 5,832,389.7 11,017,934.3 Georgia, Republic of 199 60,669.1 112,057.3 Germany 2,754 7,030,622.9 13,504,262.2 Greece 1,390 645,813.0 1,221,304.7 Hungary 846 548,733.3 1,008,471.7 Iceland 2,626 9,532.1 18,709.6 Ireland, Republic of 1,944 168,899.1 327,168.1 Israel 2,338 614,662.6 1,152,777.9 Italy 2,040 5,513,866.1 10,388,485.7 Kazakhstan 211 111,821.8 212,633.6 Kyrgyzstan 145 17,348.4 33,320.2 Latvia 398 62,882.1 115,391.7 Lithuania 420 95,557.6 175,996.3 Luxembourg 2,740 32,989.4 63,636.6 Macedonia 300 19,991.7 38,201.2 Malta 803 18,969.8 34,988.4 Moldova, Republic of 64 14,290.0 26,547.0 Monaco 1,877 2,477.0 4,685.2 Netherlands 2,255 939,828.2 1,814,885.1 Norway 2,373 470,761.4 885,799.1 a. The international dollar Poland 578 1,329,141.0 2,455,541.3 is a common currency Portugal 1,469 796,331.3 1,484,921.8 unit that takes into Romania 190 264,165.7 487,023.5 account differences Russian Federation 405 3,594,804.5 6,630,412.9 in the relative San Marino 2,805 3,175.5 6,010.7 purchasing power of Serbia and Montenegro 237 94,735.9 179,935.4 various currencies. Slovakia 690 215,042.2 398,282.1 Figures expressed in Slovenia 1,462 193,676.0 356,136.8 international dollars are calculated using Spain 1,539 4,206,901.2 7,718,179.9 purchasing power Sweden 2,097 893,237.9 1,673,172.8 parities (PPP), which Switzerland 3,229 1,054,290.7 1,986,431.5 are rates of currency Tajikistan 29 3,264.3 6,305.0 conversion constructed Turkmenistan 286 68,422.3 125,505.5 to account for Turkey 323 893,338.1 1,677,294.1 differences in price level Ukraine 152 478,529.5 879,350.3 between countries. United Kingdom 1,774 2,852,838.2 5,497,291.5 b. R = Ratio of cost of Uzbekistan 86 8,963.5 17,795.8 care for people with diabetes/cost of care for people without diabetes EUR Total 42,768,723 80,520,020

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Table 4.5 Calculated estimates of the costs of diabetes care – North American Region

Per capita health Cost of diabetes care per year expenditure (’000 international dollarsa) (international dollarsa) given values for Rb of: Country R=2 R=3 Anguilla N/A Antigua and Barbuda N/A Aruba N/A Bahamas 1,137 18,049.9 33,352.5 Barbados 915 13,577.7 25,183.0 Belize 273 1,833.1 3,477.4 Bermuda N/A British Virgin Islands N/A Canada 2,534 4,729,909.0 8,739,290.2 Cayman Islands N/A Dominica, Commonwealth of 340 1,098.8 2,041.1 Grenada 351 1,215.5 2,284.7 Guadeloupe N/A Guyana 197 5,127.5 9,702.4 Haiti 54 12,066.9 22,890.1 Jamaica 208 21,452.3 40,192.1 Martinique N/A Mexico 483 1,982,045.4 3,707,672.7 St Kitts and Nevis 658 927.7 1,750.3 St Lucia 272 1,599.0 2,997.5 St Vincent and the Grenadines 374 1,876.9 3,505.9 Trinidad and Tobago 468 29,455.4 54,899.6 USA 4,499 66,706,541.4 124,166,267.2

NA Total 73,526,777 136,815,507

N/A not available

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Table 4.6 Calculated estimates of the costs of diabetes care – South and Central American Region

Per capita health Cost of diabetes care per year expenditure (’000 international dollarsa) (international dollarsa) given values for Rb of: Country R=2 R=3 Argentina 1,091 1,349,719.3 2,566,892.2 Bolivia 158 32,687.7 62,489.7 Brazil 631 3,409,088.8 6,498,705.1 Chile 697 367,540.7 697,779.1 Colombia 616 648,755.2 1,246,094.6 Costa Rica 481 77,392.0 145,399.1 Cuba 186 173,025.7 309,922.1 Dominican Republic 357 162,156.2 297,257.2 Ecuador 78 26,851.5 51,360.5 El Salvador 388 82,225.6 155,356.1 French Guiana N/A Guatemala 192 56,149.8 106,745.2 Honduras 165 29,275.4 55,565.5 Netherlands Antilles 2,255 36,541.6 65,862.6 Nicaragua 108 16,017.2 30,285.0 Panama 464 55,970.5 104,833.0 Paraguay 323 35,824.2 69,076.4 Peru 238 179,381.8 342,020.8 Puerto Rico N/A Suriname 424 8,468.3 15,687.7 Uruguay 1,005 141,283.2 265,714.1 Venezuela 280 198,506.0 378,457.2

SACA Total 7,086,861 13,465,503

N/A not available

Table 4.7 Calculated estimates of the costs of diabetes care – South-East Asian Region

Per capita health Cost of diabetes care per year expenditure (’000 international dollarsa) (international dollarsa) given values for Rb of: Country R=2 R=3 Bangladesh 47 131,898.0 254,283.8 Bhutan 64 2,389.1 4,614.7 India 71 2,380,739.0 4,510,916.9 Maldives 254 648.7 1,274.8 Mauritius 330 25,178.2 45,900.8 Nepal 66 30,974.2 59,617.5 Sri Lanka 120 30,915.1 60,591.9

SEA Total 2,602,742 4,937,200

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Table 4.8 Calculated estimates of the costs of diabetes care – Western Pacific Region

Per capita health Cost of diabetes care per year expenditure (’000 international dollarsa) (international dollarsa) given values for Rb of: Country R=2 R=3 Australia 2,213 1,780,583.1 3,365,036.0 Brunei Darussalam 618 12,402.2 22,631.4 Cambodia 111 13,627.7 26,737.0 China, Hong Kong N/A China, Macau N/A China, People’s Republic of 205 4,751,974.7 9,259,469.2 Cook Islands 426 321.0 606.9 East Timor N/A Fiji 194 6,746.8 12,535.9 French Polynesia N/A Guam N/A Indonesia 84 209,963.7 412,172.4 Japan 2,009 12,642,179.4 23,745,326.3 Kiribati 140 487.9 922.3 Korea, Democratic People’s Republic of 33 24,287.4 46,278.8 Korea, Republic of 909 1,867,440.5 3,522,931.2 Lao People’s Democratic Republic of 52 1,435.7 2,841.9 Malaysia 234 267,650.0 492,852.2 Marshall Islands 312 1,148.2 2,126.2 Micronesia 343 1,767.9 3,326.7 Mongolia 120 2,390.7 4,716.7 Myanmar 24 7,397.4 14,636.5 Nauru 525 937.9 1,533.3 New Caledonia N/A New Zealand 1,623 296,672.6 554,408.9 Niue 1,111 101.0 185.2 Palau 482 444.9 826.3 Papua New Guinea 147 7,081.4 13,900.4 Philippines 167 164,753.2 321,967.4 Samoa 221 918.0 1,738.8 Singapore, Republic of 913 303,674.6 547,303.8 Solomon Islands 97 427.8 838.8 Taiwan N/A Thailand 237 204,644.4 401,088.9 Tokelau N/A Tonga 312 2,274.3 4,093.9 Tuvalu 860 475.3 881.0 Vanuatu 119 256.2 501.7 Vietnam 129 61,440.6 121,638.6

WP Total 22,635,907 42,906,055

N/A not available

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Table 4.9 Estimated number of people with diabetes1 and estimated total direct healthcare costs of diabetes in 25 Latin American and Caribbean countries, 2000

Direct cost per Average healthcare No. of people Direct cost person with diabetes expenditure Population with diabetes (population) per year per person per year Country (000’s) (000’s) (USD million) (USD) (USD) Argentina 34,768 1,250.3 747.0 597 320 Bahamas 279 12.8 10.7 836 Barbados 260 23.3 12.8 549 Bolivia 7,414 153.9 85.5 556 12 Brazil 159,014 4,532.6 3,952.3 872 159 Chile 14,210 496.5 295.0 594 120 Colombia 35,814 937.7 414.9 442 128 Costa Rica 3,424 154.9 96.6 624 197 Cuba 10,964 592.4 722.2 1,219 Dominican Republic 7,823 254.1 225.7 888 33 Ecuador 11,460 267.3 233.4 873 35 El Salvador 5,662 219.4 137.4 626 54 Guatemala 10,621 368.7 291.2 790 26 Guyana 856 28.4 20.4 718 Haiti 7,124 79.5 48.0 604 7 Honduras 5,654 193.0 113.8 590 23 Jamaica 2,468 181.4 136.1 750 56 Mexico 91,145 3,738.0 1,974.2 528 132 Nicaragua 4,123 136.1 85.0 625 22 Panama 2,631 120.5 104.4 866 196 Paraguay 4,828 92.5 72.0 778 46 Peru 23,532 606.8 502.4 828 56 Trinidad and Tobago 1,287 71.3 38.0 533 Uruguay 3,186 119.0 94.6 795 116 Venezuela 21,844 610.8 307.5 503 119

Total 470,391 15,241 10,691

1. Prevalence estimates taken from Amos et al, 199728.

Source: Barceló et al22

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Table 4.10 Predictions of the future costs of diabetes by region (20-79 age group), 2025

Cost of diabetes per year Cost of diabetes per year (’000 international dollarsa) (as % of total healthcare expenditure) for two values of ratiob: for two values of ratiob: Region Country R = 2 R = 3 R = 2 R = 3 AFR 1,192,556.3 2,305,837.2 3.3 6.3 Seychellesc 6,595.2 11,673.8 13 23 EMME 7,335,249.7 13,511,171.7 8.0 14.7 United Arab Emiratesc 371,147.6 620,376.7 19.7 32.8 EUR 50,539,601.5 94,318,016.1 6.7 12.5 Tajikistanc 8,378.1 15,142.0 10.7 19.3 NA 106,030,745.8 195,147,133.0 8.7 15.9 Barbadosc 22,547.0 40,493.4 11.4 20.4 SACA 12,509,955.8 23,469,465.1 6.4 12.0 Cubac 239,831.9 418,051.8 14.7 25.7 SEA 5,278,860.5 9,842,467.0 7.7 14.4 Mauritiusc 41,665.2 73,871.2 12.8 22.7 WP 30,696,300.4 57,700,700.3 5.7 10.8 Nauruc 1,316.1 2,104.7 25.1 40.1

Total 213,583,269.9 396,294,790.4 7.3 13.5

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20. Brown JB, Pedula KL, Bakst AW. The Progressive Cost of References Complications in Type 2 Diabetes Mellitus. Arch Intern Med 1999; 159:1873-1880. 1. International Diabetes Federation. The Costs of Diabetes. 21. Dawson KD, Gomes D, Gerstein H, Blanchard JF, Kahler KH. In Diabetes Atlas 2000. International Diabetes Federation, The Economic Cost of Diabetes in Canada, 1998. Diabetes Brussels, 2000; 225–235. Care 2002; 25:1303-1307. 2. International Diabetes Federation. Cost-effective approaches 22. Barceló A, Aedo C, Rajpathak S, Robles S. The cost of to diabetes care and prevention. IDF Task Force on Diabetes diabetes in Latin America and the Caribbean. Bulletin of the Health Economics. International Diabetes Federation, World Health Organization 2002; in press. Brussels, 2003. 23. Shobhana R, Rao PR , Lavanya A, Williams R, Vijay V, 3. Jönsson B. The economic impact of diabetes. Diabetes Care Ramachandran A. Expenditure on healthcare incurred by 1998; 21 Suppl 3: C7-C10. diabetic subjects in a developing country - a study from 4. Rubin R, Altman WM, et al. Healthcare expenditures for southern India. Diabetes Res Clin Pract 2000; 48:37-42. people with diabetes mellitus, 1992. J Clin Endocrinol 24. Simmons D, Peng A, Cecil A, Gatland B. The personal costs Metab 1994; 78: 809A-809F. of diabetes: a significant barrier to care in South Auckland. 5. World Health Organization. The World Health Report 2002. N Z Med J 1999; 112:383-385. World Health Organization, Geneva, 2003. 25. Lin T, Chou P, Lai M, Tsai S, Tai T. Direct cost-of-illness of 6. American Diabetes Association. Economic Costs of Diabetes patients with diabetes mellitus in Taiwan. Diabetes Res Clin in the U.S. in 2002. Diabetes Care 2003; 26:917-932. Pract 2001; 54 Suppl 1:43-46. 7. Chale SS, Swai AB, Mujinja PG, McLarty DG. Must diabetes 26. Kraut A, Walld R, Tate R, Mustard C. Impact of Diabetes on be a fatal disease in Africa? Study of costs of treatment. Employment and Income in Manitoba, Canada. Diabetes BMJ 1992; 304:1215-1218. Care 2001; 24:64-68. 8. Arab M. Diabetes mellitus in Egypt. World Health Statistics 27. McCarty DJ, Zimmet P, et al. The Rise and Rise of Diabetes in Quarterly 1992; 45:334-337. Australia. International Diabetes Institute, Victoria, 1996. 9. Rekik M, Abid M, Hachicha J, Abbes R, Moujahed M, Jarraya 28. Amos A, McCarty DL, et al. The rising global burden of A. Direct cost of the ambulatory management of diabetes at diabetes and its complications: estimates and projections to the outpatient clinic of the National Social Security Fund of the year 2010. Diabet Med 1997; 14 Suppl 5:S1-S85. Sfax. Bulletin of the World Health Organization 1994; 72:611-614. 10. Norlund A, Apelqvist J, Bitzen PO, Nyberg P, Schersten B. Cost of illness of adult diabetes mellitus underestimated if comorbidity is not considered. J Intern Med 2001; 250:57-65. 11. Björk S. The cost of diabetes and diabetes care. Diabetes Res Clin Pract 2001; 54 Suppl 1:S13-S18. 12. Jönsson P, Marke LA, Nystrom L, Wall S, Ostman J. Excess costs of medical care 1 and 8 years after diagnosis of diabetes: estimates from young and middle-aged incidence cohorts in Sweden. Diabetes Res Clin Pract 2000; 50 Suppl 1:35-47. 13. Detournay B, Fagnani F, Phillippo M, Pribil C, Charles MA, Sermet C, Basdevant A, Eschwege E. Obesity morbidity and healthcare costs in France: an analysis of the 1991-1992 Medical Care Household Survey. Int J Obes Relat Metab Disord 2000; 24:151-155. 14. van Os N, Niessen LW, Koopmanschap MA, van der Lei J. Detailed analysis of the societal costs of diabetes mellitus. Ned Tijdschr Geneeskd 2000; 29:842-846. 15. Currie CJ, Kraus D, Morgan CL, Gill L, Stott NCH, Peters JR. NHS Acute Sector Expenditure for Diabetes: the Present, Future, and Excess In-patient Cost of Care. Diabet Med 1997; 14:686-692. 16. Bagust A, Hopkinson PK, Maier W, Currie CJ. An economic model of the long-term healthcare burden of Type II diabetes. Diabetologia 2001; 44:2140-2155. 17. Williams R, Gillam S, Murphy M, Holmes J, Pringle M, Bootle S, Bottomley J, Baxter H, Chandler F. The True Costs of Type 2 Diabetes in the UK – Findings from T2ARDIS and CODE-2 UK. Monograph of studies supported by GlaxoSmithKline. GlaxoSmithKline UK, Uxbridge, 2002. 18. American Diabetes Association. Economic Consequences of Diabetes Mellitus in the U.S. in 1997. Diabetes Care 1998; 21:296-309. 19. O’Brien JA, Shomphe LA, Kavanagh PL, Raggio G, Caro JJ. Direct Medical Costs of Complications Resulting from Type 2 Diabetes in the US. Diabetes Care 1998; 21:1122-1128.

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Diabetes Atlas Second Edition Access to Insulin and Diabetes Supplies Chapter 5

Access to Insulin Chapter 5 and Diabetes Supplies

One of the major breakthroughs in medical sciences of the last century was the discovery of insulin in 1921. This discovery meant that people with diabetes who were insulin-treated survived the acute effects of the disease. The fact of the matter is that some eighty years later so many people in the world are still dying because of lack of access to insulin. Unfortunately, international economics still determines who should live or die, while we all watch on. This lack of access to insulin may be chronic or acute depending on the circumstances. The fact of the matter is that some Acute lack of access to insulin occurs eighty years after the due to natural disaster, for example the discovery of insulin

earthquake in the Democratic Republic so many people in of Congo, civil unrest including war, the world are still for example the recent Balkan war, dying because of or financial crisis as was the case in lack of access to Argentina. Nevertheless, the major insulin. Unfortunately, problem lies in the widespread chronic international lack of access to insulin that poses a economics still serious threat to the developing countries determines who should of the world. live or die, while we all watch on. For proper delivery of diabetes care, insulin, insulin syringes and needles should be available, accessible and at an affordable cost to all people with diabetes who require them. 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.

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This chapter focuses on the chronic syringes and needles 100% of the time lack of access to insulin because the was greater in urban than in rural areas International Diabetes Federation (IDF) (48 vs 32 for insulin and 41 vs 29 for Task Force on Insulin and major insulin syringes and needles) whereas the manufacturers have put in place a reverse was true for lack of access ie mechanism to alleviate the acute lack of less than 25% of the time (21 vs 5 for access to insulin whenever a situation insulin and 20 vs 7 for syringes and arises. needles). The chronic lack of access to insulin, syringes and needles was more Magnitude of the problem common in Africa than elsewhere. South and Central America also suffered from The IDF Task Force on Insulin conducted the chronic lack of access to syringes and a survey on the global access to insulin needles. Both these problems were least in 1997. In that survey, 48 of the 73 common in Europe. responding countries reported continual and uninterrupted availability of insulin A similar survey, the Global Access to in urban areas, whereas 20 reported Insulin and Diabetes Supplies Survey, that insulin was available 25-99% of the was conducted by the IDF Task Force time and 5 reported availability of less on Insulin in 2003. The results of this than 25%. survey are summarized in this chapter. Eighty-five participants from 74 countries The 1997 survey showed that in the completed the questionnaire on insulin seven IDF regions access to insulin, accessibility.

It is regrettable that many developing countries did not participate in this Box 5.1 survey despite several reminders. There are several shortcomings in drawing What is Insulin? absolute conclusions from such a survey; however, it is the only reliable document nsulin is the internal secretion of the pancreas formed which we have to assess global access to by groups of cells called the islets of Langerhans in this I insulin, syringes and needles. 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. Global access to insulin

Forty-four and 40 of the 74 countries Insulin is injected into the body by people with type 1 reported continual and uninterrupted diabetes in whom the cells that produce insulin have been access to insulin for people with type 1 destroyed. This is the most common form of diabetes in and type 2 diabetes respectively. children and young adults, and they depend on insulin for However, it is significant to note that survival. Insulin may also be used by people with type 2 people with type 1 diabetes in 30 diabetes. In type 2 diabetes, the body needs more insulin countries did not have access to insulin than it can produce. 100% of the time (see Table 5.1), while people with type 2 diabetes in 34 Since the landmark discovery of insulin by Frederick countries did not have 100% access (see Banting and Charles Best in 1921, huge steps forward Table 5.2). have been made in research and development in creating genetically engineered human insulin. Until recently insulin The distribution of access to insulin was derived from a limited resource of the pancreas of was different in the various regions cattle and pigs. for both people with type 1 and type 2 diabetes (see Figures 5.1 and 5.2). Only Africa had no country with 100%

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accessibility to insulin. The countries Figure 5.1 with the lowest accessibility were the Access to insulin for people with type 1 diabetes by region Democratic Republic of Congo where �� people with type 1 diabetes had access to insulin for less than 25% of the time �� and Zambia where those with type 2 �� diabetes had access only 26-49% of the �

� �� time. In Europe, Ukraine had the lowest � � �

accessibility to insulin (less than 25%); in � � ��

South and Central America, El Salvador � � ��

and Peru (26-49%) and in North America, � �

Guyana (50-74 %). � �

� �� Causes of lack of access � ��

to insulin �� The most important causes of the lack �� of access to insulin in both people with type 1 and type 2 diabetes were (see � �� Figure 5.3): ��

• insulin is too expensive; ��

• lack of availability in all regional areas; ��

• transportation problems; �� • lack of adequate supply to meet �� demand; and �� • very poor quality of insulin.

High cost was the most important cause Figure 5.2 for the lack of access to insulin in people Access to insulin for people with type 2 diabetes by region with type 1 diabetes in most countries �� in Africa (7 out of 9), but less so in South and Central America (3 out of 8) �� and North America (2 out of 10) (see �� Table 5.3). Two countries, Zambia and �

� �� Sri Lanka, reported poor quality of insulin � � �

as a cause of lack of access to insulin � � ��

in people with type 2 diabetes (see � � �� Table 5.4). � � � � �

� ��

Cost of insulin �

� ��

At present, human insulin is the most �� available form of insulin in the world, according to the results of the survey. �� This is followed by pork, beef and � pork/beef mixture, as shown in �� Figure 5.4. ��

��

Animal insulin is considerably cheaper �� in those countries where both human �� and animal insulin are available, �� except in some countries in the North ��

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Figure 5.3 Causes of lack of access to insulin

��

� � ��

��

Figure 5.4 Bangladesh (SEA), and Japan and Types of insulin available around the world Hong Kong (WP).

�� In many countries, insulin in vial form �� is significantly cheaper than the same �� type of insulin in pen-fill cartridge form. Insulin in vial form should continue to be available in economically developing countries to people who otherwise would �� have to pay a higher price for the same insulin in pen-fill form.

Taxes are still a significant factor affecting the price of insulin (and other diabetes supplies) in a great number of countries even though WHO essential American and Western Pacific Regions, drugs guidelines state there should be as shown in Figure 5.5 and Table 5.5. no taxes on insulin. Taxes were added on In Africa, for example, the average cost the price of insulin in 7 out of 8 countries of human insulin is twice as expensive in SACA; 5 out of 9 in Africa; 4 out of 8 as animal insulin. A box of 10 ml U-100 in WP; 12 out of 31 in Europe; 1 out of 3 human insulin was cheapest and most in SEA; and 2 out of 10 in NA (see Figure expensive respectively in Senegal and 5.6). No taxes were levied in the four Kenya (AFR), Qatar and Libya (EMME), responding countries in EMME. Taxes Romania and Italy (EUR), Commonwealth varied from 1% of cost in Kazakhstan to of Dominica and USA (NA), Cuba and 80% in Poland. Specifically in Africa, it El Salvador (SACA), Sri Lanka and was 14% in South Africa and 48% in Togo.

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Cost implications Figure 5.5 Table 5.6 shows that when the price of Average cost of 10 ml vial of U-100 insulin by region insulin is compared to the gross national �� product (GNP) of the countries, insulin is 3 to 26 times less affordable in Africa �� than in all other regions. Human insulin

is most affordable in Western Pacific and ��

Europe, and least affordable in Africa � � �

while animal insulin is most affordable in � ��

South and Central America and Europe, � � � �� and least affordable in Africa. � � � � �

� �� The main reason for the expansion � � of diabetes services in the developed �� countries was the discovery and

introduction of insulin. Developing � countries face major scourges including AIDS, TB and malaria, which compete for � health priority with diabetes. Although ��

insulin is a life-saving drug, in a situation ��

of grossly restricted medical resources, �� the ‘opportunity cost’ of keeping alive a resource-consuming person with diabetes is a valid if chilling question. This explains why four African countries Figure 5.6 reported an awareness of death due to Average percentage of taxes on imported and locally lack of access to insulin in people with produced insulin in four regions type 1 diabetes. �� Access to diabetes supplies �� It would appear from the Global Access to Insulin and Diabetes Supplies Survey, �� 2003 that blood glucose testing strips � �

are even less accessible than insulin. � �

� ��

Urine testing strips are significantly more � � accessible because they are much more �

affordable. They provide a viable testing �� method in the absence of affordable glucose testing. There seems to be evidence that the use of urine strips may � be decreasing without a commensurate increase in the use of blood glucose � testing strips. ��

��

Only 40 countries had access to insulin �� syringes and needles 100% of the time. Among the regions, Africa had the lowest access to insulin syringes and needles. Europe had the highest access followed by North America (see Table 5.7). The average cost of 100 insulin syringes was

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Figure 5.7 highest in North America, followed by Average cost of 100 insulin syringes by region South and Central America and Africa, and cheapest in South-East Asia and �� Western Pacific (see Figure 5.7).

Self-monitoring of diabetes �� Urine testing seems to be the method of � � �

� choice of self-monitoring of diabetes (see � � Figure 5.8). �

� ��

� In fact, in 71 countries there are � � � individuals who do not monitor their �

� ��

� diabetes either by blood glucose or urine � �

� testing. � � According to the survey, the main reasons for not practising self-monitoring were � (see Figure 5.9): ��

• high cost of testing supplies; • lack of diabetes education; • lack of interest by patients; and • lack of testing supplies. Figure 5.8 Self-monitoring of glucose and methods used High cost of supplies was the major reason given by all responding countries �� in Africa, 75% of the countries in EMME, 71% in Europe, 90% in North America, �� 88% in SACA and 86% in Western Pacific

�� (see Figure 5.10). � � � � �

� ��

� Cost of diabetes supplies � � � � ��

� There was a great disparity in the cost �

� of diabetes supplies among the different � �

� ��

� regions, for instance blood glucose � � meters cost, on average, US$105 per �� glucose meter in the Western Pacific and

�� US$61 in South and Central America (see Table 5.8). Similarly, a box of 50 blood � glucose strips costs US$50 in North � �� America and US$20 in South-East Asia �� while a box of 100 urine glucose strips �� costs US$20 in North America and US$5 �� in South-East Asia (see Figure 5.11). In some countries, however, these diabetes supplies are subsidized or supplied free of charge to particular groups of people with diabetes.

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Figure 5.9 Reasons why people with diabetes do not practise self-monitoring of blood glucose

��

� ��

��

Figure 5.10 Main reasons for not practising self-monitoring by region

��

� ��

��

� ��

��

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Figure 5.11 Average cost of diabetes supplies by region

a. Blood glucose meter b. 100 urine test strips c. 50 blood glucose strips

��

� ��

� � � � � ��

� � � ��

Conclusion

The chronic lack of access to insulin and diabetes supplies in most regions especially the developing countries pose serious challenges to the international diabetes community. IDF has positioned itself to look for long-term solutions to these problems. Our individual and collective responsibilities are important to alleviate these problems. At the national level IDF can serve as a catalyst to massive price reductions as it has been the case in India. The Task Force on Insulin will continue to work with other groups within and outside IDF to establish national collaborative projects.

It still appears that Derek Wall, an ecologist, was right when he said, “At present cats have more power and influence than the poor of this planet. Accidents of geography and colonial history should no longer determine who gets the fish.” The international diabetes family can defend the rights of those who will die because they lack insulin, and work towards a world where insulin and other diabetes supplies are freely available to all those with diabetes.

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Profile: Hamisi Rashidi

wice a day Hamisi Rashidi removes a vial of insulin from a mud pot filled with water for This daily injections. The mud pot is the only way Hamisi, 12, can store his supply of insulin without it being destroyed. Sometimes, he says, “the water seeps into the insulin bottles diluting the insulin, and due to that I get high blood glucose even if I have injected insulin.”

Storage is a major problem for Hamisi, who has had type 1 diabetes since he was three. His parents cannot afford to buy a refrigerator; they live in a one-room house without electricity or running water in Dar es Salaam, Tanzania.

His parents also cannot afford to buy syringes although Hamisi obtains his insulin free of charge from the District Hospital. He uses a disposable syringe for about two and a half weeks before buying a new one. His parents worry greatly about sustaining his insulin treatment with their meagre earnings. Hamisi’s father does odd jobs while his mother is a housewife.

An added expense has now arisen with his weakened eyesight, which was discovered during a recent screening programme conducted by the Tanzanian Diabetes Association on World Diabetes Day. He has been advised to wear spectacles.

Hamisi has learnt to cope with the ups and downs and to find the right balance in order to avoid hypoglycaemia and hyperglycaemia. His parents have taught him to keep to a strict schedule for his meals and insulin injections. Says his mother, “Whenever he is not well we ask him to tell us if the sugar levels are high or low. He knows and understands more than we do and is the best judge during such a time.”

Optimistic and cheerful by nature, Hamisi welcomes his insulin injections rather than dreads them: “I’m not afraid; I like to inject insulin as it makes me hungry and I feel better. Otherwise I don’t feel hungry and I don’t like to eat anything.”

Hamisi, the second child in a family of six children, is the only one to have diabetes. His parents had never heard about the disease and were heartbroken on hearing the diagnosis. They were not sure what they would do and how they would treat Hamisi. “I was so worried about my child that I stopped eating and sleeping and would watch him all the time,” recalls his mother.

Although Hamisi wonders at times why he is the only one in the family to have diabetes, he does not see much difference between himself and his friends who do not have the disease, “I can do what they can do. I will be a doctor when I grow up and help people with diabetes.”

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Table 5.1 Access to insulin for people with type 1 diabetes

AFR EMME EUR NA SACA SEA WP Total No. of countries 9 4 32 10 8 3 8 74 <25% 2 0 0 0 0 0 0 2 26-49% 1 0 0 0 0 0 0 1 50-74% 3 0 0 1 3 0 0 7 75-99% 3 1 4 5 2 2 3 20 100% 0 3 28 4 3 1 5 44

Table 5.2 Access to insulin for people with type 2 diabetes

AFR EMME EUR NA SACA SEA WP Total No. of countries 9 4 32 10 8 3 8 74 <25% 1 0 1 0 0 0 0 2 26-49% 2 0 0 0 3 0 0 5 50-74% 2 0 1 1 0 0 1 5 75-99% 4 1 5 5 3 2 2 22 100% 0 3 25 4 2 1 5 40

Table 5.3 Causes of lack of access to insulin for people with type 1 diabetes

AFR EMME EUR NA SACA SEA WP Total No. of countries 9 4 32 10 8 3 8 74 Insulin is too expensive 7 0 2 2 3 1 0 15 Not available in regional areas 5 1 1 2 4 1 0 14 Transportation problems 3 0 0 0 2 1 1 7 Supply is less than required 2 0 1 1 2 0 0 6 Insulin is of very poor quality 0 0 1 0 1 1 0 3

Table 5.4 Causes of lack of access to insulin for people with type 2 diabetes

AFR EMME EUR NA SACA SEA WP Total No. of countries 9 4 32 10 8 3 8 74 Insulin is too expensive 6 0 1 0 1 1 0 9 Not available in regional areas 4 1 1 1 2 1 1 11 Transportation problems 3 0 0 0 1 1 0 5 Supply is less than required 2 0 2 1 2 0 0 7 Insulin is of very poor quality 1 0 0 0 0 1 0 2 Preference is given to type 1 0 0 1 1 3 1 0 6

AFR African Region EMME Eastern Mediterranean and Middle East Region EUR European Region NA North American Region SACA South and Central American Region SEA South-East Asian Region WP Western Pacific Region

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Table 5.5 Number of countries where 10 ml vial of U-100 insulin is available and cost (median and minimum-maximum) (USD) of human and animal insulin by region

AFR EMME EUR NA SACA SEA WP Total No. of countries 9 4 32 10 8 3 8 74 Human insulin No. of countries 7 4 22 9 7 3 6 58 Cost per box of 10 ml vial 18 (2-21) 4.6 (1-8) 14 (6-26) 14 (5.6-45) 19 (0.04-32) 10 (3-12.5) 9 (3-15) 13 (0.04-45)

Pork insulin No. of countries 4 0 5 3 4 2 1 19 Cost per box of 10 ml vial 8 (2.5-11) 7 (5-25) 25 (10-45) 11 (0.04-20) 7 (6-8) 11 9 (0.04-45)

Beef insulin No. of countries 2 1 3 0 2 1 0 9 Cost per box of 10 ml vial 9 (7-11) 3.4 28 (8.5-43) 6 (0.04-12) 3 8.5 (0.04-43)

Mixture of beef/pork insulin No. of countries 2 0 2 0 1 0 0 5 Cost per box of 10 ml vial 9 (7-11) N/A 0.04 7 (0.04-11)

N/A not available

Table 5.6 Number of countries where 10 ml vial of U-100 insulin is available and cost reported to GNP (median and minimum-maximum) (USD) of human and animal insulin by region

AFR EMME EUR NA SACA SEA WP Total No. of countries 9 4 32 10 8 3 8 74 Human insulin No. of countries 7 4 22 9 7 3 6 58 Cost (x1000/GNP) per box of 10 ml vial 13 (1-37) 2 (0.3-5) 1 (0.3-4) 2 (1-3) 2 (0.01-8) 4 (0.4-7) 0.5 (0.1-4) 1.3 (0.01-37)

Pork insulin No. of countries 4 0 5 3 4 2 1 19 Cost (x1000/GNP) per box of 10 ml vial 11 (5-13) 1 (0.4-2) 1.5 (1-2) 2 (0.01- 2) 4 (2-6) 5 1.6 (0.01-13)

Beef insulin No. of countries 2 1 3 0 2 1 0 9 Cost (x1000/GNP) per box of 10 ml vial 10.6 (9.5-12) 2 1.4 (1-2) 0.5 (0.01-1) 1 1.4 (0.01-12)

Mixture of beef/pork insulin No. of countries 2 0 2 0 1 0 0 5 Cost (x1000/GNP) per box of 10 ml vial 11 (9-12) N/A 0.01 10 (0.01-12)

GNP gross national product N/A not available

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Table 5.7 Access to insulin syringes and needles for people with diabetes

AFR EMME EUR NA SACA SEA WP Total No. of countries 9 4 32 10 8 3 8 74 <25% 2 0 0 0 0 0 1 3 26-49% 2 0 2 0 1 0 0 5 50-74% 0 0 0 1 3 0 2 6 75-99% 5 2 5 5 1 2 0 20 100% 0 2 25 4 3 1 5 40

Table 5.8 Cost of other diabetes supplies (median and minimum-maximum) (USD)

AFR EMME EUR* NA* SACA SEA WP Total* No. of countries 9 4 32 10 8 3 8 74 Cost of 100 syringes 14 (5-30) 11 (4-30) 12 (0-300) 23 (19-30) 15 (0.5-25) 10 (10-12.5) 10 (7-32) 13 (0-300) Cost of one insulin pen 40 (30-50) 36 (21-97) 39 (0-103) 0 (0-30) 12.5 (0-30) 10 (3-20) 25 (0-44) 25 (0-103) Cost of one blood glucose meter 96 (35-207) 65 (60-80) 65 (0-150) 65 (0-105) 61 (30-110) 90 (50-110) 105 (10-130) 70 (0-207) Cost of 50 blood glucose test strips 36 (15-45) 22 (15-35) 31 (0-50) 50 (20-55) 30 (20-48) 20 (20-21) 29 (3-45) 30 (0-55) Cost of 100 urine test strips 12 (5-30) 9 (7-30) 10 (0-100) 20 (0-30) 15 (8-30) 5 (2-10) 8 (5-25) 10 (0-100)

* The minimum cost is zero when the diabetes supply was given free to the patient.

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List of countries which participated in Bibliography the Global Access to Insulin and Diabetes Supplies Survey, 2003 1. Chale SS, Swai AB, Mujinja PG, McLarty DG. Must diabetes be a fatal disease in Africa? Study of costs of treatment. Africa (AFR) BMJ 1992; 304:1215-1218. Cameroon, Democratic Republic of Congo, Côte d’Ivoire, Kenya, 2. Jervell J. Variations in the utilization and cost of insulin. IDF Senegal, South Africa, Tanzania, Togo and Zambia. Bulletin 1996; 41:1-2. 3. IDF Task Force on Insulin. Access to insulin. A report of the Eastern Mediterranean and Middle East (EMME) IDF Task Force on Insulin 1994-97. International Diabetes Egypt, Libya, Pakistan and Qatar. Federation, Brussels, 1997. 4. King H. Insulin: availability, affordability, and Europe (EUR) harmonization. World Health Organization, Drug, Geneva, Albania, Austria, Belgium, Croatia, Cyprus, Czech Republic, 1998. 4:219-223. Denmark, Estonia, Finland, Georgia, Germany, Greece, Hungary, 5. Shobhana R, Rao PR , Lavanya A, Williams R, Vijay V, Ireland, Israel, Italy, Kazakhstan, Lithuania, Luxembourg, Malta, Ramachandran A. Expenditure on healthcare incurred by Netherlands, Norway, Poland, Portugal, Romania, Serbia and diabetic subjects in a developing country – a study from Montenegro, Slovenia, Spain, Sweden, Turkey, UK and Ukraine. southern India. Diabetes Res Clin Pract 2000; 48:37-42. 6. Lin T, Chou P, Lai M, Tsai S, Tai T. Direct cost-of-illness of North America (NA) patients with diabetes mellitus in Taiwan. Diabetes Res Clin Anguilla, Belize, Bermuda, British Virgin Islands, Canada, Pract 2001; 54 Suppl 1:43-46. Commonwealth of Dominica, Guyana, Jamaica, Mexico and USA.

South and Central America (SACA) Argentina, Bolivia, Brazil, Chile, Cuba, El Salvador, Peru and Uruguay.

South-East Asia (SEA) Bangladesh, Mauritius and Sri Lanka.

Western Pacific (WP) Australia, China Hong Kong, Japan, New Zealand, Philippines, Singapore, Taiwan and Thailand.

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Diabetes Education Chapter 6

iabetes education has been shown to Dbe effective and is now considered an integral part of diabetes care. In acknowledging the critical importance of education, the International Diabetes Federation (IDF) established the Diabetes Education Consultative Section (DECS) to address the education needs of IDF member associations.

In continued recognition and support of education, this chapter of the Diabetes Atlas is devoted specifically to diabetes education and is divided into three sections: the first summarizes the evidence-based studies supporting the effectiveness of diabetes education, the 6.1 Effectiveness of Self- second is a report of education practices management Education in the seven IDF regions based on a 6.2 Educational Practices: comprehensive survey, and the final a Global View section provides projected cost savings associated when people with diabetes 6.3 Cost-effectiveness of receive education. Diabetes Education

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6.1 Effectiveness of Self-management Education

Introduction 3 adhere to self-care practices; and 4 make needed changes in their health Although the medical dimensions of habits. diabetes care such as eye exams and blood glucose monitoring have improved More broadly, diabetes self-management in recent years, outcomes for many education assists people in coping with people with diabetes remain poor (1,2). the mental and physical demands of their While many factors contribute to poor illness, given their unique economic, outcome, this apparent contradiction also cultural and social circumstances. Diabetes self- reflects the central role that people with management education diabetes themselves play in determining Why is self-management is a multi-faceted their health status, and the challenges important? process involving much associated with supporting their efforts more than helping to manage their self-care (3). Improving outcomes people with diabetes Glucose self-monitoring is essential for monitor their blood Diabetes self-management is among the identifying episodes of extremely high glucose, or take most difficult of all chronic illness self- and low blood glucose (hyperglycaemia their medication as management regimens. To effectively and hypoglycaemia), especially among prescribed. Diabetes self-manage diabetes, those with the people with type 1 diabetes. This was education must be an disease must identify symptoms of the conclusion of a review of scientific ongoing process rather emerging health crises, adhere to often evidence by Piette and Glasgow than a one-time event complex medication schedules, and supporting various diabetes self-care because a person’s modify long-standing lifestyle behaviours practices and their promotion through health status and need such as their diet and physical activity self-management supports (see Box for support changes levels. Not surprisingly, many people 6.1) (9). There is no evidence, however, over time. have difficulty meeting the demands that glucose self-monitoring improves of their illness and experience poorer outcomes among people with type 2 outcomes as a result. diabetes (12, 13), although this could change if effective systems are put This section reviews the findings in place to address the cause of their from recent research on diabetes self- problems. management supports for adults. More detailed reviews have been published Foot self-care is essential for people with previously, and readers are encouraged to diabetes in order to avoid infections seek these out for additional information and ulcers leading to amputation. Foot about specific topics such as foot self-care education is an effective means care education, medication adherence of improving foot care practices and enhancement, or promotion of smoking outcomes (14, 15). Assisting people with cessation within primary care clinics (4-11). diabetes in taking their medication as prescribed is also important, and a variety Goal of diabetes education of low-cost and simple interventions such as day-specific pill containers and The goal of diabetes self-management simplified dosing schedules are effective education is to support the efforts of in doing this (16-19). people with diabetes to: 1 understand the nature of their illness Changing lifestyle and its treatment; With regard to lifestyle behaviours, 2 identify emerging health problems in smoking cessation is an essential aspect early, reversible stages; of diabetes self-care, and interventions

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to help people quit smoking increase Box 6.1 cessation rates (20, 21). Brief advice to quit smoking produces important Issues to be addressed by diabetes effects, although behaviouralcounselling self-management education accompanied by medication and ongoing support has the greatest impact (22, 23). • Glucose self-monitoring (for some) • Foot care Many people with type 2 diabetes are • Medication adherence sedentary, and increasing their physical • Smoking cessation activity levels can be important. Effective • Increasing physical activity physical activity counselling strategies • Reducing dietary fat and caloric intake have been identified that can improve glucose control (24) of people with type 2 diabetes as well as other cardiovascular risk factors, such as blood pressure (25) and cholesterol levels (26). Counselling and support to decrease the amount of dietary fat and overall caloric intake have shown some success (11, 27, 28). Two confidence or ‘self-efficacy’ regarding important studies recently demonstrated self-management. that lifestyle interventions promoting physical activity plus dietary changes can A successful programme for achieving delay the onset of type 2 diabetes among these goals has been developed by high-risk individuals (29, 30). Kate Lorig and colleagues at Stanford University (37) in the USA. The Where should education programme can be delivered in multiple take place? languages, and recent evaluations indicate that it produces lasting Group visits in medical settings reductions in symptoms, physician visits People with diabetes often learn as and costs relative to others receiving much or more within a group context usual care (38). Ongoing research is than they do on their own or through evaluating the impact of this intervention one-to-one visits with clinicians. In one on diabetes treatment outcomes among study, participants in group visits had low-income Spanish-speakers in northern fewer emergency department visits, California. visits to sub-specialists and repeat hospitalizations (31). Similar effects of In another community-based study, group visits, including improvements in elderly people with diabetes received glycaemia control, satisfaction, healthcare disability prevention and disease self- utilization and costs of care, have been management education in a senior reported in a wide range of populations centre (39). Individuals receiving the and health systems, including large health intervention had substantially less decline maintenance organizations (32, 33), in physical function, greater levels of under-served populations (34) and health physical activity and less reliance on systems in different countries (35, 36). medications. Those participating in the groups also used less hospital care Community-based than those in a comparison group. peer-support groups Community-based groups such as People with diabetes also can improve these may be particularly important in their self-care through classes led by non- settings where people with diabetes have clinician peers and structured to improve difficulty accessing care within traditional their understanding of their illness and healthcare settings.

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Ongoing home support Female physicians often engage in more via telephone patient-centred communication than their Self-management support provided male counterparts (54), and patients are through regular telephone follow-up more satisfied with female providers improves outcomes of people with (55-58). Continuity of care has been diabetes. In one study (40) among elderly associated with better communication men with type 2 diabetes, monthly calls among asthma patients (59) and greater by a nurse-educator improved glycaemic patient satisfaction and quality in general control, and a more recent study had (60, 61). similar results (41). These studies are consistent with the broader literature on A training programme developed by telephone care, showing that telephone Robert Anderson and colleagues (62) calls can improve the health of those who for diabetes educators to help them are chronically ill and may even serve as learn how to teach people with diabetes an effective alternative to face-to-face more effective communication strategies office visits (28, 42, 43). and become more actively involved in their own treatment. Following training, Effectivecommunication educators show significant improvement in their counselling skills and in their When people with diabetes play attitudes toward supporting patient central roles in setting their own self- autonomy (62). care goals, they are more likely to adhere to treatment plans (44-46). The empowerment approach has been Diabetes educators can contribute to demonstrated to produce better patient this process by providing them with outcomes than usual care (63), and the information they need for priority- another approach to empowering patients setting and problem-solving, assisting at the time of clinic visits has also been them in identifying realistic targets for shown to improve glucose levels (64). behavioural changes, and providing ongoing emotional support and Role of emerging encouragement. health technologies

Through these efforts, educators can A variety of novel technologies has been improve the long-term ability of people developed to support self-care efforts with diabetes to maintain an effective self- of people with diabetes and provide management regimen and help them avoid an alternative to traditional education emotional burnout (47, 48). More effective occurring within outpatient clinics (65). communication between the individual and educator can lead to better self-care Interactive software behaviour as well as improvements in Interactive software accessed on a health outcomes (49-53). personal computer using CD-ROMs or other hardware represents one Characteristics of patients, providers and strategy for delivering behaviour change health systems may influence the quality interventions efficiently and effectively of patient-provider interactions. Race in the context of busy primary care and ethnicity may constitute barriers to practices. These systems can be placed in communication with potentially negative clinic waiting rooms where they can reach effects on patients’ willingness to receive large numbers of people, require minimal necessary services and follow self-care staffing, and provide self-paced and plans. tailored educational messages (66).

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A clinic-based touch-screen computer Box 6.2 system was developed by Glasgow and colleagues to assist diabetes patients Components of effective self-management assess their health behaviours, self- programmes management goals and barriers to goal attainment (67). Compared to similar • Ongoing support rather than one-time counselling patients, those using the CD-ROM system • Group visits and peer-to-peer counselling had improvements in their diet and lower • Telephone care including the use of automated cholesterol levels (68, 69). telephone calls • Effective communication with providers to set self- Automated telephone systems management goals and overcome barriers Automated telephone systems can allow • Use of interactive technologies for frequent follow-up with individuals • A coordinated systems approach who have difficulty accessing clinic- based services or who lack the computer supports necessary for more ‘high-tech’ interventions. Those who are chronically ill can provide valid and reliable information using their touch-tone telephone during automated monitoring experience by using audio and video, calls (70, 71). and are potentially available 24 hours per day. Internet-based diabetes supports A study, by Piette and colleagues, found also allow people with diabetes to that a group of low-income English- and communicate with their clinicians, Spanish-speaking people with diabetes experts in self-care, or one another. receiving bi-weekly automated calls with telephone nurse follow-up responded to One of the most definitive studies of the calls consistently over the 12-month internet-based diabetes supports (81) study period (72). These individuals used evaluated a web-based self-management the calls to access self-care education programme in which participants were (73), and reported information that encouraged to log on to a specially- identified those at greatest risk for designed website, review their progress developing problems (74). toward self-management goals, and access other services such as an online The intervention improved their blood log of their progress and personal glucose self-monitoring, foot care, counselling and support. At follow-up, weight self-monitoring and medication those using the website and those in the adherence (75). The study also found comparison group improved in their self- improvements in their glucose control, reported physical activity, however there diabetes-related symptoms and were no significant differences between symptoms of depression (76). These the two groups. Individuals who used the same investigators replicated this study system more frequently reported greater in another US health system and had change in physical activity than those similar findings (77). who used it less often.

Internet-based support Summary Internet-based diabetes self-care support has the potential to reach large numbers Diabetes self-management education is of people, and even computer novices a multi-faceted process involving much are willing to use internet-based diabetes more than helping people with diabetes education programmes (78-80). Such monitor their blood glucose, or take systems can enhance the educational their medication as prescribed. Diabetes

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education must be an ongoing process rather than a one-time event because a person’s health status and need for support changes over time (Box 6.2) (11).

One-on-one counselling may be helpful to improving self-care, although group sessions led either by clinicians or others with diabetes also can be effective. Telephone care can be a vital link between people with diabetes and their healthcare providers for ongoing self- management support, especially when there is difficulty accessing face-to-face services. Automated telephone calls can extend the reach of self-management education when staffing is limited or an individual needs frequent monitoring and behaviour change supports.

Effective communication with healthcare providers is strongly linked to improvements in self-care and outcomes, and self-management educators can play an important role in empowering people with diabetes to become active participants in identifying self-care goals and overcoming barriers to their achievement. Overall, self-management education is most likely to be successful when it is part of a comprehensive and coordinated approach to diabetes care (82).

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patient compliance: a meta-analysis. Medical Care 1998; References 36:1138-1161. 20. Fiore M, Bailey W, Cohen S. Smoking Cessation. Clinical 1. Harris MI. Healthcare and health status and outcomes Practice Guideline Number 18. Rockville: U.S. Department of for patients with type 2 diabetes. Diabetes Care 2000; Health and Human Services, Public Health Service, Agency 23:754-758. for Health Care Policy and Research, 1996. 2. Saaddine JB, Engelgau MM, Beckles GL, Gregg EW, 21. Haire-Joshu D, Glasgow RE, Tibbs TL. Technical review: Thompson TJ, Narayan KM. A diabetes report card for the smoking and diabetes. Diabetes Care 1999; 22:1887-1898. United States: quality of care in the 1990’s. Ann Intern Med 22. Tang J, Law M, Wald N. How effective is nicotine 2002; 136:565-574. replacement therapy in helping people to stop smoking? 3. Goldman DP, Smith JP. Can patient self-management help BMJ 1994; 308:21-26. explain the SES health gradient? PNAS 2002; 99:10929- 23. Fiore M, Smith S, Jorenby D, Baker T. The effectiveness of 10934. the nicotine patch for smoking cessation: a meta-analysis. 4. Brown SA. Effects of educational interventions in diabetes JAMA 1994; 271:1940-1947. care: a meta-analysis of findings. Nurs Res 1988; 24. Boule NG, Haddad E, Kenny GP, Wells GA and Sigal RJ. 37:223-230. Effects of exercise on glycemic control and body mass 5. Brown SA. Diabetes patient education interventions and in type 2 diabetes mellitus: a meta-analysis of controlled outcomes: a meta-analysis revisited. Patient Educ Couns clinical trials. JAMA 2001; 286:1218-1227. 1990; 16:189-215. 25. Wareham NH, Wong MY, Hennings S, et al. Quantifying the 6. Brown SA. Meta-analysis of diabetes patient education association between habitual energy expenditure and blood research: variations in intervention effects across studies. pressure. Int J Epidemiol 2000; 29:655-660. Res Nurs Health 1992; 15:409-419. 26. Parkkari JM, Natri AM, Kannus P, et al. A controlled trial of 7. Clement S. Diabetes self-management education. Diabetes the health benefits of regular walking on a golf course. Am Care 1995; 18(8):1204-1214. J Med 2000; 109:102-108. 8. Padgett D, Mumford E, Hynes M, Carter R. Meta-analysis of 27. Lacey KO, Kimberly O, Chyun DA, Grey M. An integrative the effects of educational and psychosocial interventions literature review of cardiac risk factor management in on management of diabetes mellitus. J Clin Epidemiol 1988; diabetes education interventions. The Diabetes Educator 41(10):1007-1030. 2000; 26:812-820. 9. Piette JD, Glasgow R. Strategies for improving behavioral 28. Debusk RF, Houston Miller N, Superko HR, et al. A case- and health outcomes among patients with diabetes: self- management system for coronary risk factor modification management education. In Evidence-Based Diabetes Care, after acute myocardial infarction. Ann Intern Med 1994; eds Gerstein HC, Haynes RB. Ontario, Canada: BC Decker 120:721-729. Publishers 2001, pp 207-251. 29. Diabetes Prevention Program Research Group. Reduction in 10. Brown SA. Interventions to promote diabetes self- the incidence of type 2 diabetes with lifestyle intervention management: state of the science. Diabetes Educator 1999; or metformin. N Engl J Med 2002; 346:393-403. 25 Suppl 6:52-61. 30. Tuomilehto J, Lindstrom J, Eriksson JG, et al. Prevention 11. Norris SL, Engelgau MM, Narayan KMV. Effectiveness of of type 2 diabetes mellitus by changes in lifestyle among self-management training in type 2 diabetes. A systematic subjects with impaired glucose tolerance. N Engl J Med review of randomized controlled trials. Diabetes Care 2001; 2001; 344:1343-1350. 24:561-587. 31. Beck A, Scott J, Williams P, Robertson B, Jackson D, Gade G, 12. Faas A, Schellevis FG, Van Ejik JTM. The efficacy of self- Cowan P. A randomized trial of group outpatient visits for monitoring of blood glucose in NIDDM subjects: a criteria- chronically ill older HMO members: the cooperative health based literature review. Diabetes Care 1997; 20:1482-1486. care clinic [see comments]. J Amer Geriatr Soc 1997; 45(5): 13. Gallichan M. Self monitoring of glucose by people with 543-549. diabetes: evidence based practice. BMJ 1997; 314:964-967. 32. Sadur C, Moline N, Costa M, et al. Diabetes management 14. Litzelman DK, Slemenda CW, Langefeld CD, Hays LM, in a health maintenance organization: efficacy of care Welch MA, Bild DE, Ford ES, Vinicor F. Reduction of lower management using cluster visits. Diabetes Care 1999; extremity clinical abnormalities in patients with non-insulin- 22:2011-2017. dependent diabetes mellitus. Ann Intern Med 1993; 119(1): 33. Wagner E, et al. Chronic care clinics for diabetes in primary 36-41. care: a system-wide randomized trial. Diabetes Care 2001; 15. Uccioli L, Faglia E, Monticone G, Favales F, Durola L, 24(4):695-700. Aldeghi A, Quarantiello A, Calia P, Menzinger G. 34. Keyserling TC, et al. A randomized trial of an intervention Manufactured shoes in the prevention of diabetic foot to improve self-care behaviors of African-American women ulcers. Diabetes Care 1995; 18:1376-1378. with type 2 diabetes: impact on physical activity. Diabetes 16. McKenney JM, Munroe WP, Wright JT Jr. Impact of an Care 2002; 25(9):1576-1583. electronic medication compliance aid on long-term blood 35. Trento M, et al. Lifestyle intervention by group care pressure control. J Clin Pharmacol 1992; 32(3):277-283. prevents deterioration of type II diabetes: a 4-year RCT. 17. Friedman RH, Kazis LE, Jette A, Smith MB, Stollerman J, Diabetologia 2002; 45(9):1231-1239. Torgerson J, Carey K. A telecommunications system for 36. Trento M, Passera P, Tomalino M, Bajardi M, Pomero F, monitoring and counseling patients with hypertension. Allione A, Vaccari P, Molinatti GM, Porta M. Group visits Impact on medication adherence and blood pressure improve metabolic control in type 2 diabetes: a 2-year control. Am J Hypertens 1996; 9(4 Pt 1):285-292. follow-up. Diabetes Care 2001; 24(6):995-1000. 18. Rich MW, Gray MB, Beckham V, Wittenberg C, Luther P. 37. Lorig KR, Mazonson PD, Holman HR. Evidence suggesting Effect of a multidisciplinary intervention on medication that health education for self-management in patients compliance in elderly patients with congestive heart failure. with chronic arthritis has sustained health benefits while Am J Med 1996; 101(3):270-276. reducing health care costs. Arthritis Rheum 1993; 36(4): 19. Roter D, Debra L, Hall JA, Merisca R, Nordstrom B, Cretin D, 439-446. Svardstad B. Effectiveness of interventions to improve 38. Lorig KR, Sobel DS, Stewart AL, Brown BW Jr, Bandura A, Ritter P, Gonzalez VM, Laurent DD, Holman HR. Evidence 212 213

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suggesting that a chronic disease self-management 57. Zare N, Sorenson JR, Heeren T. Sex of provider as a variable program can improve health status while reducing in effective genetic counseling. Soc Sci Med 1984; 19:671- hospitalization: a randomized trial. Med Care 1999; 675. 37(1):5-14. 58. Linn LS, Cope DW, Leake B. The effect of gender and 39. Leveille SG, Wagner EH, Davis C, Grothaus L, Wallace J, training of residents on satisfaction ratings by patients. LoGerfo M, Kent D. Preventing disability and managing J Med Educ 1984; 59:964-966. chronic illness in frail older adults: A randomized trial of 59. Love MM, Mainous AG, 3rd, Talbert JC, Hager GL. Continuity a community-based partnership with primary care [see of care and the physician-patient relationship: the comments]. J Amer Geriatr Soc 1998; 46(10):1191-1198. importance of continuity for adult patients with asthma. 40. Weinberger M, Kirkman MS, Samsa GP, Shortliffe A, J Fam Pract 2000; 49:998-1004. Landsman PB, Cowper PA, Simel DL, Feussner JR. A nurse- 60. Howie JG, Heaney DJ, Maxwell M, et al. Quality at general coordinated intervention for primary care patients with non- practice consultations: cross sectional survey. BMJ 1999; insulin-dependent diabetes mellitus: impact on glycemic 319:738-743. control and health-related quality of life. J Gen Intern Med 61. Hjortdahl P, Laerum E. Continuity of care in general practice: 1995; 10(2):59-66. effect on patient satisfaction. BMJ 1992; 304:1287-1290. 41. Aubert RE, Herman WH, Waters J, Moore W, Sutton D, 62. Anderson RM, Funnell MM, Barr PA, Dedrick RF, Davis WK. Peterson BL, Bailey CM, Koplan JP. Nurse case management Learning to empower patients: results of a professional to improve glycemic control in diabetic patients in a health education program for diabetes educators. Diabetes Care maintenance organization: a randomized, controlled trial. 1991; 14(2):584-590. Ann Intern Med 1998; 129(8):605-612. 63. Anderson RM, Funnell MM, Butler PM, Arnold MS, 42. Weinberger M, Tierney WM, Booher P, Katz BP. Can the Fitzgerald JT, Feste CC. Patient empowerment. Results of a provision of information to patients with osteoarthritis randomized controlled trial. Diabetes Care 1995; improve functional status? A randomized, controlled trial. 18(7):943-949. Arthritis Rheum 1989; 32:1577-1583. 64 . Greenfield S, Kaplan S, Ware JE Jr. Expanding patient 43. Wasson J, Gaudette C, Whaley F, Sauvigne A, Baribeau P, involvement in care. Effects on patient outcomes. Ann Welch HG. Telephone care as a substitute for routine clinic Intern Med 1985; 102:520-528. follow-up. JAMA 1992; 267(13):1788-1793. 65. Piette JD. Enhancing support via interactive technologies. 44. Glasgow RE, Anderson RM. In diabetes care, moving from Current Diabetes Reports 2002; 2(2):160-165. compliance to adherence is not enough. Something entirely 66. Castaldini M, Saltmarch M, Luck S, Sucher K. The different is needed. Diabetes Care 1999; 22:2090-2092. development and pilot testing of a multimedia CD-ROM 45. Anderson RM, Funnell MM. Compliance and adherence for diabetes education. The Diabetes Educator 1998; are dysfunctional concepts in diabetes care. The Diabetes 24(3):285-296. Educator 2000; 26:597-604. 67. Glasgow RE, Toobart DJ, Hampson. Effects of a brief 46. Olivarius NF, Beck-Nielsen H, Andreasen AH, Horder M, office-based intervention to facilitate diabetes dietary self- Pedersen PA. Randomised controlled trial of structured management. Diabetes Care 1996; 19(8):835-842. personal care of type 2 diabetes mellitus. BMJ 2001; 323: 68. Glasgow RE, La Chance PA, Toobert DJ, Brown J, 946-947. Hampson SE, Riddle MC. Long-term effects and costs of 47. Charman D. Burnout and diabetes: reflections from working brief behavioural dietary intervention for patients with with educators and patients. J Clin Psychol 2000; diabetes delivered from the medical office. Patient Educ 56:607-617. Couns 1997; 32(3):175-184. 48. Hoover JW. Patient burnout, and other reasons for 69. Glasgow RE, Toobert DJ. Brief, computer-assisted diabetes noncompliance. The Diabetes Educator 1983; 9:41-43. dietary self-management counseling: effects on behavior, 49. Heisler M, Bouknight RR, Hayward RA. The relative physiologic outcomes, and quality of life. Med Care 2000; importance of physician communication, participatory 38:1062-1073. decision-making, and patient understanding in diabetes 70. Piette JD. Moving diabetes management from clinic self-management. J Gen Intern Med 2002; 17:243-252. to community: development of a prototype based on 50. DiMatteo MR. The physician-patient relationship: effects automated voice messaging. The Diabetes Educator 1997; on the quality of health care. Clin Obstet Gynecol 1994; 23(6):672-679. 37:149-161. 71. Piette JD. Interactive voice response systems in the 51. Sherbourne CD, Hays RD, Ordway L, DiMatteo MR, diagnosis and management of chronic disease. Am J Manag Kravitz RL. Antecedents of adherence to medical Care 2000; 6(7):817-827. recommendations: results from the Medical Outcomes 72. Piette JD, Mah CA. The feasibility of automated voice Study. J Behav Med 1992; 15:447-468. messaging as an adjunct to outpatient diabetes care. 52. Kaplan SH, Greenfield S, Ware JE, Jr. Assessing the effects of Diabetes Care 1997; 20(1):15-21. physician-patient interactions on the outcomes of chronic 73. Piette JD. Patient education via automated calls: a study of disease [published erratum] appears in Med Care 1989; English and Spanish speakers with diabetes. Am J Prev Med 27:S110-127. 1999; 17(2):138-141. 53. Stewart MA. Effective physician-patient communication and 74. Piette JD, McPhee SJ, Weinberger M, Mah CA, Kraemer FB. health outcomes: a review. CMAJ 1995; 152:1423-1433. Use of automated telephone disease management calls in 54. Roter DL, Hall JA, Aoki Y. Physician gender effects in medical an ethnically diverse sample of low-income patients with communication: a meta-analytic review. JAMA 2002; 288: diabetes. Diabetes Care 1999; 22(8):1302-1309. 756-767. 75. Piette JD, Weinberger M, McPhee SJ, Crapo LA, Kraemer FB. 55. Sprague-Jones J. Gender effects in physician-patient Do automated calls with nurse follow-up improve self-care interaction. In The Medical Interview: Clinical Care, and glycemic control among english- and spanish-speaking Education, and Research, eds Lipkin M, Putnam SM, patients with diabetes? A randomized controlled trial. Am J Lazare A. Springer-Verlag, New York, 1995; pp 163-171. Med 2000; 108(1):20-27. 56. Arnold RM, Martin SC, Parker RM. Taking care of patients 76. Piette JD, Weinberger M, McPhee SJ. The effect of automated – does it matter whether the physician is a woman? West J calls with telephone nurse follow-up on patient-centered Med 1988; 149:729-733. 214 215

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outcomes of diabetes care (a randomized controlled trial); Med Care 2000; 38:218-230. 77. Piette JD, Weinberger M, Kraemer FB, McPhee SJ. Impact of automated calls with nurse follow-up on diabetes treatment outcomes in a Department of Veterans Affairs healthcare system: a randomized controlled trial. Diabetes Care 2001; 24(2):202-208. 78. McKay HG, Feil EG, Glasgow RE, Brown JE. Feasibility and use of an internet support service for diabetes self- management. The Diabetes Educator 1998; 24(2):174-179. 79. Feil EG, Glasgow RE, Boles S, McKay HG. Who participates in Internet-based self-management programs? A study among novice computer users in a primary care setting. The Diabetes Educator 2000; 26(5):806-811. 80. Zrebiec JF, Jacobson AM. What attracts patients with diabetes to an Internet support group? A 21-month long website study. Diabet Med 2001; 18:154-158. 81. McKay HG, King D, Eakin EG, Seeley JR, Glasgow RE. The diabetes network internet-based physical activity intervention: a randomized pilot study. Diabetes Care 2001; 24(8):1328-1334. 82. Renders CM, Valk GD, Griffin SJ, Wagner EH, et al. Interventions to improve the management of diabetes in primary care, outpatient, and community settings: A systematic review. Diabetes Care 2001; 24:1821-1833.

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6.2 Educational Practices: a Global View

Introduction Survey response

The efforts of the IDFDiabetes Education The survey questionnaire was sent to Consultative Section (DECS) are targeted all IDF members associations by mail to address the needs of three audiences: and electronically. At every opportunity the person with diabetes and those DECS members, regional chairs and affected by the disease, thehealthcare managers distributed and encouraged professional responsible for providing survey responses. Some 122 survey diabetes care, and the public. In an questionnaires were returned and attempt to capture educational practices analysed. The vast majority of the that apply to each of these audiences, respondents completing the survey for DECS members representing all diabetes each country identified themselves as disciplines from each of the IDF regions physicians and in some cases educators. designed a survey that was sent to The surveys responses represented: member associations. • 57 countries The survey was designed to gain an • 7 regions understanding of diabetes educational – Africa (AFR) (n=7) practice as it applies to all three of the – Eastern Mediterranean and audiences: the person with diabetes, Middle East (EMME) (n=5) health professionals and the public. – Europe (EUR) (n=35) Members of the consultative section – North America (NA) (n=6) recognize that this survey serves as a – South and Central America crude methodology in capturing data (SACA) (n=18) and information; however it does offer – South-East Asia (SEA) (n=8) the first opportunity to gain a baseline – Western Pacific (WP) (n=36) understanding of practices and concerns. It is hoped that this attempt and its Summary of results findings will pique continued interest in diabetes education efforts and the The following summarizes survey development of future tracking, reporting findings according to regions since and intervention efforts. efforts of the consultative section are often targeted with far-reaching regional approaches. More detailed information for each member country is available in Figure 6.1 addressing country-specific needs. Providers of diabetes education Educational resources Physicians were identified as the main �� provider of diabetes education in most regions, as shown in Figure 6.1, when

�� respondents were asked who provides education in their country. The exception was in the Eastern Mediterranean and Middle East Region, where pharmacists were most likely to provide education. �� Short training courses of 40-120 hours were most often the mechanism for

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Figure 6.2 Type of training available to diabetes educators

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training, as shown in Figure 6.2, when Figure 6.3 respondents were asked how people Availability of teaching tools were trained to be educators. However, �� the African and South-East Asian Regions �� reported that there was very limited or no educator training available. ��

Teaching tools are reported to be available in all regions, but every region supported the need for computerized �� resources and networking opportunities. The media proved to be the tool most available in all the regions, as indicated in Figure 6.3. ADA American Diabetes Association

Respondents expressed interest in having an international summit addressing the Figure 6.4 global needs and problems related to Understanding and appreciating the role of diabetes educators diabetes education, and identified IDF as �� a resource for support in training and the �� development of standards for practice (see Box 6.3).

Role of diabetes educators All regions reported that people with �� diabetes understood and appreciated the role of diabetes educators, as shown in Figure 6.4. This was in contrast to

health authorities, and to some extent, �� physicians, not many of whom were

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Box 6.3

Diabetes education training course: the Caribbean example

he Diabetes Education Consultative Section (DECS) has successfully organized training courses in Tcollaboration with IDF regions and local diabetes associations. The Caribbean Diabetes Education Course, organized by the IDF North American Region in collaboration with the Diabetes Association of Barbados, is a good example of such training courses.

The course, which was based on models developed by DECS and the Declaration of the Americas on Diabetes (DOTA), was run in two parts. Part one was held in the Barbados and part two, held in the Bahamas, was a follow-up a year later.

Nurses, dietitians, pharmacists and educators from 13 Caribbean island countries attended the five-day course in Barbados. Participants came away with updated knowledge in the management of diabetes and its complications as well as developing their skills in diabetes education and organization. An important objective was to facilitate the establishment of a programme plan for diabetes education in each participant’s country.

Mentors were assigned to participants and worked with them throughout the week. This proved to be an invaluable tool as the evaluation at the end of the course showed: “Excellent guidance for the programme and ongoing projects – the mentoring concept keeps the group focused.”

Course content included both theory and practical application. Participants were also asked to work on projects such as foot care education programmes for patients and healthcare professionals, educating healthcare professionals on diabetes management and healthy lifestyle education which was aimed at prevention. Projects were to be developed in the next year with strict deadlines. Participants who completed the project were invited to the follow-up meeting in the Bahamas the following year.

The course was geared towards motivating the participants to apply their training on returning to their countries. Each participant was asked to propose changes they would make to their practice.

The follow-up course, which took place a year later in the Bahamas, was organized this time in association with the Bahamas Diabetic Association.

The follow-up course programme was developed based on the IDF International Curriculum for Diabetes Health Professional Education (1). The course also included a poster presentation of the projects that the participants from the Barbados course had worked on in collaboration with their mentors.

reported to show understanding of the Access to education role of diabetes educators in some of Although all countries reported that the regions. Nonetheless, respondents people with diabetes have access to reported that the majority of physicians diabetes education, they nonetheless in all regions, except Africa, did promote identifiedbarriers to access. Barriers were and refer patients for diabetes education. analysed according to four categories In addition, all of the respondents were outlined in the ‘Barriers to Diabetes aware of published studies validating the Care’ instrument (2) used to measure importance of education.

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Figure 6.5 Barriers to education

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the healthcare provider’s perceptions of Discussion barriers. Limitations Each of the four categories refers to There are several limitations to the specific problems: interpretation of the summary report based on challenges inherent in the 1 Psychological: addresses health information gathered through the survey. beliefs/self-efficacy; Although all IDF member associations 2 Educational: refers to lack of received the survey forms, response knowledge or education services; rates varied. Some regions, such as 3 Internal physical: refers to other Europe and Western Pacific, had a high diabetes-related problems such as number of responses while other regions heart or kidney disease and the had a lower participation. This could be effects of treatment; and reflective of the make-up of a particular 4 External physical: refers to problems region. For example, the Western Pacific that are financial or limitations to represents 19 member associations with proper access. many smaller islands, while South-East Asia with a large population affected The categories most frequently reported by diabetes has only five member as being significant barriers were the associations. external physical and educational, as shown in Figure 6.5. In other words, Each of the regions has a diverse group financial resources, limited access, lack of of member countries that vary in size, knowledge and educational resources are populations, culture, healthcare practices perceived to be the biggest challenges. and socio-economics. For example, the North American Region includes large Training and advocacy efforts directed developed countries such as Canada toward health ministers and public and the United States, and developing awareness were some of the mechanisms countries such as Mexico and the small most often identified as means to address Caribbean islands. these barriers, as seen in Figure 6.6. The regional descriptions in the survey provide summary information and do not provide the detail needed to appreciate

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Figure 6.6 Means to overcome barriers to diabetes education

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the practices and needs of specific References countries. Descriptions according to 1. IDF Consultative Section on Diabetes countries and regions will vary in their Education. International Curriculum for level of detail in accordance with the Diabetes Health Professional Education. information that was received. International Diabetes Federation, Brussels, 2002. 2. Simmons D, Weblemoe T, Voyle J, Prichard A, Common themes Leakehe L, Gatland B. Personal barriers Despite the apparent limitations to diabetes care: Lessons from a multi- consistent themes were reported that ethnic community in New Zealand. Diabetic Medicine 1998; 15(11):958-964. need to be addressed as the world incidence and prevalence of diabetes grow. From the survey it appears that although some countries do have national health programmes that include attention to diabetes education others do not. All the regions reported poor funding for education.

Recurrent themes for potential solutions occurred and should be considered. For prevention and treatment of diabetes to be successful through education initiatives, governments, and local, national and international health associations need to organize efforts to promote the training, financial support, access and public awareness of diabetes education.

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6.3 Cost-Effectiveness of Diabetes Education

Introduction Three independent reviews note that the economic costs and benefits of Economic issues in diabetes care are diabetes education have not been fully garnering great attention throughout addressed (1-3). Several studies provide the world today. This attention has been either a poor accounting of costs (such as particularly pronounced in recent years. neglecting to account for the programme Cost issues in diabetes self-management costs inherent in providing education), training are of interest because of three or an inadequate comparison group to current and significant influences; first, assess the impact on diabetes-related the recognition that diabetes is increasing outcomes. A multi-centre throughout the world, second, the intervention in recognition that self-management training Despite the recognized limitations 10 countries in is effective in improving the health of in economic methodology, Klonoff Latin America has persons with diabetes, and third, the and Schwartz (1) conclude that self- demonstrated that an desire of many healthcare payers to limit management training in diabetes is educational programme healthcare costs. probably cost-effective. This judgment is can reduce the cost based on a large number of studies that of drugs by 62%. In this light, cost-effectiveness suggest an economic benefit to self- Another programme analyses are often used to evaluate management training programmes. in Argentina found a the economic arguments surrounding reduction in diabetes- diabetes treatments and interventions. For example, reduced future related costs of 38%. A cost-effectiveness analysis generally hospitalizations associated with self- summarizes the impact of an management interventions have been intervention by characterizing the cost noted in several (1), though, not all of the intervention relative to the health reports (4, 5). Hospital costs represent outcomes obtained. These studies are the largest expenditure for diabetes care used to advocate for the adoption of in several countries and reducing hospital a healthcare intervention. Typically, costs thereby generally saves money. A the policy decision is whether a new multi-centre intervention in 10 countries intervention is better able to meet in Latin America has also demonstrated a healthcare goal than the existing that an educational programme can standard of care at a reasonable cost. reduce the cost of drugs by 62% (6). Another programme in Argentina found Current understanding a reduction in diabetes-related costs of 38% (7). Economic arguments for the adoption of self-management training can be Diabetes education is also an integral part a powerful tool for advocates and of several interventions that have been others seeking to improve the health shown to save money. These include of the diabetes population. Does the interventions that address diabetes and implementation of diabetes education pregnancy (8, 9) and those that shift the represent value for money? The answer initiation of insulin therapy from inpatient is not clearly understood at this time. to outpatient settings (10-13). Both the multi-faceted nature of diabetes self-management and the dynamic way in More recently, self-management and which it is used in diabetes care make it diabetes education have been a vital difficult to decipher the economic benefit component in landmark intensive related to diabetes education alone. treatment and lifestyle modification

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clinical trials. Intensive treatment, as practised in the Diabetes Control and Complications Trial (DCCT) and United Kingdom Prospective Diabetes Study (UKPDS), is now generally regarded as being cost effective, where health benefits can be obtained at a reasonable additional cost (14, 15). Emerging work from the Diabetes Prevention Program gives promise to the economic benefit of preventing diabetes through lifestyle changes.

Future needs

In the current healthcare environment, questions arise over the cost of self-care and diabetes education programmes and who will pay for it. While most evidence is encouraging regarding the economic benefits of diabetes education, the multi-faceted nature of self-management training and the team approach to diabetes care limits our ability to conclusively demonstrate its economic effect. As economic data provide effect to advocacy arguments, future evaluations of education interventions should seek to fully describe the associated economic costs and benefits.

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References

1. Klonoff DC, Schwartz DM. An economic analysis of interventions for diabetes. Diabetes Care 2000; 23(3):390-404. 2. Norris SL, Engelgau MM, Narayan KMV. Effectiveness of self-management training in type 2 diabetes; a systematic review of randomized controlled trials. Diabetes Care 2001; 24:561-587. 3. Kaplan RM, Davis WK. Evaluating the costs and benefits of outpatient diabetes education and nutrition counseling. Diabetes Care 1986; 9(1):81-86. 4. Rettig BA, Shrauger DG, Recker RR, Gallagher TF, Wiltse H. A randomized study of the effects of a home diabetes education program. Diabetes Care 1986; 9(2):173-178. 5. de Weerdt I, Visser AP, Kok GJ, de Weerdt O, Van der Veen EA. Randomized controlled multicentre evaluation of an education programme for insulin-treated diabetic patients: effects on metabolic control, quality of life, and costs of therapy. Diabet Med 1991; 8:338-345. 6. White F, Vega J, Aedo C, Jadue L, Robles S, Salazar R, Delgado I. Proyecto de demostración en educación en diabetes. Informe Final. Organización Pan Americana de la Salud, Eli Lilly, 1998. 7. Gagliardino JJ, Etchegoyen G. A model educational program for people with type 2 diabetes: a cooperative Latin American implementation study (PEDNID-LA). Diabetes Care 2001; 24(6):1001-1007. 8. Scheffler RM, Feuchtbaum LB, Phibbs CS. Prevention: the cost-effectiveness of the California diabetes and pregnancy program. Am J Public Health 1992; 82:168-175. 9. Elixhauser A, Weschler JM, Kitzmiller JL, Marks JS, Bennert Jr HW, Coustan DR, Gabbe SG, Herman WH, Kaufmann RC, Ogata ES, Sepe SJ. Cost-benefit analysis of preconception care for women with established diabetes mellitus. Diabetes Care 1993; 16(8):1146-1157. 10. Simell T, Moren R, Keltikangas-Jarvinen L, Hakalax J, Simell O. Short-term and long-term initial stay in hospital of children with insulin-dependent diabetes: adjustment of families after two years. Acta Paediatr 1995; 84:41-50. 11. Penfornis A, Millot L. Initiating insulin treatment in insulin- requiring type 2 diabetic patients: comparative efficiency and cost of outpatient and inpatient management. INNOV Study Group. Diabetes Metab 1998; 24(2):137-142. 12. Mengistu M, Lungi Y, Mamo F. Inpatient or outpatient initiation of insulin therapy. Experience and cost effective analysis in a suboptimal clinical setting. Trop Geogr Med 1991; 43(1-2):180-183. 13. Dougherty G, Schiffrin A, White D, Soderstrom L, Sufrategui M. Home-based management can achieve intensification cost-effectively in Type 1 diabetes. Pediatrics 1999; 103(1):122-128. 14. The DCCT Research Group. Lifetime benefits and costs of intensive therapy as practiced in the DCCT. JAMA 1996; 276:1409-1415. 15. Gray A, Raikou M, McGuire A, Fenn P, Stevens R, Cull C, et al. Cost effectiveness of an intensive blood glucose control policy in patients with type 2 diabetes: Economic analysis alongside randomised controlled trial (UKPDS 41). BMJ 2000; 320:1373-1378.

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Meeting the Challenges Chapter 7

hile other chapters discuss diabetes Wfrom a global perspective, this chapter looks at it from a regional viewpoint. This close-up of the seven regions, reflecting the IDF regional structure, will provide readers with an overview of diabetes prevalence, care and management as well as the challenges posed by the diabetes epidemic.

The seven regions are:

• Africa (AFR) • Eastern Mediterranean and Middle East (EMME) • Europe (EUR) • North America (NA) 7.1 Africa • South and Central America (SACA) 7.2 Eastern Mediterranean • South-East Asia (SEA) and Middle East • Western Pacific (WP)

7.3 Europe Although diabetes is the common enemy, 7.4 North America evidence shows that the challenges differ from region to region as a result of 7.5 South and Central America several complex and interrelated factors. 7.6 South-East Asia Actions carried out at regional levels also indicate that culturally appropriate 7.7 Western Pacific strategies must be identified in order to improve the lives of people with diabetes as well as prevent those at risk from developing the disease.

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7.1 Africa

The landscape of sub-Saharan Africa At a glance is dominated by the twin disasters of poverty and HIV infection. All of the All diabetes and IGT 2003 2025 countries, except South Africa, Gabon and Zimbabwe, currently have per Total population (millions) 666.6 1,107.4 capita gross domestic products (GDPs) Adult population (millions) of less than US$2,000, and for half of (20-79 years) 295.1 541.1 these countries the figure is less than Diabetes prevalence (%) US$1,000. The greatest life expectancy (20-79 years) 2.4 2.8 is in Senegal (63 years), and in over half Diabetes numbers (millions) the countries life expectancy at birth (20-79 years) 7.1 15.0 is less than 50 years. Two of the three IGT prevalence (%) countries with higher GDPs, South Africa (20-79 years) 7.3 7.3 and Zimbabwe, have HIV infection rates IGT numbers (millions) currently estimated at 20% and 25% (20-79 years) 21.4 39.4 respectively (1).

While HIV infection and AIDS so dominate the health needs for sub-Saharan Africa, there is only a small proportion of the population reaching ages at which type 2 diabetes becomes a major health Introduction concern. For all sub-Saharan Africa, only 9.7% of the population is currently 50 Diabetes exerts a considerable toll on years of age or older, and this is expected health resources of the developing to increase to only 10.5% by 2025. countries of sub-Saharan Africa. The Thus the effects of HIV and malnutrition chronicity of the disease and diabetic combine to greatly reduce the size of the complications also place a heavy burden groups most at risk for type 2 diabetes. on people with diabetes and their families. Diabetes and IGT prevalence

Of the 49 least developed countries There are marked discrepancies between in the world, as defined by the United the prevalences of diabetes among Nations Economic and Social Council, 33 different communities in sub-Saharan are in sub-Saharan Africa. The economic Africa (see Chapter 1). The highest cost of diabetes and its complications prevalences are among the ethnic Indian cannot be met by most of the individuals population of Tanzania (2) and South and families in these countries whose Africa (3). The studies from Tanzania incomes are insufficient to purchase (4, 5) (urban:rural ratio of 5:1) and insulin, oral hypoglycaemic agents and Cameroon (6) (ratio of 2:1) both confirm other supplies for diabetes management. the marked urban/rural discrepancy in diabetes prevalence, with the consequent The rate at which new cases of diabetes likely increases as more people move to are emerging poses an additional burden urban areas. on countries already stretched to the limit by common life-threatening infections The availability of prevalence data for such as malaria, tuberculosis and sub-Saharan Africa is very limited, and HIV/AIDS. nearly all the data in Chapter 1 were

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derived from studies from South Africa (7, kilometres from where the study was 8), Tanzania (4, 5), Ghana (9), Cameroon undertaken. (6) and Sudan (10). This meant that data from these studies were applied to It should be noted that the Cameroon populations living up to several thousand and Ghana studies indicated markedly

Figure 7.1 Prevalence estimates of diabetes in selected countries – African Region

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Figure 7.2 Prevalence estimates of impaired glucose tolerance in selected countries – African Region

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rising prevalence of impaired glucose At a glance tolerance (IGT), which now varies between 2.2% and 16.2%. Type 1 diabetes 2003 Incidence of type 1 diabetes Child population (millions) The need for extrapolation of rates of (0-14 years) 295.0 childhood type 1 diabetes was also particularly evident in the sub-Saharan Type 1 diabetes prevalence (%) African region. Published rates were (0-14 years) 0.01 found for only three of the countries in this region, and some of the studies Type 1 diabetes numbers (thousands) were of poor quality and based on (0-14 years) 35.1 small numbers. Consequently imperfect estimates of rates from Nigeria, Zambia and Tanzania have had to be used for widespread extrapolations because of the dearth of published studies (see Chapter 2).

different prevalences of diabetes and IGT Diabetes care among the urban participants surveyed, and these differences are too pronounced Most of the diabetes care services in the to be a consequence of the changed developing countries of sub-Saharan WHO diagnostic criteria since 1999 (11). Africa have been established through Notwithstanding that Cameroon and unsystematic, needs-based efforts. This Ghana are about 1,000 kilometres apart, is due to the limited resources of these and classified by the United Nations countries which have to be divided (12) as being in different parts of Africa between fighting poverty, implementing (central and western, respectively), it was education strategies, providing housing decided to use the average of the results and appropriate sanitation, as well as of the two studies to apply to the other the social, economic and health burden African countries not otherwise applying of fighting the increasing prevalence and the Tanzanian, South African or Sudanese incidence of HIV and AIDS. data. As the burden of diabetes and That the data should need to be its complications increases with extrapolated to such distant and probably modernization, economic wellbeing and dissimilar countries and populations westernized lifestyle, these resource- indicates the great need for further limited countries are unable to provide epidemiological investigation in the even minimum care in some instances, let region. Such a need can also be linked alone secondary and tertiary care. with the high rate of diabetes that had not been previously detected, but There is an urgent need for a multi- found only at the time of surveying. sectoral approach in which governments, Undiagnosed diabetes accounted for 60% the pharmaceutical industry, national of those with the disease in Cameroon diabetes associations, healthcare (6), 70% in Ghana (9) and over 80% of the providers and people with diabetes can recent Tanzania survey (5). play a role in providing at least minimum standards of care that would help those The impact of type 2 diabetes is bound affected maintain the best possible to continue if nothing is done to curb the quality of life.

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Regional initiatives References

1. CIA. World Factbook 2002. Central The IDF African Region has addressed Intelligence Agency, 2002. two critical issues by forming task forces 2. Ramaiya KL, Denver E, Yudkin JS. on diabetes clinical care guidelines and Diabetes, impaired glucose tolerance and cardiovascular disease risk factors in the diabetes education. Asian Indian Bhatia community living in Tanzania and in the United Kingdom. Diabet The objective of the Task Force on Med 1995; 12(10):904-910. Diabetes Clinical Care Guidelines is to 3. Omar MA, Seedat MA, Dyer RB, Motala AA, et al. South African Indians show a high provide standardized clinical guidelines prevalence of NIDDM and bimodality in for diabetes care and to promote its plasma glucose distribution patterns. implementation and use in order to Diabetes Care 1994; 17(1):70-73. 4. McLarty DG, Swai AB, Kitange AM, Masuki G, improve the quality of care provided to et al. Prevalence of diabetes and impaired people with diabetes. glucose tolerance in rural Tanzania. Lancet 1989; 1(8643):871-875. 5. Aspray TJ, Mugusi F, Rashid S, Whiting D, The aim of the Task Force on Diabetes et al. Rural and urban differences in diabetes Education is to provide high quality prevalence in Tanzania: the role of obesity, information by adequately trained physical inactivity and urban living. Trans R individuals to people with diabetes so Soc Trop Med Hyg 2000; 94(6):637-644. 6. Mbanya JC, Ngogang J, Salah JN, as to improve their standard of care. Minkoulou E, et al. Prevalence of NIDDM and impaired glucose tolerance in a rural and an A standardized curriculum taking into urban population in Cameroon. Diabetologia 1997; 40(7):824-829. consideration socio-economic variations 7. Omar MA, Seedat MA, Motala AA, Dyer RB, within the region will be developed et al. The prevalence of diabetes mellitus using existing resources such as the IDF and impaired glucose tolerance in a group of urban South African blacks. S Afr Med J Diabetes Education Consultative Section 1993; 83(9):641-643. (DECS) and the Pan African Diabetes 8. Levitt NS, Katzenellenbogen JM, Bradshaw D, Education Study Group (PADEG). Hoffman MN, et al. The prevalence and identification of risk factors for NIDDM in urban Africans in Cape Town, South Africa. Diabetes Care 1993; 16(4):601-607. 9. Amoah AG, Owusu SK, Adjei S. Diabetes in Ghana: a community based prevalence study in Greater Accra. Diabetes Res Clin Pract 2002; 56(3):197-205. 10. Elbagir MN, Eltom MA, Elmahadi EM, Kadam IM, Berne C. A population-based study of the prevalence of diabetes and impaired glucose tolerance in adults in northern Sudan. Diabetes Care 1996; 19:1126-1128. 11. World Health Organization. Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications; Part 1: Diagnosis and Classification of Diabetes Mellitus. World Health Organization, Department of Noncommunicable Disease Surveillance, Geneva, 1999. 12. United Nations Population Division. World Population Prospects: The 2000 Revision. United Nations, Geneva, 2001.

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7.2 Eastern Mediterranean and Middle East

Introduction At a glance

Diabetes prevalence in some countries of the Eastern Mediterranean and Middle East All diabetes and IGT 2003 2025 Region (EMME) are among the highest in the world. This vast region extends from Total population (millions) 544.6 839.2 Pakistan in the east to Morocco in the Adult population (millions) west, and the population is a mosaic of (20-79 years) 276.0 493.6 several ethnic groups. The age distribution Diabetes prevalence (%) (20-79 years) 7.0 8.0 pattern of the population is pyramidal Diabetes numbers (millions) with about 50% of the population below (20-79 years) 19.2 39.4 the age of 20 years. IGT prevalence (%) (20-79 years) 6.8 7.4 Over the past three decades major social IGT numbers (millions) and economic changes have occurred (20-79 years) 18.7 36.5 in the majority of these nations. These include progressive urbanization, decreasing infant mortality and increasing life expectancy. Current life expectancy exceeds 65 years in most member countries, while per capita GDP varies markedly, from US$800 in Afghanistan to with IGT is expected to also double from US$21,200 in Qatar. 18.7 million today to 36.5 million in 2025, increasing the likelihood of further Rapid economic development, especially increases in the prevalence of diabetes as among the more wealthy oil-producing the century proceeds. countries, has been associated with tremendous changes in lifestyle towards The ageing of populations, together with the westernized pattern reflected by socio-economic changes and changes in nutrition, less physical activity, westernization, has resulted in the tendency to increased obesity and more dramatic increase in the diabetes smoking (1-5). prevalence. Studies conducted in different populations have reported prevalences as Diabetes and IGT prevalence high as 20% in the United Arab Emirates (6), 16% in Qatar and 15% in Bahrain (7), The last two decades have witnessed a but even in much less affluent Pakistan the change in diabetes epidemiology. It is prevalence is 8.5% (8-10). now recognized that it is the developing countries, and the migrant population Four of the countries of the region – from the Indian subcontinent living in the United Arab Emirates, Bahrain, Kuwait and developed countries, which presently face Oman (6, 7, 11, 12) – have had studies the greatest burden of diabetes. performed showing their current diabetes prevalence to be among the world’s 10 The explosion of diabetes in the EMME highest, and a similar situation applies for Region is mainly due to type 2 diabetes. the IGT prevalence of these countries (see An estimated 19.2 million people, or 7% Chapter 1). As with many other countries of the adult population, have diabetes. with high diabetes prevalence, the onset This is anticipated to more than double of type 2 diabetes tends to occur at a by 2025. Similarly the number of persons relatively young age.

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In contrast to Africa, there are a large areas with the changes in lifestyle leading number of studies ascertaining diabetes to increased prevalence of diabetes and prevalence, so that of the 22 countries all related metabolic dysfunctions. A good of the region, 13 have data from which example is the migration of Nubians from national prevalence estimates could be southern Egypt to the northern cities derived. (13) and of Indo-Pakistanis to western countries (14,15). Differences in prevalence rates in different geographic areas and among Whereas in some countries gestational various ethnic groups are quite marked. diabetes mellitus (GDM) is reported to be In general, prevalences of both diabetes about 3.5%, GDM was detected in 10.2% and impaired glucose tolerance (IGT) are of pregnant women in the high risk group higher in urban areas compared to rural and 0.6% in cases with no risk factor in a communities. Certain rural communities, study from Pakistan (16). furthermore, seem to be protected and have appreciably lower prevalence rates, Incidence of type 1 diabetes such as the Bedouins in the Egyptian In the EMME Region about half of the deserts (3). countries have published incidence rates for type 1 diabetes. By far the largest Recent studies confirm the tremendous contribution to the total number of effect of migration from rural to urban estimated childhood type 1 cases for this

Figure 7.3 Prevalence estimates of diabetes in selected countries – Eastern Mediterranean and Middle East Region

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region comes from Egypt whose estimate as life expectancy, infant mortality, accounts for about a quarter of the availability of hospital beds, number region’s total (see Chapter 2). of physician and nurse per capita, are improving. Furthermore, some of these Diabetic complications parameters are satisfactory, even in countries with lower incomes, such as In some recent unpublished studies on the Egypt (1, 19). epidemiology of diabetic complications in Pakistan and Egypt, there are indications Although government and household that nephropathy occurs in 14-20% of expenditures on health vary in the people with diabetes, neuropathy 40%, region, the general pattern of these retinopathy 32-43%, foot ulcers 4-7%, two parameters is nearer to that typical associated obesity 80% and hypertension in developing countries. So, in contrast 64% (17, 18). Lack of proper glycaemic to the developed European countries, control was present in 50-80% of those expenditure on health constitutes studied. a smaller fraction of the total national production compared to expenditures Costs of diabetes on food, defence and education (1, 4, 5).

With progressive economic development In general, the economic burden of in the region, health parameters, such diabetes in the EMME countries is great

Figure 7.4 Prevalence estimates of impaired glucose tolerance in selected countries – Eastern Mediterranean and Middle East Region

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These programmes were more easily At a glance implemented by countries with smaller population and high income than in Type 1 diabetes 2003 countries with larger populations.

Child population (millions) In general higher standards of diabetes (0-14 years) 205.8 care are provided in urban than rural areas. Primary care for diabetes is Type 1 diabetes prevalence (%) generally carried out by general (0-14 years) 0.02 practitioners or physicians and less commonly by diabetologists in diabetes Type 1 diabetes numbers (thousands) clinics at university hospitals and diabetes (0-14 years) 46.5 institutes. Diabetes clinics with elaborate facilities and organized referral systems provide services at secondary and tertiary levels in the capitals and major cities of all countries. However, certain aspects of diabetes care are evidently lacking, such as services of dietitians and more because of the high prevalence rate seriously, foot care specialists. coupled with the high cost of diabetes and limited resources. This is more evident Diabetes camps and day school in the lower income countries with big programmes for children and adolescents populations such as Egypt, Morocco and are organized by several EMME countries Pakistan (1, 4, 5, 19). eg Tunisia, Qatar, Bahrain, Iran, Syria and Egypt. Some earlier studies have indicated that the direct cost of diabetes, ie ambulatory Diabetes associations and hospital care, may make up more than one-third of total available government Most of the countries in this area have resources for health expenditure. diabetes associations. The diabetes Moreover, the progressively increasing associations vary markedly in their prices of recently introduced medications membership size from less than 200 to place a further burden on people with more than 14,000, and in their capacities diabetes, especially in the lower income to carry full diabetes programmes for care, countries. Therefore, programmes for advocacy and education. government subsidies, whether partial or whole, are available in different forms in Some national diabetes associations eg some countries. in Pakistan, Egypt and Iran have regular diabetes magazines published in local Diabetes care languages while others also have regular scientific diabetes journals such as the Standards for diabetes care provision Egyptian Diabetes Journal. differ between different countries according to available resources, although Educational courses for people with not exactly corresponding to their diabetes and for physicians are organized absolute levels of per capita income (4). by almost all of the national associations, and frequently also by health authorities. National diabetes programmes based Recently, educational programmes for on IDF and WHO recommendations were nurses and pharmacists are gaining adopted by several countries in the region. interest (19).

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Public awareness about self-care and References prevention of complications has increased 1. Arab M. The Economics of Diabetes Care in the Middle East. over the years through programmes In International Text Book of Diabetes Mellitus, Eds Alberti carried out by the national associations, KGMM, et al. J Wiley & Sons second edition, 1997. especially during World Diabetes Day 2. Arab M. Epidemiology of Diabetes Mellitus in Egypt. Egypt J of Diab 1997; 2:1-14. events. 3. Arab M, El Sewi F. Diabetes in the Egyptian Deserts: a very low prevalence. Diabetes Care 1996; 19:90. Sociological considerations 4. Arab M. Socioeconomic background of Diabetes in Mediterranean countries. Proceedings of MGSD, Madrid. Medicographia 1993;16 suppl 1. Although misconceptions about diabetes 5. The World Bank. World Bank Data, WHO parameters, may still exist widely in some areas, they 1999-2000. are being actively corrected through 6. Malik M, Bakir A, Abi Saab B, Roglic G, et al. Prevalence of Diabetes Impaired Fasting Glucose, Impaired Glucose educational efforts. The high rate of Tolerance, Hypertension and Obesity in the Multi-ethnic illiteracy in some countries indicates the Population of the United Arab Emirates. Unpublished. use of specific tools for public and patient Abu Dhabi, 2002. 7. Al-Mahroos, McKeigue FPM. High prevalence of diabetes in education. Television programmes play an Bahrainis. Associations with ethnicity and raised plasma important role to achieve this objective. cholesterol. Diabetes Care 1998; 21(6):936-942. 8. Shera AS, Rafique G, Khawaja IA, Baqai S, et al. Pakistan Since Moslems constitute the majority National Diabetes Survey: prevalence of glucose intolerance and associated factors in Baluchistan province. Diabetes of the population, certain aspects of Res Clin Pract 1999; 44(1):49-58. the Moslem faith have close interaction 9. Shera AS, Rafique G, Khwaja IA, Ara J, et al. Pakistan with diabetes management, through its national diabetes survey: prevalence of glucose intolerance and associated factors in Shikarpur, Sindh Province. Diabet doctrines of encouragement of exercise, Med 1995; 12(12):1116-1121. moderation of food intake, cleanliness 10. Shera AS, Rafique G, Khwaja IA, Baqai S, et al. Pakistan and self preservation of health. Fasting, National Diabetes Survey prevalence of glucose intolerance and associated factors in North West at Frontier Province during the holy month of Ramadan, (NWFP) of Pakistan. J Pak Med Assoc 1999; 49(9):206-211. requires some modification of diabetes 11. Abdella N, Al Arouj M, Al Nakhi A, Al Assoussi A, et al. Non- management, in order to avoid the insulin-dependent diabetes in Kuwait: prevalence rates and hazards of hypoglycaemia or of disturbing associated risk factors. Diabetes Res Clin Pract 1998; 42(3): 187-196. the metabolic control. Exemption from 12. Al-Lawati JA, Al Riyami AM, Mohammed AJ, Jousilahti P. fasting is allowed during sickness, while Increasing prevalence of diabetes mellitus in Oman. Diabet travelling, for the elderly and whenever Med 2002; 19(11):954-957. 13. Arab M, Abdel–Rehim A, Khalifa KMA, Kafrawy N, there is risk of endangering health and El-Guisery D. Prevalence of diabetes and related metabolic safety (4). changes among the Egyptian Nubians and the effect of changes in their lifestyle as a result of migration to urbanized communities. The Egyptian Diabetes Journal July Diabetes research 1997; 2:59-64. 14. Mather HM, Keen H. The Southall Diabetes Survey: Scientificresearch in the EMME Region is prevalence of diabetes in Asians and Europeans. BMJ 1985; mostly carried out at state universities and 291:1081-1084. 15. Simmons D, Williams DRR, Powell MJ. Prevalence of diabetes medical institutes. Specific research on in a predominantly Asian community: preliminary findings national diabetes problems, particularly of the Coventry diabetes study. BMJ 1989; 298:18-21. in the fields of epidemiology and socio- 16. Samad N, Shera As, Ara JH. Gestational Diabetes Mellitus – Screening in a Developing Country. J Pak Med Assoc 1996; economics, is gaining increased interest. 46(11):249-252. Some diabetes associations have 17. Shera AS, Jawad F, Maqsood A, Jamal S, Azfar M, Ahmed U. contributed and published extensive Prevalence of chronic complications and associated factors in type 2 diabetes. Diabetic Association of Pakistan and epidemiological studies on diabetes and WHO Collaborating Centre for Diabetes. Unpublished. its complications, the cost of diabetes Karachi, Pakistan, 2003. and the effect of lifestyle changes in 18. Arab M, Kafrawy N, Kamel M, Rifaie M. Epidemiology of the region. diabetes complications in Egypt. Unpublished. Egypt, 2003. 19. Arab M. The socio-economic impact of diabetes in developing countries. Proc. of “Advances in type 2 Diabetes Management” Meeting, Istanbul, May 2002.

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7.3 Europe

Introduction At a glance

Among the European Region’s 51 countries, which extend from Kyrgyzstan All diabetes and IGT 2003 2025 in the east to Iceland in the northwest, exists a great diversity of populations and Total population (millions) 871.8 862.6 affluence, with GDP varying from over Adult population (millions) US$40,000 per capita for Luxembourg (20-79 years) 621.2 646.3 to less than US$4,000 for several of the Diabetes prevalence (%) former socialist republics. (20-79 years) 7.8 9.1 Diabetes numbers (millions) Diabetes and IGT prevalence (20-79 years) 48.4 58.6 IGT prevalence (%) Abnormal glucose tolerance in this region (20-79 years) 10.2 10.9 shows little association with affluence, IGT numbers (millions) and there was no evidence that any (20-79 years) 63.2 70.6 difference in urban/rural prevalence existed except in Turkey (1), and the Central Asian Republics of Kazakhstan, Kyrgyzstan, Tajikistan and Turkmenistan (for which data were extrapolated from neighbouring Uzbekistan (2)). Prevalence rates for diabetes show a wide variation from Augsburg (6). Similarly data from from 2.0% in Iceland to 10.2% in Germany two regions of Italy (7, 8) were applied (see Figure 7.5). to more than 100 million people from Italy and France. There is a clear need The lack of data from many of the former for better data from those countries that socialist republics required that data for can afford to ascertain the extent of the many countries be extrapolated from two epidemic. studies from Poland - urban Krakow (3), and the urban and rural areas near Lublin To a large degree the high prevalence (4). These data suggested high levels of of abnormal glucose tolerance is a diabetes currently, and such high levels consequence of the relatively old of IGT that the diabetes prevalence will population of the region, such that almost certainly increase by 2025 to currently a third of the region’s levels above those indicated in Tables population is over 50 years of age, which 1.18 and 1.20 in Chapter 1, as these took is expected to increase to over 40% by no account of the higher incidence of 2025. Thus the number of persons with diabetes among those with IGT. diabetes and IGT will increase, although the total regional population will have Surprisingly there is a paucity of good decreased. This will place an increasing data from many of the more affluent financial burden on the declining western countries of the region. The working age population to provide largest nationwide survey from Germany resources for the health consequences indicated only those with known diabetes of rising diabetes prevalence in the older (5), with total diabetes prevalence population. The region has the resources determined by applying the 1:1 ratio to be at the forefront of efforts to amend for known:newly diagnosed diabetes lifestyle factors contributing to the determined from an age restricted survey prevalence of diabetes.

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At a glance In the central European countries formerly related to the Soviet bloc, such Type 1 diabetes 2003 as Hungary, Poland, Czech Republic, Romania, Slovenia and Slovakia, the Child population (millions) quality of care is rapidly evolving to (0-14 years) 161.5 the most advanced standards. In other countries such as Bulgaria, Georgia, Type 1 diabetes prevalence (%) Ukraine, Moldova, Belarus and Russia, (0-14 years) 0.06 existing economic and environmental difficulties have an impact on the Type 1 diabetes numbers (thousands) availability of good quality diabetes (0-14 years) 90.1 care throughout the country, although the growth of specialized and advanced centres is creating a basis for positive development when it will be allowed by more favourable conditions.

In the most eastern part of the region, Incidence of type 1 diabetes socio-economic and geographical Compared with other regions, the conditions make it difficult to foresee European Region has by far the most a satisfactory progression towards complete and reliable data on the rates adequate standards of care in the near of childhood type 1 diabetes with a large future if appropriate international support proportion of countries having registries is not provided. In the Balkan area, for that are either nationwide or cover instance, there are significant gradients in several different parts of the country. The adequate diabetes care availability within countries making the largest contribution a restricted geographical area. Diabetes to the total rates for childhood type 1 care in Croatia has benefited from long- diabetes were United Kingdom, Germany standing experience and from stability and Russia reflecting to some degree for nearly a decade, while other countries the large childhood populations in these and provinces are still affected from the countries (see Chapter 2). recent civil war and still unstable political situations. Diabetes care In the most advanced countries the The European Region is characterized by shared care approach consisting of an a wide variety of diabetes care delivery integration of different levels of care, due to differences in national healthcare from highly specialized to primary systems and available resources of the care with the involvement of medical country. and non-medical professionals such as dietitians, podologists, nurse educators, Within the region, it is possible to find the psychologists, is becoming an increasing most advanced healthcare systems and reality while in nearby deprived countries some of the most deprived. The level of regular access to insulin is still a major the quality of diabetes care in the western issue. and northern areas of the continent is rather high with a tendency towards In some countries, intensified therapy a certain degree of homogeneity in both for type 1 and type 2 diabetes is European Union (EU) member countries, the normal standard, and campaigns although some differences still exist even for screening of undiagnosed diabetes in that cluster. and for complications are regularly

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performed. There are also widespread an adequate level of care, which would pilot initiatives, primarily in Finland, overcome language and cultural barriers for the primary prevention of type and take into consideration differences 2 diabetes, while in other countries in nutritional habits, behaviours, beliefs, resources are lacking for minimal values and, in most of the cases, interventions for the prevention of major socio-economic circumstances. complications and to even secure the survival of people with diabetes. National diabetes programmes

A pressing issue has arisen from Most countries in the European Region migration within the European Region have a national diabetes programme. and from other parts of the world. The The St Vincent Declaration has been used need is more and more evident for by many as a framework for strategic greater attention to be paid to migrants action (see Chapter 8). The prevention of affected by diabetes in order to guarantee type 2 diabetes is the main focus of many

Figure 7.5 Prevalence estimates of diabetes in selected countries – European Region

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national diabetes programmes with key especially the Finnish Diabetes action being taken to raise awareness Association which played a leading role. among the public. Each national model should be unique While some countries have yet to to meet national needs and cultural implement their programmes, others specifics. The expertise gathered in other have made great strides in countries however could be very useful implementation and development. for a specific country when planning a A good example is Finland where an national diabetes programme. Cyprus, extensive national diabetes programme is for instance, has recently started working now underway (see Box 7.1). The on a national plan for diabetes using programme, implemented in 2000, was the Finnish model and learning from developed with the participation of the Finns’ practical experiences from different stakeholders in diabetes care, preparing a national programme.

Figure 7.6 Prevalence estimates of impaired glucose tolerance in selected countries – European Region

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The United Kingdom (UK) is a good Box 7.1 example of a governmental approach towards tackling the problem of diabetes National diabetes programme: but in general, the role of governments the Finnish model has not been strong enough in this area. The St Vincent Declaration has been inland has a very extensive national programme called in existence since the late 1980s but Fthe Development Programme for the Prevention and its goals related to improving health Care of Diabetes in Finland (DEHKO 2000−2010). The outcome have yet to be reached in programme took two years, between 1998 and 2000, to most countries and thus are still valid. develop by nearly 100 diabetes experts, including people However, the raised awareness of with diabetes. It was approved at a consensus meeting in diabetes, increased research and greater 2000, and implementation started in the same year. practical collaboration with regard to complications, diabetes economics and By the beginning of 2003 there had been three rounds of prevention can be attributed in some auditing carried out by external auditors. The programme itself was audited in 2000, feedback by primary healthcare way to the St Vincent Declaration and professionals were audited in 2001, and the preparation its original action programme. Today, process and the first three years of implementation were there are enough knowledge and skills audited in 2003. in the region to really start building and implementing concrete national diabetes The programme defines clear goals and 25 action programmes. recommendations, of which 10 are key actions. Through these, the programme covers the primary, secondary and Initiatives tertiary prevention of diabetes and its complications. The most important key action is prevention of type 2 diabetes, The problem of overweight and lack of and a detailed prevention programme for 2002-2003 was physical activity is as much an issue in prepared and distributed to primary and occupational this region as elsewhere in the world. healthcare institutions. Awareness campaigns in favour of a The national diabetes programme is initiated and healthy lifestyle are being promoted coordinated by the Finnish Diabetes Association (FDA) at EU, regional and national levels by and financed by a governmental body, corporate partners diabetes organizations. These campaigns and the FDA. The programme is available in English, both are meeting with success in convincing printed and on the website: www.diabetes.fi. top decision makers to take action to prevent or delay type 2 diabetes. A recent event held at the European Parliament, for example, obtained strong support from the European Commission President as well as the EU Health Commissioner and President of the European Parliament. table at the European Parliament in order to involve decision makers at the highest Another key initiative has been the level in influencing policies and for establishment of an EU diabetes working raising awareness on the ‘diabetes time group by members of the European bomb’. Parliament to discuss issues such as the inclusion of diabetes on the public health Diabetes organizations have also taken agenda and in EU policy, discrimination initiatives at the national level with the against people with diabetes and the aim to eradicate laws which discriminate diabetes situation in EU candidate against people with diabetes. Issues countries. regarding discrimination in driving licences, insurance and at work are The IDF European Region has also been being raised in some parliaments, for instrumental in organizing a yearly round example in the UK, and studies are being

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undertaken in several countries including References Ireland, Denmark and UK. 1. Satman I, Yilmaz T, Sengul A, Salman S, et al. Population- Based Study of Diabetes and Risk Characteristics in Turkey: Cultural and strategic initiatives Results of the Turkish Diabetes Epidemiology Study promoted by the IDF European Region, (TURDEP). Diabetes Care 2002; 25(9):1551-1556. 2. King H, Abdullaev B, Djumaeva S, Nikitin V, et al. Glucose especially under the umbrella of the intolerance and associated factors in the Fergana Valley, St Vincent Declaration, have raised Uzbekistan. Diabet Med 1998; 15(12):1052-1062. awareness of diabetes throughout the 3. Szurkowska M, Szybinski S, Nazim A, Szafraniec K, et al. region and a further follow-up is taking Prevalence of type II diabetes mellitus in population of Krakow. Pol Arch Med Wewn 2001; 106(3):771-779. place, adapted to new environmental and 4. Lopatynski J, Mardarowicz G, Nicer T, Szczesniak G, et al. behavioural circumstances. The prevalence of type II diabetes mellitus in rural urban population over 35 years of age in Lublin region (Eastern Poland). Pol Arch Med Wewn 2001; 106(3):781-786. Diabetes research 5. Thefeld W. Prevalence of diabetes mellitus in the adult German population. Gesundheitswesen 1999; Diabetes research is carried out in the 61 Spec No.:S85-89. 6. Rathmann W, Haastert B, Icks A, Lowel H, et al. High European Region at the highest level in prevalence of undiagnosed diabetes mellitus in Southern all possible fields, from basic to more Germany: Target populations for efficient screening. The clinically oriented. A number of centres KORA survey 2000. Diabetologia 2003; 46(2):182-189. of excellence have been established 7. Garancini MP, Calori G, Ruotolo G, Manara E, et al. Prevalence of NIDDM and impaired glucose tolerance in throughout the region. However the Italy: an OGTT-based population study. Diabetologia 1995; amount of funds made available by 38(3):306-313. national governments and international 8. Verrillo A, de Teresa A, La Rocca S, Giarrusso PC. Prevalence of diabetes mellitus and impaired glucose tolerance agencies is not adequate. One result in a rural area of Italy. Diabetes Res 1985; 2(6):301-306. of this has been the drain of scientists towards better funded institutions, in particular in the United States.

Nonetheless, an alliance between the IDF European Region and the European Association for the Study of Diabetes (EASD) has resulted in success in influencing the European Commission to reintroduce research funding for diabetes within the Sixth Framework Programme for research, the most important research programme in the EU. IDF member associations played a significant role, coordinated by the IDF European Region, in mobilizing national governments and parliaments in a successful lobbying initiative that was unprecedented, and at the same time gained IDF an accreditation as the reference institution for any diabetes initiative in Europe.

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7.4 North America The North American Region has focused its efforts over the last few years in implementing the goals relating to education, awareness and quality of care At a glance in the Declaration.

All diabetes and IGT 2003 2025 Although the region has 23 countries and areas, 69% of the adult population resides Total population (millions) 441.7 533.8 in the USA, with a further 20% living in Adult population (millions) Mexico and 8% in Canada. The remaining (20-79 years) 289.6 374.5 3% of the region’s adult population reside Diabetes prevalence (%) in the other 20 smaller nations. Whereas (20-79 years) 7.9 9.7 the USA, Canada and Bermuda have per Diabetes numbers (millions) capita GDPs of over US$25,000, many of (20-79 years) 23.0 36.2 the smaller nations have per capita GDPs IGT prevalence (%) of less than US$5,000 with Haiti having (20-79 years) 7.0 7.9 the lowest at US$1,700. IGT numbers (millions) (20-79 years) 20.3 29.6 Diabetes and IGT prevalence

The high prevalence of abnormal glucose tolerance in Canada and the USA are very much a consequence of their older age distribution, such that 29% of their population are currently over 50 years of age, and this is expected to increase to 37% by 2025. This contrasts with 14% Introduction increasing to 25% for Mexico, and 19% increasing to 28% for the Caribbean (see The North American (NA) Region has the Chapter 1). highest prevalence of diabetes among the IDF regions with 7.9%, or 23 million, The data published in Tables 1.24 and in the adult population. The countries in 1.25 in Chapter 1 indicated the expected the region represent not only different number of persons with impaired fasting geographical characteristics and levels glucose (IFG) for Canada and the USA, of socio-economic development but also based on the data from NHANES III, which diverse cultures. concentrated on assessment based on the fasting glucose. When the published Faced with a dramatic increase in data were extrapolated to determine IGT diabetes as well as mounting costs in numbers, the results suggested that in diabetes care, the Declaration of the 2003 for the USA, the prevalence of IGT Americas on Diabetes (DOTA) was created would be 11% (21.6 million persons), and in 1996 with the collaboration of the IDF’s for Canada also 11% (2.5 million persons); North American, and South and Central both figures being about 50% higher American Regions, the Pan American than the IFG numbers and prevalences. Health Organization (PAHO) and industry. By 2025 the expected prevalences are The Declaration recognizes diabetes as expected to be about 12%, with numbers a common, growing, serious and costly still about 50% higher than for IFG. public health problem affecting millions in the Americas and PAHO has endorsed As all the Caribbean islands other than it as a guide to national programme Barbados, Guadeloupe and Martinique development (see Chapter 8). had their estimates extrapolated from

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Jamaican data (1), the differences in At a glance prevalence are a consequence only of different age distributions for the islands, and for those islands whose Type 1 diabetes 2003 population distributions were based on the world population (2), their lower Child population (millions) prevalences suggest that their actual age (0-14 years) 105.2 structure is probably older than the world distribution. Type 1 diabetes prevalence (%) (0-14 years) 0.06 Incidence of type 1 diabetes Although no published rates were Type 1 diabetes numbers (thousands) available for childhood type 1 diabetes in (0-14 years) 64.7 many of the smaller Caribbean islands in the North American Region, it was usually possible to extrapolate rates from an island in close proximity, although such rates were often based on very small numbers of cases. The USA estimate, which accounts for more than three- quarters of the region’s total, and to a been diagnosed, some five million lesser extent the estimate for Canada unfortunately are not aware that they predominate (see Chapter 2). have the disease.

United States of America Each day approximately 2,700 people Diabetes is the fifth leading cause of are diagnosed with diabetes; about one disease in the United States, where million people will be diagnosed this year. some 16 million people, or 8% of the The prevalence is expected to increase to adult population have diabetes. While 9%, affecting some 23 million adults by an estimated 11 million people have 2025. The prevalence of diabetes rises

Figure 7.7 Prevalence estimates of diabetes in selected countries – North American Region

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with age in the United States, as it does in an overall rate 2.6 times that of the other parts of the world. While the rate of general population. The rate varies diabetes for all adults 20 years or older is greatly by region and tribe; in some 8%, the prevalence rate climbs to 20%, or tribes over 50% of the adults have 7 million, for the age group 65 and older. diabetes.

The problem of diabetes is likely to be Diabetes is one of the most costly health compounded by the high prevalence rate problems in America. The total annual of IGT in the adult population. Today, economic cost of diabetes in 2002 was some 21 million people, or 11% in the estimated to be US$131 billion dollars, adult population, have IGT. including some US$91 billion in direct medical and treatment costs and almost Of the 16 million adults with diabetes, US$40 billion for indirect costs attributed more than 90% have type 2 diabetes. to disability and mortality. Type 2 diabetes is more common among these ethnic groups: Canada Diabetes mellitus is a major health • African Americans are twice as likely problem affecting some 9%, or 2 million, to have type 2 diabetes as the general in the adult Canadian population. The population. An estimated 2.8 million prevalence of diabetes is expected to rise African Americans, or 13%, have to some 3 million, or 11% in the adult diabetes. population by 2025. • Hispanic/Latino Americans are almost twice as likely to have type 2 As in many other western countries diabetes as the general population. about 90% of the diabetic population Diabetes affects 2 million, or 10%, of have type 2 diabetes with prevalence on the Hispanic/Latino population in the the increase as the general population United States. ages. The prevalence of diabetes in the • Native Americans and Alaska natives indigenous population, however, appears have the highest prevalence of to be increasing much more rapidly than diabetes in the United States, with in other population groups.

Figure 7.8 Prevalence estimates of impaired glucose tolerance in selected countries – North American Region

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In addition the growing multicultural rates of between 5% and 10% in the adult nature of the country means that new population, and IGT prevalence rates of Canadians are unusually susceptible to between 7% and 18%. type 2 diabetes as they assume western culture. This rising trend is reflected in New advances the high prevalence of IGT which affects 2.5 million adults, or 11% in the adult The overall thrust in this region has been population. to raise awareness of diabetes among the general population and intensify diabetes Major studies into the risks and education amongst the health team and complications of diabetes are underway people with diabetes in particular. or have been recently completed. The linkage between diabetes and obesity has There are new advances on the horizon in been identified while the complications the prevention and treatment of diabetes. of heart disease, renal failure, blindness Government-supported and industry and lower extremity amputations have researchers in the region, mainly USA been explored. Action is being taken and Canada, are pursuing advances in to increase public and professional treatment and prevention for both type 1 awareness of these linkages. and type 2 diabetes. For prevention of type 1, studies are underway to identify The major challenge facing Canada environmental triggers that may be is to change the behaviour of its subject to modification or elimination, people so that they assume increased which could effectively prevent type 1 responsibility for their own health and diabetes in those at risk. In type 2 wellbeing. Governments are considering diabetes, recently concluded trials have preventative healthcare strategies to shown that a majority of this type of assist in this regard. diabetes can be prevented or at least delayed by sustained lifestyle changes Mexico (diet and exercise). The estimated prevalence rate in Mexico is 7% in the adult population, or 4.4 Other research is aimed at lessening the million people, which puts it among the burden of diabetes by improving glucose top 10 countries in the world in terms monitoring, including the use of non- of the number of people with diabetes. invasive or minimally invasive glucose Estimates show that the number of sensors. New types of insulin and insulin people is expected to more than double delivery devices are being developed that to some 9 million by 2025. may allow needle-free insulin delivery and more physiologically normal insulin Data for IGT show that almost as delivery. Drug development sponsored many people, some 4 million, have the by industry is exploring new methods condition, and that this too is set to to improve management of type 2 increase to 6 million by 2025. diabetes and to arrest and even reverse the progression of complications such as Caribbean islands neuropathy, nephropathy and vascular There are few studies done on diabetes disease. prevalence in the Caribbean. There is a study currently underway on the prevalence of diabetes and hypertension in Haiti as well as a pilot project on quality of care. Nonetheless, estimates from the islands based on previous studies indicate diabetes prevalence

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References

1. Wilks R, Rotimi C, Bennett F, McFarlane-Anderson N, Kaufman JS, Anderson SG, Cooper RS, Cruickshank JK, Forrester T. Diabetes in the Caribbean: results of a population survey from Spanish Town, Jamaica. Diabet Med 1999; 16:875-883. 2. United Nations Population Division. World Population Prospects: The 2000 Revision. United Nations, Geneva, 2001.

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7.5 South and Central America

and Paraguay to less than 20% in At a glance Argentina and Uruguay, where there was a strong white non-Hispanic immigration, All diabetes and IGT 2003 2025 mainly from Italy. There has also been a significant immigration from Japan and Total population (millions) 422.8 544.6 the Middle East. Adult population (millions) (20-79 years) 251.8 363.9 Diabetes prevalence Diabetes prevalence (%) (20-79 years) 5.6 7.2 Considerable extrapolation was required Diabetes numbers (millions) in this region as 15 countries do not have (20-79 years) 14.2 26.2 any epidemiological data from which IGT prevalence (%) diabetes prevalence could be derived (see (20-79 years) 7.3 8.1 Chapter 1). IGT numbers (millions) (20-79 years) 18.5 29.5 Nonetheless, both South America and Central America have similar age distribution profiles, currently about 15% of the population older than 50 years, with this figure likely to increase to 25% by 2025. Thus the region has a markedly younger age distribution than most of North America, and otherwise would Introduction have a similar burden of diabetes. The likelihood is that diabetes will become a The South and Central American (SACA) more major health priority for the region Region encompasses 22 countries with given the decreasing difference in age a population of more than 420 million. distribution between this region and Most of the countries are still developing North America, and with the continuing economically, with Argentina, having momentum for urbanization. the highest per capita GDP (US$10,200) despite a recent fall, and Cuba the lowest Between 30% and 50% of people with at US$2,300 (1). type 2 diabetes are not aware that they have the condition (in the rural areas it Some 82% of the region’s population can be as high as 100%). Type 2 is often live in South America, 9% in Central diagnosed late. America and 9% in the Caribbean islands. The admixture between native Indians, Incidence of type 1 diabetes white Iberians and black Africans has The variable ethnic composition of the been occurring since the 16th century. SACA Region may have an influence on There are still countries such as Bolivia, the incidence of type 1 diabetes mellitus. Guatemala and Peru where more than For example, the incidence of type 1 40% of the population is considered diabetes is relatively high in Uruguay American Indian. (mainly Caucasoid population) and very low in Peru (mainly mestizos population). The proportion of mestizos (descendants There are some exceptions such as Puerto of American Indians and Spaniards) in Rico, where, although its population has the population range from 80% or more an admixture of Hispanic, African and in Chile, Ecuador, El Salvador, Honduras Taíno Indian, there is a high incidence of

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type 1 diabetes in youngsters that has At a glance been increasing recently. Thus, although the incidence of childhood type 1 diabetes in the SACA Region is generally Type 1 diabetes 2003 low, there are some sharp contrasts between the rates in neighbouring Child population (millions) countries (see Chapter 2). (0-14 years) 126.0

Diabetes care Type 1 diabetes prevalence (%) (0-14 years) 0.03 National diabetes associations have been the main promoters of public Type 1 diabetes numbers (thousands) awareness and diabetes education in the (0-14 years) 40.4 SACA Region. The oldest, such as the Uruguayan and the Colombian Diabetes Associations, have been active for more than 40 years. These non-governmental and non-profit organizations, usually with very small budgets, provide educational courses and materials, and organize under control, particularly in the case of diabetes awareness programmes. those who are insulin-dependent.

The associations in some countries In many countries of the region less than run diabetes care centres which offer 20% of the population are covered by specialized medical care and education as social security and the rest have to rely well as medications, laboratory tests and on very deficient and overcrowded public self-monitoring equipment at a very low health centres with scarce resources, cost. This has been for a long time the or go to the private sector which most only means for many people with low and cannot afford. Only a few countries such very low incomes to keep their diabetes as Costa Rica and Cuba have a social

Figure 7.9 Prevalence estimates of diabetes in selected countries – South and Central American Region

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security system that covers the whole The Latin American Diabetes Association, population. ALAD, a scientific organization formed by health professionals, has developed In countries such as Argentina, Chile, evidence-based guidelines for the Uruguay, Puerto Rico and Colombia, prevention and treatment of type 2 health maintenance organizations provide diabetes and its complications. The a basic health plan for most of the ALAD working groups on diabetes and working population and their families pregnancy, GTDE, and on diabetes in which includes some medicines such as children and adolescents, GELADNA, insulin and a few oral agents but no self- have also developed guidelines on the monitoring elements. Everyone, including treatment of these specific problems. the unemployed, has the legal right to benefit from this plan in some countries National diabetes programmes but the resources needed to make this possible are still far from adequate. The interest in diabetes mellitus as a Argentina has passed a law protecting public health problem is increasing in people with diabetes but its enforcement the region. The prevention and treatment has been slow and difficult for the same of non-communicable chronic diseases reasons. is now considered one of the main priorities in most countries where not In the Dominican Republic, IDF member long ago most of the resources went to associations in collaboration with the the mother and child programmes. Some community have established the National countries such as Argentina, Brazil, Chile, Institute of Diabetes, Endocrinology Colombia, Cuba, Costa Rica, Paraguay and Nutrition (INDEN), the only diabetes and Venezuela are implementing national hospital in Latin America, which provides diabetes programmes. excellent services for people with diabetes. It is also a training centre for The impetus to implement national multidisciplinary healthcare professions. diabetes programmes was given a boost

Figure 7.10 Prevalence estimates of impaired glucose tolerance in selected countries – South and Central American Region

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with the signing of the Declaration of the Reference Americas on Diabetes (DOTA) in 1996, in 1. CIA. World Factbook 2002. Central San Juan, Puerto Rico (see Chapter 8). Intelligence Agency, 2002.

Regional initiatives

The IDF SACA Region is the most representative organization, and the most structured at national and regional levels in Latin America in the field of diabetes, with participation by people with diabetes and their relatives, as well as healthcare professionals and industry partners.

Different task forces have been appointed to meet particular regional needs, such as the Task Forces on Emergencies, Diabetes in Children, Education, Association Development and National Diabetes Programmes.

Examples of the work of these task forces include the involvement of the Task Force on Emergencies in procuring aid during disaster situations in Venezuela, Colombia, Peru and El Salvador. A task force on anti-fraud in medications has dealt with unethical medication issues and has been successful recently in identifying a network from another region marketing and selling products as though they were in Latin America.

In addition, the Task Force on National Diabetes Programmes has developed a model diabetes law for Latin American countries that is being considered by several national assemblies or parliaments in the region.

Training courses for diabetes educators, with field testing courses in three model centres in Puerto Rico, Colombia and Argentina, have been organized by the Task Force on Education. Ongoing projects include national training courses for educators in Brazil, and possibly in Uruguay and Bolivia.

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7.6 South-East Asia

Introduction At a glance

The South-East Asian (SEA) Region includes only seven countries, but as All diabetes and IGT 2003 2025 with the USA numerically dominating the North America Region, so here does India, Total population (millions) 1,251.4 1,629.7 with its adult population comprising 85% Adult population (millions) of the region. Mauritius has the highest (20-79 years) 705.3 1,081.0 per capita GDP at US$10,800, while the Diabetes prevalence (%) other countries all have per capita GDPs (20-79 years) 5.6 7.5 of less than US$4,000, although India Diabetes numbers (millions) with a current annual growth of 5% is (20-79 years) 39.3 81.6 experiencing economic development at a IGT prevalence (%) faster pace than almost anywhere in the (20-79 years) 13.2 13.5 world except its neighbour, China. IGT numbers (millions) (20-79 years) 93.4 146.3 Diabetes and IGT prevalence

Economic progress is inevitably associated with increasing urbanization, and it appears that features of urban life tend to increase the prevalence of diabetes among adults of Indian ethnic background to a greater extent than for than double to 73 million by 2025. The other populations (1), which is why a world’s highest regional IGT prevalence 4:1 ratio for urban:rural prevalence was is further evidence of the likely marked applied for the Indian, Nepalese and increase in the diabetes prevalence. Bhutan populations (see Chapter 1). Mauritius, the second smallest country The anticipated increase in diabetes in the region, highlights the extent to prevalence for the region from 5.6% which persons of Indian ethnicity appear to 7.5% by 2025 is very much a predisposed to diabetes, when exposed consequence of the increasing life to more affluent economic circumstances. expectancy in India, where the proportion This island has the world’s eighth highest of the population over 50 years is diabetes prevalence, currently 11% and expected to increase from 15% to 23% expected to rise to 15% by 2025, and between 2003 and 2025, and the urban a similarly high IGT prevalence of 16%, proportion from 30% to 42% (2). Evidence likely to increase to nearly 18% (see suggests that in more affluent parts Figures 7.11 and 7.12). of the country the rural prevalence is higher than less affluent rural areas (3), A substantial number of clinical and indicating that increasing economic epidemiological studies on diabetes have growth will escalate diabetes prevalence been published by various centres in in India even more than these possibly India and by the Bangladesh Institute of conservative estimates have suggested. Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders India currently has the world’s largest (BIRDEM). These centres have also diabetic population with an estimated 35 developed basic research facilities on million people. This is expected to more diabetes and related areas.

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more frequently used and it therefore At a glance plays a pivotal role in the estimates for this region. Type 1 diabetes 2003 The South-East Asian Region contributes Child population (millions) more than any other to the worldwide (0-14 years) 412.2 childhood type 1 diabetes total. Diabetes- associated mortality and tropical or Type 1 diabetes prevalence (%) malnutrition diabetes are also likely (0-14 years) 0.03 to play important roles in this region, but unfortunately there is inadequate Type 1 diabetes numbers (thousands) information to address these issues. (0-14 years) 104.8 These points reinforce the need for much more detailed data on childhood diabetes in this region.

Diabetes care

Increasing prevalence of diabetes and diabetes-related disorders and Incidence of type 1 diabetes complications pose a serious threat to Only two countries in the region have the healthcare delivery systems in the published rates for type 1 diabetes in region. This region is expected to have childhood and therefore extrapolation the largest diabetic population in the of rates was necessary for the data in world by 2025 with almost 82 million Chapter 2. The rate from China, although people. Unfortunately, diabetes is not yet outside the region, was used for some considered a national problem with high extrapolations, but the rate for India was priority in almost all the countries of the

Figure 7.11 Prevalence estimates of diabetes – South-East Asian Region

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region, where only diabetes associations of trained manpower, non-availability give focused attention to the disease. of comprehensive care and absence of good tertiary care departments dedicated In general diabetes is treated as any to diabetes. According to a World Bank other ordinary disease in national health report the public sector is still the main policy. There is no demand analysis and provider of healthcare services and is separate budget for diabetes care and grossly under-funded. research. It is now important to integrate diabetes healthcare into national health Private sector care policies and also into the curricula of As a result of the inadequate care in the undergraduate and postgraduate studies. public sector, a number of people with diabetes go to private practitioners and The existing system of diabetes clinics for their care. In reality, there healthcare may be broadly divided into is a substantial contribution of public two sectors: public and private. The sector to this type of private sector. relative contribution of the different For example, almost all public sector sectors greatly varies from country to physicians are engaged in private practice country and even locality to locality. in chamber, clinic and private hospitals. With the exception of a few centres, no Public sector care well-planned system of diabetes care, Reasonable infrastructure has already particularly in primary services, have been built for delivering a good level been developed in this sector. of services in the region. However, diabetes care is still inadequate in Education and awareness public facilities due to governmental priority to communicable diseases Professional bodies, healthcare societies over non-communicable diseases. This and associations, in general, play an situation is exacerbated by a lack of appreciable role in creating awareness focused attention to diabetes, scarcity about diabetes, and its prevention and

Figure 7.12 Prevalence estimates of impaired glucose tolerance – South-East Asian Region

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management through media. It is the References national diabetes associations, however, 1. Ramachandran A, Snehalatha C, Latha E, Manoharan M, which have played a significant role in Vijay V. Impacts of urbanisation on the lifestyle and diabetes healthcare in the region. on the prevalence of diabetes in native Asian Indian population. Diabetes Res Clin Pract 1999; 44:207-213. 2. United Nations. Department for Economic and Social The Diabetic Association of India plays Information - Population Division. World urbanization an important role in creating public prospects: the 1994 revision. Estimates and projections awareness and also in training healthcare of urban and rural populations and of urban providers and professionals particularly agglomerations. United Nations, New York, 1995. 3. Kutty VR, Soman CR, Joseph A, Pisharody R, Vijayakumar K. through the All India Institute of Diabetes Type 2 diabetes in southern Kerala: variation in in Bombay (4). The Institute also provides prevalence among geographic divisions within a region. diabetes healthcare to a substantial Natl Med J India 2000; 13:287-292. 4. Diabetic Association of India. 1999 Problem Census Report number of people with diabetes. of India. Questionnaire proforma of IDF SEA Region for the mid-term regional meeting held on March 26, 1999. Bangladesh appears to have the most well organized diabetes association with countrywide coordination among branches and a dynamic system of comprehensive healthcare delivery for people with diabetes. It has become highly successful in creating diabetes awareness. It also has a programme of manpower development, community mobilization and generation of resources for self-sustenance.

A programme for diabetes education in the public sector is generally absent in this region. There are, however, educational activities run by the national diabetes associations. These activities include both training for healthcare providers as well as diabetes education for people with diabetes. Other educational activities include public awareness promotion, for example in India, through newsletters and journals (4).

The Diabetic Association of Bangladesh provides a more systematic series of programmes on diabetes education. Through its central institute, BIRDEM, it also runs postgraduate degrees and diplomas under the University of Dhaka. BIRDEM has been a World Health Organization collaborating centre since 1980.

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7.7 Western Pacific

as well as the diabetes epidemic, and At a glance the problem of limited resources and lack of government awareness of the All diabetes and IGT 2003 2025 seriousness of the diabetes threat to their populations. Total population (millions) 2,110.7 2,445.7 Adult population (millions) The countries also have populations (20-79 years) 1,383.6 1,750.5 of diverse ethnicity, with Singapore Diabetes prevalence (%) having large Chinese, Malay and Indian (20-79 years) 3.1 4.3 communities, Australia and New Zealand Diabetes numbers (millions) being principally Caucasian but also (20-79 years) 43.0 75.8 having extremely culturally diverse IGT prevalence (%) populations, and the Pacific islands (20-79 years) 5.7 6.9 having Polynesian, Melanesian and IGT numbers (millions) Micronesian populations, as well as more (20-79 years) 78.6 120.2 recent Indian immigrant communities.

Diabetes and IGT prevalence

Not surprisingly there is a great diversity in the prevalence of diabetes in adults, with the world’s highest found in the Introduction Micronesian population of Nauru, and the ethnically mixed population of The Western Pacific (WP) Region is a Singapore currently has the sixth highest huge region in terms of both geography documented prevalence (see Chapter 1). and population. The region extends from Mongolia and Japan in the north to However, simply because of its New Zealand in the south. Apart from population size, it is in China that the sheer size, the region is characterized diabetes epidemic has the greatest by great diversity of lifestyle, affluence, potential to explode. Although the economics, culture, social circumstances current prevalence there of 2.7% is and geography. among the region’s lowest, the high prevalence among Chinese populations in The world’s most populous region the more urbanized and affluent cities of contains 39 disparate countries and Hong Kong and Singapore indicate what territories with populations ranging from may develop as China rapidly urbanizes 1.3 billion for China to less than 5,000 and expands economically. The data in the smallest Pacific island nations of indicated for 2025 are likely to represent Niue and Tokelau. Similarly the economic an underestimate of the diabetes problem profile varies from per capita GDPs of in China if it continues to develop about US$25,000 for Australia, Hong economically faster than almost any other Kong, Japan and Singapore to less than country in the world. US$2,000 in Cambodia and some of the smallest Pacific islands. These numbers, while alarming in their own right, still do not tell the whole The less economically advanced countries story. Although type 1 diabetes is of the region struggle with the double relatively less common in the region, burden of managing infectious diseases with the exception of Australia and New

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Zealand, than among countries with population. This trend towards a younger predominantly Caucasian populations, age of development of the disease has there is an emerging problem of type 2 major health implications, particularly as diabetes in children and adolescents, it targets specifically the economically particularly in an urbanized setting and productive sector of the population. in strong association with rising rates of obesity in children. Incidence of type 1 diabetes With the exception of Australia and New In Japan, for example, 80% of children Zealand, the rates of childhood type 1 with diabetes now have type 2 diabetes. diabetes in this region appear uniformly In the adult population also, increasing low. Despite its very low incidence, China numbers of young adults are developing accounts for almost half of the region’s the condition and the age group under total. However, the Western Pacific Region greatest threat from the rising prevalence makes the smallest contribution of all rates is the 40-59 year age group. to the world total of type 1 diabetes This age group now comprises the even though it has the largest childhood largest group, about 45% in the diabetic population (see Chapter 2).

Figure 7.13 Prevalence estimates of diabetes in selected countries – Western Pacific Region

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The plan proposes objectives, strategies At a glance and expected outcomes for each goal and provides examples of activities Type 1 diabetes 2003 which might be undertaken at a regional, national or local level to work towards Child population (millions) achievement of the goals. (0-14 years) 516.2 National diabetes programmes Type 1 diabetes prevalence (%) As would be expected from a region (0-14 years) 0.004 as large and diverse as this, standards of management and care show much Type 1 diabetes numbers (thousands) variation, as do healthcare delivery (0-14 years) 21.6 systems. Standards of management and care vary from very high indeed in centres of excellence in the more developed and affluent nations to almost non-existent in impoverished or strife- torn nations.

The WPDD and its action plan recognize Diabetes initiatives the need to address these discrepancies and provide a mechanism for countries to Western Pacific Declaration plan and put into place countermeasures. on Diabetes Further, steps are being taken now that The working relationship between the the action plan has provided a structure IDF WP Region and the WHO Western within which work can be done. Pacific Regional Office (WHO/WPRO) is of prime importance to the development The priority given to diabetes by of effective programmes and strategies governments also varies greatly, but within the region. This relationship increased cooperation within the WPDD continues to grow following the structure has led to more governments formation of the alliance with the identifying diabetes as a key health Secretariat of the Pacific Community initiative and integrating such initiatives (SPC) that brought about the Western with their non-communicable diseases Pacific Declaration on Diabetes (WPDD), programmes. co-signed in 2000 by these three partner organizations (see Chapter 8). While the seriousness of the problems facing countries of the Western A plan of action, to facilitate and guide Pacific Region cannot be ignored, the implementation of the WPDD, has been enthusiastic adoption of the WPDD and endorsed by IDF member associations the significance of the plan of action in the region, health ministers of the provide real hope that the region is WHO/WPRO member countries and moving to address this epidemic. territories as well as those of the SPC. Examples of the influence of the WPDD The WPDD Plan of Action sets clear include a range of different levels and goals covering primary prevention, early types of activities. The WHO/WPRO is diagnosis and care of the diagnosed, and supporting the development of national building the capacity of health systems to action plans in individual countries provide equitable, accessible, affordable and fostering the development of and effective prevention and care services national diabetes guidelines throughout to people with or at risk of diabetes. the region.

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The WPDD was also responsible for of Diabetes Education Strategies for IDF the Royal Australasian College of WP Region and WPDD’. This workshop Surgeons adding a diabetes component was outcome driven and charged to its Pacific Islands Project and many representatives with the responsibility countries, such as Korea, are using the of returning to their country to develop WPDD and its plan of action to lobby their and implement a new diabetes education governments for increased resources for strategy and provide a feedback report. diabetes and to create broad awareness This approach is in keeping with the of the disease as a public health threat. philosophy of the WPDD Plan of Action.

Education The SPC, also in support of the WPDD, The region has seen a continuation and has developed and is implementing an expansion of education and awareness introductory diabetes training manual for programmes utilizing mechanisms health workers in Pacific island countries pioneered in the region. Of note was in an effort to raise the quality of the workshop entitled ‘Implementation diabetes care provided at the community

Figure 7.14 Prevalence estimates of impaired glucose tolerance in selected countries – Western Pacific Region

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level. This manual, entitled ‘Diabetes is provision of diabetes services where Everybody’s Business’, promotes personal three years ago no service was provided. responsibility among community health workers for identifying people at risk of Major tasks on the work plan of the diabetes, gives basic risk factor advice, WPDD Steering Committee for the near and provides improved routine care for future focus on taking stock of diabetes people with diagnosed diabetes. activities in the region, increasing the development and implementation of Practical targets and treatments national diabetes programmes where they The Western Pacific Region is at the are not already in place, and promoting forefront of the diabetes epidemic, with strategies aimed at wide implementation the potential for devastating health of recognized standards of diabetes care consequences. The overwhelming and prevention. evidence is, however, that optimal glycaemic control of type 2 diabetes Many countries have made genuine can minimize risks and complications and positive progress, assisted by IDF, and that one of the ways to assist the WHO, SPC and WPDD initiatives in the achievement of good control is through development of disease management the provision of treatment guidelines. programmes and in the enhancement of diabetes awareness and education. The third edition of the ‘Asia Pacific Cultural barriers, for example in the Type 2 Diabetes Practical Targets and use of non-healthcare professionals in Treatments’ was produced by the Asia diabetes care, are now being broken Pacific Type 2 Diabetes Policy Group (1). down. The goal has been, since the first edition, to target the prevention and management Diabetes is now recognized as an of type 2 diabetes. The third edition issue of vital importance by many deals with new medications and data on governmental and non-governmental the prevention of type 2 diabetes and agencies and cooperation within the addresses the increasing incidence of region is increasing steadily. In addition, type 2 in children and adolescents. It through the increasing influence of the seeks not to be a substitute for national WPDD, governments are taking greater guidelines but to complement them and interest in the need for investment in add the authority that can be provided addressing the diabetes problem in their by a regional approach. It also seeks to communities, and more governments provide guidelines where there are none. are introducing diabetes programmes, often integrated with non-communicable Tasks ahead disease programmes and frequently with the support and involvement of other The region faces enormous difficulties governmental agencies from within the and all indications are that this will region. These issues provide a glimmer worsen in the immediate future. The of hope in what otherwise appears as a availability of epidemiological and desperate situation in many countries. other data continues to grow enhancing knowledge of the true situation in many countries in the region and with it the capacity to take effective action. These data continue to provide a basis for Reference increased action in many parts of the region through a number of cooperative 1. Asia Pacific Type 2 Diabetes Policy Group.Asia Pacific Type 2 Diabetes Practical Targets and Treatments. Third edition. International Diabetes ventures. Together, the countries of Federation, Western Pacific Region, and World Health Organization, the region are working to improve the Western Pacific Regional Office, 2002.

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n facing the challenges brought about Iby the diabetes epidemic, diabetes associations and regional organizations have galvanized into action. Declarations on diabetes, spelling out strategic actions, have been signed in five regions: Eastern Mediterranean and Middle East, Europe, North America together with South and Central America, and Western Pacific.

These declarations reflect the significance of strategic alliances with organizations such as the World Health Organization (WHO) at all levels, as well as with other stakeholders in healthcare including governments and industry. 8.1 St Vincent Declaration

8.2 Declaration of the Americas While the declarations are couched in on Diabetes culturally appropriate terms and geared toward regional needs, the core of these 8.3 Western Pacific Declaration initiatives are nonetheless similar. They on Diabetes seek to implement national diabetes 8.4 Declaration of the Eastern programmes, empower people with Mediterranean and Middle diabetes, improve the quality of diabetes East Region care, promote research and raise public awareness of a costly health problem.

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8.1 The St Vincent Declaration

The first decade of the Introduction normal expectations in quality and SVD has demonstrated quantity. the feasibility and Diabetes is a major and growing chronic • Prevention and cure of diabetes and possibility of new disease with a strong impact in terms of of its complications by intensifying approaches to diabetes health and costs, both at individual and research efforts. care and the importance societal levels, as shown in the earlier of focusing on the chapters. In spite of medical progress, A series of specific targets was also real outcomes of the a large number of people with diabetes identified in order to reach these two disease rather than on still suffer from the consequences of the goals, in particular to combat diabetic the processes. It has disease as a result of low quality of care complications: also demonstrated that and social inequalities (1). local solutions to local 1 Reduce new blindness due to problems need to be Several studies had shown a wide diabetes by one-third or more. defined. variation of care provided throughout 2 Reduce numbers of people entering Europe; moreover in some cases the end-stage diabetic renal failure by at quality of healthcare was far from set least one-third. standards and recognized goals. This was 3 Reduce by one-half the rate of limb mainly due to the poor use of available amputations for diabetic gangrene. resources, related in the majority of cases 4 Cut morbidity and mortality from to a lack of programmatic activities and coronary heart disease in people with clear healthcare policies. diabetes by vigorous programmes of risk factor reduction. Recognizing the wide variation in the 5 Achieve pregnancy outcome standard of diabetes care, a meeting was in women with diabetes that convened in St Vincent, Italy, in 1989, to approximates that of non-diabetic discuss how to implement better quality women. healthcare for people with diabetes (2). The meeting was organized under the Reducing diabetic auspices of the Regional Offices of complications IDF and the World Health Organization (WHO), and involved diabetes experts, Since 1989, several actions have been representatives of governments and undertaken at different levels throughout organizations of people with diabetes Europe for the implementation of quality from a number of European countries. of care programmes according to SVD goals and targets. Some 51 governments The immediate outcome of the meeting have nominated liaison persons for was the St Vincent Declaration (SVD), a formal relationships with the SVD document identifying goals and targets movement, and 46 have created national for the improvement of the quality of life diabetes task forces with the mission to of people with diabetes. develop and implement national and local diabetes programmes. Goals and targets In 37 European countries, representing The SVD established two general goals 72% of the total, a national diabetes for people with diabetes: programme has been designed and officially endorsed by national • Sustained improvement in health governments (3). It was clear from experiences and a life approaching the beginning, however, that the major obstacle to the achievement

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of the desired results was the lack of card was produced for data collection and information about the real entity of the a specific computer program, Save Eyes problem. in Europe (SEE), was developed for the management of the screening protocol. A questionnaire sent to national liaison persons indicated that data was available Nephropathy in 55% of the countries for blindness The guidelines for the prevention due to diabetes, 60% for end-stage renal of renal failure were subdivided disease leading to kidney transplantation into indications for screening and and 50% for amputations above ankle indications for treatment. The section (4). Some of the countries also produced on screening provided guidance on various national data on the impact of the the best procedures for the detection disease in terms of late complications (4). of microalbuminuria or persistent proteinuria. The second part provided Guidelines for better care clear guidelines for treatment of kidney disease according to the stage of A number of SVD working groups progression. were created with the remit to develop guidelines for better care. As a Amputation result of their activity, the St Vincent The guidelines for the prevention of Declaration Action Programme, a plan foot ulcers and amputations provided for the practical implementation of the suggestions for screening and diagnostic declaration, was developed (5). procedures, follow-up of people at risk and for care of overt lesions. Particular The programme was accompanied by a attention was given to the definition of series of guidelines for various aspects of the team of professionals involved in diabetes care with particular attention to foot care and to the fundamental role of late complications, including a protocol education in the prevention of the onset for the screening of diabetic retinopathy, or the progression of lesions. and guidelines for the prevention of renal failure, foot ulcers and amputations, and Cardiovascular disease coronary artery disease. The guidelines on cardiovascular disease (CVD) and stroke covered primary and These guidelines were subsequently secondary prevention. Particular attention updated in the SVD Action Programme was paid to the control of the risk factors Implementation Document (6). The for macrovascular disease and to the need for an adaptation of the guidelines target levels for each risk factor. according to local circumstances was highly recommended. Local initiatives

Retinopathy The SVD recommendations The protocol for the screening of diabetic generated several initiatives for local retinopathy was approved by experts implementation, some of which focused representing 30 diabetes and ophthalmic mainly on organizational and educational societies across Europe. The aim of the aspects, while others aimed more at protocol was the definition of a reliable clinical elements. screening tool able to identify early lesions and the most appropriate use Eye complications of resources in order to guarantee the The SVD implementation in the Stockholm same opportunities for access to eye County initiative comprised both examination for people with diabetes in organizational and educational aspects Europe. A diabetic retinopathy screening in which an educational programme

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combined with a campaign for screening in some centres to 90% in others. These diabetic eye disease and evaluating a results showed that the first step in the monitoring system for new blindness (7). reduction of complication should be a coordinated effort both for screening and The educational programme was divided treatment. into two sections. The first aimed at increasing awareness and competence A more recent survey was carried out of healthcare professionals, people with in Germany with data on new cases of diabetes, administrators and politicians, blindness collected from 1990 to 1998 and highlighted the effectiveness of (11). The study showed a reduction in preventative measures. The second was a the incidence rate of 3% for each year two-week continuous medical educational of observation. All these results showed programme for professionals working in that screening is an effective measure for the primary healthcare centres. reducing eye complications in accordance with the SVD specific guidelines. The campaign for screening eye disease was conducted through a mobile photo- Kidney complications screening service, which contacted all The PROSIT Project (Proteinuria Screening diabetic patients from hospital inpatient and Intervention Project) was launched registers, followed by an immediate in Germany as part of the national referral to an ophthalmologist in cases of implementation of the SVD (12). The people at risk. project focused on identification procedures for facilitating the screening Data collection covered the period of diabetic nephropathy. 1981–1995 while the screening was performed from 1990 to 1995 (8). One of the major achievements of the Results showed progressive decrease of project was the validation of self-testing blindness incidence. The final reduction for microalbuminuria. The study showed was equivalent to around one-third with that the available self-test methods respect to the basal level, indicating could be effectively used forscreening. the achievement of the SVD target for The combination of the effectiveness of diabetic retinopathy. the test and the low price of equipment created the conditions for widespread A prerequisite for planning effective screening for diabetic nephropathy. treatment strategies is the availability Further, the need for action was of facilities. A study was conducted highlighted in a preliminary study within in the UK in 1991 to determine which the same project which showed that treatment facilities were available only a minority of people with diabetes and how treatment was provided (9). was screened annually for diabetic Responses, from a questionnaire to all nephropathy in Germany. ophthalmologists in England and Wales, showed that screening facilities were A recent study was conducted in 20 inadequate for a large number of people European countries to evaluate the and that there was a wide variation in compliance to guidelines for first care provided, especially in waiting times referral to nephrologists (13). It was for first visit and treatment in different found that only 30% of type 1 and 22% centres. of type 2 diabetic patients had first referral according to the guidelines. A similar study was repeated in 1996 to Moreover 50% of those who were placed evaluate the possible changes (10); the in replacement therapy had the first data confirmed a wide variation of care referral within three months prior to provided for screening, from 25% of cases replacement. The results highlighted

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the low standardization of care and the produced as reports from healthcare negative impact on outcomes. implementation initiatives. At the same time, methodologies adopted Amputations for scientific protocols, eg randomized The Danish Amputation Register Study and control group comparison, are Group analysed the incidence of major not appropriate for evaluating the lower limb amputations from 1982 to effectiveness of the action programmes. 1993 (14). In total, 2,848 cases were studied: a progressive reduction of Moreover, the factors that influence the incidence, with a total of 40% reduction outcome are not always identifiable, and occurred by 1993. unpredictable environmental variations might intervene in long-term, large-scale Amongst the activities carried out within initiatives, such as political changes, the regional diabetes project in Umbria, variability of available resources, Italy, a survey on diabetes-related prevailing educational and cultural amputations highlighted that 1,283 standards, and conflicts. This has been non-traumatic amputations were particularly true in Europe in the last performed in that region from 1991 decade. to 1998. No significant changes were observed in the overall incidence rate Other factors that make difficult the during the observational period; however, documentation of the outcomes are the ratio between major amputations the lack of precise and well-defined (above the ankle) and minor amputations healthcare plans of action that have in (below the ankle) was significantly their stead healthcare policies which reduced (15). produce scattered initiatives, and the difficulty in coordinating multidisciplinary Evaluating the SVD impact initiatives. Moreover it is difficult to define the role of the SVD movement in A report, based on information provided ongoing activities that might or might not by SVD national liaison persons and have taken advantage of the SVD climate. published data, found that the following results had been achieved (4): A further element of difficulty is represented by the absence of baseline • reduction of blindness in three data collected according to appropriate countries; epidemiological procedures in areas • reduction of cardiovascular disease where the interventions have been and end-stage renal disease in three carried out. Data collected in the quality countries; development process have frequently • reduction in major amputations in six been used for providing the evidence that countries; should have been produced according • reduction in hospitalization due to to accepted epidemiological analysis. late complications of diabetes in five However, the information required countries; and for quality development is gathered • reduction in healthcare expenditure according to procedures designed for related to diabetes in two countries. satisfying that specific process and not for epidemiological purposes. However, one of the major issues in SVD-related projects is the difficulty of scientifically documenting the evidence of the outcomes due to the intrinsic characteristics of such activities, which means that the results are usually

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Platform for further The development and implementation development of diabetes registries has been a step taken to reconcile evidence-based studies The major achievements of the SVD (16) and quality care benchmarking. Once in may be summarized as: place the registries will provide reliable population-based epidemiological data • the consolidated awareness of the that are continuously updated, allowing need for and the feasibility of broad monitoring of the diabetes problem. partnership; • the promotion of appropriate The platform produced by the quality approaches for the planning of care networks and installed for the interventions; registries supports the implementation • the identification and implementation of standards of care and facilitates a of specific methodologies for quality widespread adoption of shared care. development; and A number of projects are flourishing in • the need to define and apply correct Europe, where advanced projects have methods for producing evidence. been developed in countries such as the United Kingdom, Denmark, France, In many European countries SVD-related Germany, Italy, the Netherlands, Finland initiatives produced national programmes and Greece (23). for diabetes adopted by governments, the impact of which, however, is While the technological aspects no extremely difficult to quantify owing longer represent a critical issue, to the complexity and variability of the the most challenging topics are the different environments. regulatory ones, such as the ownership of data, confidentiality, access rights, The promotion of defined and structured etc, and also the human, cultural and methodologies for the development of environmental barriers that need to quality of care has been a major focus be surmounted and that are currently of the SVD movement. Benchmarking responsible for the difficulties in realizing and external comparison, and quality large-scale projects (24). circles are well-known procedures, whose applicability in diabetes care has been Conclusion demonstrated in many initiatives. For example, within the DiabCare project, The first decade of the SVD has indicators for diabetes care have been demonstrated the feasibility and identified mostly in terms of outcomes possibility of new approaches to diabetes and processes (17). care and the importance of focusing on the real outcomes of the disease Instruments for data collection have rather than on the processes. It has also been produced, such as the Basic demonstrated that local solutions to local Information Sheet, and various systems problems need to be defined. for data transmission such as the DiabCare programme and DiabCare Fax The experience gained has also shown solution within the DiabCare Quality that available knowledge is poorly Network (Qnet). In some countries, for applied, and this problem is not just example France (18), Germany (19), the found in the less advanced countries. Netherlands (20), Italy (21) and Spain The awareness of such widely accepted (22), broad initiatives have proven the findings is creating the conditions for feasibility and effectiveness of large-scale concrete initiatives aimed at large- data collection and benchmarking for the scale prevention of end-stage diabetes improvement of quality of diabetes care. complications.

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However, given the nature and time scale for the development of diabetic complications such as eye disease, kidney disease and CVD, the real benefit of the SVD movement will require a greater length of time to be evident.

It is not inappropriate to claim that, in many countries worldwide, the effect of national action plans for diabetes produced a change in attitude in healthcare professionals, people with diabetes and other stakeholders. This change is likely to reduce successfully the burden of diabetes by decreasing the prevalence of blindness, end-stage renal failure, stroke and myocardial infarction in the years to come, which would not have been the case without the SVD movement.

Adapted from ‘The St Vincent Declaration: experience gained for better outcome of cardiovascular, eye and kidney complications in the future’ by M Massi Benedetti, J Akwe Akwi, P Ferolla, MO Federici. In Diabetes: From Research to Diagnosis and Treatment, ed. Itamar R, Skyler J, Eleazar S. London: Martin Dunitz, 2003.

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19. Selbmann HK, Pietsch-Breitfeld B. DiabCare QNet activities References Germany. The St Vincent Declaration Newsletter 1995; Suppl 1:28–29. 1. World Health Organization (Europe) and International 20. DiabCare Q-Net NL. St Vincent goals into practice. Diabetes Diabetes Federation (Europe). The action programme for Nutr Metab 1997; 10 Suppl 1:59. the implementation of the St Vincent Declaration for the 21. Massi Benedetti M, Norgiolini R, Capani F, et al. The improvement of diabetes healthcare. Jointly organized by DiabCare Quality Network as an instrument for quality WHO Europe and IDF Europe. World Health Organization, development in diabetes. Diabetes Nutr Metab 1997; ICT/CLR 055, 23 Oct 1990 (8438r). 10 Suppl:68. 2. World Health Organization (Europe) and International 22. Brugues E, Bosch F, Corcoy R, et al. Benefits of the combined Diabetes Federation (Europe). Diabetes care and research in operation of DiabCare Q-Net and Diabcard system: ‘the Europe: the St Vincent Declaration. Diabet Med 1990; Spanish experience’. Diabetes Nutr Metab 1997; 10 Suppl 7:360. 1:64. 3. Background to St Vincent. The SVD Newsletter issue 1998; 23. Diabetes ‘Registers’ Into the Millennium, 7th Workshop of 13 Summer:4. the DOIT EASD Study Group Gubbio, (PG-Italy), 12–14th May 4. Bergrem H, Kalo I, Staehr Johansen K. The St Vincent 2000. www.doit-easd.org/en/meetings. Declaration - Monitoring the St Vincent Declaration 24. Vaughan NJA. Confidentiality and diabetes registers. activities. The SVD Newsletter 10th Anniversary Issue 1999; Diabetes Nutr Metab 2001; 14:114–117. 14 Autumn:8. 5. Krans HMJ, Porta M, Keen H, Staehr Johansen K. Diabetes care research in Europe: St Vincent Declaration action programme. WHO Office, Copenhagen, 1995; EUR/ICT/CLR 055/3. 6. Krans HMJ, Porta M, Keen H, Staehr Johansen K. Diabetes care research in Europe: St Vincent Declaration action programme. Implementation document. Giornale Italiano di Diabetologia 1995; 15:1. 7. Rosenqvist U. Implementation of the St Vincent Declaration in Stockholm county, Sweden. Giornale Italiano di Diabetologia 1993; 13 Suppl:75–76. 8. Backlund LB, Algvere PV, Rosenqvist U. New blindness in diabetes reduced by more than one-third in Stockholm County. Diabet Med 1997; Sep 14:732–740. 9. Kohner EM, Lavin M, Hamilton AM. The management of diabetic retinopathy. Giornale Italiano di Diabetologia 1993; 13 Suppl:77–79. 10. Bagga P, Verma D, Walton C, et al. Survey of diabetic retinopathy screening services in England and Wales. Diabet Med 1998; 15:780–782. 11. Tautner C, Haastert B, Giani G, Berger M. Incidence of blindness in southern Germany between 1990 and 1998. Diabetologia 2001; 44:147–150. 12. Piehlmeier W, Renner R, Kimmerling T, et al. Evaluation of the Micral-Test S, a qualitative immunologic patient self- test for microalbuminuria: the PROSIT project. Proteinuria Screening and Intervention. Diabet Med 1998; 15:883–885. 13. Bergrem H. Quality of care for persons with diabetic nephropathy: Timeliness of first referral to nephrologist. Diabetes Nutr Metab 2002; 15:109–115. 14. Ebskov B, Ebskov L. Major lower limb amputation in diabetic patients: development during 1982 to 1993. Diabetologia 1996; 39:1607–1610. 15. Scionti L, Massi Benedetti M, on behalf of the Cooperative Study Group of the ‘Progetto Umbria Diabete’. A 8-year population-based survey of non-traumatic lower extremity amputations in diabetic and non-diabetic patients in an Italian region. Diabetes 2001; 50 Suppl 2:A228. 16. Bergrem H, Kalo I, Staehr Johansen K. The St Vincent Declaration - The main achievements. The SVD Newsletter 10th Anniversary Issue 1999; 14 Autumn:8. 17. Piewernetz K, Home PD, Snorgaard O, et al. Monitoring the targets of the St Vincent Declaration and the implementation of quality management in diabetes care: the DiabCare Initiative. Diabet Med 1993; 10:371–377. 18. Attali J, Klinebreil L. The support of young students in the implementation of DiabCare QNet and the St Vincent declaration. The St Vincent Declaration Newsletter 1995; Suppl 1:27–28.

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Box 8.1

Consensus on the aetiology of type 2 diabetes mellitus

Preamble specially convened meeting, Diabetes in Asia, was held in Colombo, Sri Lanka in 2002 for the Aexpress purpose of arriving at an aetiological consensus on type 2 diabetes mellitus and the development of a primary prevention strategy. This meeting was hosted by the Diabetes Association of Sri Lanka and attended by over 350 opinion leaders representing 30 countries worldwide. At the conclusion of the deliberations a consensus was reached on the aetiology and primary prevention of type 2 diabetes, which was submitted for information and possible action by IDF and WHO.

Consensus Document A consensus was reached on the ‘Aetiology and Prevention of Type 2 Diabetes Mellitus’ at the Diabetes in Asia 2002 meeting held on 6-7 July 2002 in Colombo, Sri Lanka.

Proposition Cardiovascular Disease (CVD). Physical inactivity • Current increase in the prevalence of type 2 is independently associated with increased insulin diabetes mellitus worldwide accepted with resistance. Lifestyle changes in subjects with IGT Level ‘A’ evidence* decreases progression to diabetes. • Increased incidence of type 2 diabetes mellitus in childhood and adolescence accepted with Accepted as a significant aetiological factor Level ‘A’ evidence – Level ‘A’ evidence.

Genetics Stress Genetics is recognized as playing an important Compelling animal evidence and mechanistic role in the aetiopathogenesis of diabetes. studies suggest a relationship between Stress and Monogenic forms have been identified. Insulin Resistance with predisposition to Type 2 Susceptibility genes have also been identified in Diabetes Mellitus. the common forms of type 2 diabetes mellitus. Genetic studies have contributed to the discovery Accepted as an aetiological factor of new pathogenic mechanisms. – Level ‘B’ evidence*. • Further evaluation recommended Accepted as a significant aetiological factor – Level ‘A’ evidence. Primary prevention Further studies need to be pursued. All of the above are likely to underline the Genetic counseling not recommended at present. urgent need for the primary prevention of type 2 diabetes mellitus and facilitate the introduction Foetal origins of programmes, which must be tailored to local Epidemiological studies have reported a higher circumstances in order to be effective. These incidence of type 2 diabetes mellitus in subjects should include lifestyle changes in all those at with a low birth weight. The hypothesis that risk. nutrition of the mother can profoundly affect the metabolic outcome of the offspring has been Concerted actions, by governments and non- confirmed by elegant mechanistic animal studies. governmental organizations, should be directed to the following: Low birth weight accepted as a significant • Increasing awareness aetiological factor – Level ‘A’ evidence. • Promotion of education at all levels • Poor nourishment of the foetus increases risk • Multi-sectoral advocacy of metabolic syndrome and type 2 diabetes mellitus and postnatal over-nutrition may aggravate the syndrome. • Animal studies are confirmatory. Further clinical research in human beings recommended.

Lifestyle There is a global epidemic of obesity affecting all ages. Obesity is associated with insulin resistance. * Level ‘A’ evidence – indicates full acceptance There is a strong association between Obesity, * Level ‘B’ evidence – partial acceptance with more evidence Diabetes, Impaired Glucose Tolerance (IGT) and needed.

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8.2 Declaration of the Americas on Diabetes

Diabetes mellitus is Introduction Diabetes education a growing pandemic. A standardized programme on diabetes In 1996, an estimated The Declaration of the Americas on education to train diabetes educators 30 million people with Diabetes (DOTA) movement began with was developed and initially carried out diabetes live in the a consensus development conference in at three centres in Argentina, Colombia Americas, more than a 1996 when the Declaration was drafted. and Puerto Rico. An overall diabetes quarter of the world’s The Declaration recognized diabetes education strategy in DOTA’s strategic total case load. By the as a pandemic and called for strategic plan addresses the need for more year 2010 the Americas action in diabetes education, awareness diabetes educators in Latin America. case load is expected to and advocacy, quality of care, national increase to 45 million, diabetes programme development, At the same time, the DOTA coalition taking into account epidemiology and organizational has developed a set of educational demographic ageing alliances. A resolution was then passed standards for diabetes programmes for of populations and by the Pan American Health Organization people with diabetes in Latin America trends in underlying Directing Council recognizing the and the Caribbean. These were based risk factors which are Declaration as a guide to national on standards already established by the related to the process programme development. American Diabetes Association (ADA), of modernization that the American Association for Diabetes is taking place in all The founding organizations were the Educators and the IDF Diabetes Education developing countries. North American (NA) and South and Consultative Section (DECS). Central American (SACA) Regions of IDF, Declaration of the Americas the Pan American Health Organization A Caribbean Diabetes Education course, on Diabetes (PAHO), and industry partners. supported by DOTA, was organized in Barbados by the IDF North American DOTA has expanded its partnerships Region in association with the Diabetes to include other diabetes-related Association of Barbados (see Box 6.3 in organizations in the Americas such as Chapter 6). In addition to utilizing the the Latin American Diabetes Association DOTA standardized model programme (ALAD), the Diabetes Association of the and the DECS model, the course Caribbean, the International Society for incorporated a successful mentor system. Pediatric and Adolescent Diabetes, the National Diabetes Education Program A DOTA-PAHO regional workshop, (US), and the American Association Building Blocks in Diabetes Education, for Diabetes Educators. Future targets brought together representatives from include expanding partnerships to 24 countries across the Americas in support projects at the country level. the Dominican Republic. The aim of the workshop was to develop a building Priorities blocks model for educational activities based on three scenarios detailing The DOTA coalition has prioritized the national capacity levels. During the following core areas in its strategic plan: workshop, the scenarios and educational activities to fit each scenario were • diabetes education; identified. • epidemiology (quality of care systems and surveillance); • children and adolescents and diabetes; • national programme development; and • awareness.

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Quality of care A three-year programme on data collection and assessment, Qualidiab, has also been started to measure and evaluate quality of care in six countries - Argentina, Brazil, Chile, Colombia, Paraguay and Uruguay. The initial results from Qualidiab indicate that there is a need for better quality of care.

A Caribbean pilot on assessment of quality of care is also underway. The pilot currently includes Jamaica and St Lucia, and potentially will include the Bahamas and Trinidad and Tobago.

Association development Development and leadership courses, organized by IDF and PAHO, have been carried out to strengthen diabetes associations. This is regarded as an important step in creating the structures and cooperation necessary to establish national diabetes programmes and to expand DOTA through multi-sectoral collaborations. A DOTA strategic planning workshop carried out by PAHO in Bolivia has supported the efforts on diabetes and has led to the establishment of a national diabetes programme.

Public awareness DOTA has also facilitated the development of a model public awareness plan and has encouraged the development of local awareness campaigns. A strategic plan on awareness was formulated at a strategic planning workshop, which took place in Trinidad and Tobago. The workshop was supported by DOTA and organized by the IDF North American Region in association with the Diabetes Association of Trinidad and Tobago (DATT). The strategic plan is currently being implemented by DATT.

For more information on DOTA and its initiatives, please visit www.dota.org.

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8.3 Western Pacific Declaration on Diabetes

A point of particular Introduction • Goal 1: Primary prevention of diabetes importance in the • Goal 2: Secondary prevention Western Pacific Region The Western Pacific Declaration on (detection and management of is that the largest Diabetes (WPDD) was introduced in diabetes and prevention of diabetes rise in the number of recognition of the massive diabetes complications) people with diabetes is problem in the Western Pacific Region, • Goal 3: Organization of healthcare likely to occur in the with current estimates of at least 43 systems. economically-productive million affected individuals, together age groups. The with the clear need for a concerted and Endorsement by partners huge cost of diabetes collaborative approach to tackle the care and the loss of problem and to stem predicted future Since the launch of the WPDD in Malaysia, productivity due to rises. the Declaration and its plan of action has illness will impose a been endorsed and taken into policy by heavy burden on many The WPDD, launched in 2000, is all three partner organizations. These developing countries in an alliance between three partner endorsements are essential to empower the future. organizations in the region: the IDF the WPDD to develop its important role Western Pacific Region, the Secretariat of advocacy on behalf of the cause of Western Pacific Declaration of the Pacific Community (SPC) and the diabetes in the region. on Diabetes World Health Organization Western Pacific Regional Office (WHO/WPRO). Endorsement at the Regional Committee Meeting of WHO/WPRO took place in the The different strengths, approaches Philippines in the same year the WPDD and overlapping profiles of these three was launched. This endorsement by partner organizations are being utilized governments was unanimous and led to within the WPDD to maximize and a resolution urging the WHO Regional strengthen the resources required for the Director to promote activities supporting fight against diabetes. For example WHO the Declaration. This was followed by works through governments whereas IDF further endorsement at a meeting of the works through its member associations. Pacific Island Country Health Ministers The SPC also works through governments held in Papua New Guinea the following of member countries, the Pacific islands, year. The WPDD is also fully endorsed by and has a particular interest in nutrition the IDF Western Pacific Regional Council and lifestyle. as well as by the IDF Executive Board.

The potential for synergy is clear. Thus A corporate partner and supporters group the agreement of the three partners to has also been formed within the structure the proposals made in the Declaration of the WPDD and has made seeding can, by both separate and combined financial donations to assist with the endeavour, allow more effective action to development of the Declaration and the combat the region’s problems. implementation of the plan of action.

Main goals Initiatives

The Declaration consists of an eight-point A number of activities have already statement supported by a background been initiated in support of all three explanatory document. There is also a goals of the WPDD. Numerous individual comprehensive, detailed five-year plan of programmes have been initiated in action, 2001 to 2005, organized within areas in support of diabetes prevention the framework of three main goals: (Goal 1). These have been initiated,

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promoted or supervised by WHO/WPRO. delegates from developing countries. Examples include programmes within The WHO/WPRO and SPC made Vietnam, China, Mongolia, Philippines and additional funding available to allow several Pacific island countries. some of these delegates to attend the Third World Congress on Diabetes A document written from a regional Prevention in Hong Kong. perspective, ‘Type 2 Diabetes: Practical Targets and Treatments’, has been 3 The WHO/WPRO and SPC also made endorsed as being consistent with the funds available, under the auspices goal of secondary prevention (Goal 2). of the WPDD, to allow delegates This is a simple reference guide for from Mongolia, Philippines, Vietnam, front-line workers caring for people with Tonga and Fiji to attend the Third diabetes in the region. World Congress on Diabetes Prevention and to contribute by The development of IDF member making presentations at a one-day associations is an example of an activity workshop held by the WPDD during related to the organization of healthcare the congress. systems (Goal 3). New associations in Cambodia, Samoa and Vietnam indicate 4 Other activities included support for the success of this. a train-the-trainer course for diabetes educators in Singapore, and funds for A number of projects have also been translation of an information leaflet supported financially by the WPDD. into Chinese for distribution at the Examples include: IDF Western Pacific Regional Congress in Beijing. An exhibition was mounted 1 The Second Asia-Pacific Diabetes to promote the aims and goals of the Epidemiology Training Course held WPDD at this congress. at the Chinese University of Hong Kong. The course received funding For further information about the WPDD support from WPDD as well as the and its activities, and to obtain copies National Institutes of Health, USA, the of the various documents including the Hong Kong Foundation for Research Declaration Statement and Background and Development in Diabetes, and Document, and Plan of Action, please further support from Japan and visit www.wpdd.org. Korea. Students from 15 countries and areas attended the course - Australia, Cambodia, China, Hawaii, Hong Kong, Indonesia, Japan, Korea, Malaysia, Mongolia, Philippines, Taiwan, Thailand, Tonga and Vietnam. Several of the students are already engaged in major activities in their own countries eg Vietnam, Cambodia and Mongolia.

2 The IDF Western Pacific Region together with the IDF Diabetes Education Consultative Section (DECS) held a leadership workshop in Hong Kong. Funding was made available to support the activities of the workshop and, in particular, to assist

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8.4 Declaration of the Eastern Mediterranean and Middle East Region

The EMME Declaration Introduction problem with great human and economic seeks to establish burdens. It called for action in the diabetes as priority The Declaration of the Eastern following core areas: health concern and Mediterranean and Middle East (EMME) • National diabetes strategies recognize it as a Region was adopted in 2001 by IDF • Prevention of diabetes and its serious, common health member associations in recognition of complications problem with great the increasing prevalence of diabetes • Diabetes education human and economic in their region, the emergence of • Research burdens. diabetes complications as a cause of • Collaboration with stakeholders early morbidity and mortality, and the • Discrimination enormous and mounting burden on healthcare. National diabetes strategies The declaration called for the The declaration seeks to establish development of national diabetes diabetes as priority health concern and strategies with clear objectives, process recognize it as a serious, common health indicators and outcome measures,

Profile: Zehra Naeemullah

“I had no knowledge of diabetes, because no one in my or my husband’s family, or any of our close friends had diabetes,” says 60 year-old Zehra Naeemullah from Pakistan. “My first contact with this condition was when my youngest daughter got married and we learned that her father-in-law and his sister had diabetes. I was perturbed as now this disease would come into our family never contemplating that very soon I too would be affected.”

Zehra, a housewife and mother of three grown-up daughters, was diagnosed with type 2 diabetes about two years ago when she went to the doctor because the frequency of urination was combined with an urgency that became very intense and intolerable. The random blood sugar report of 450mg/dl was a complete surprise and she could not believe it to be true. “I just could not imagine at first that the diagnosis was correct and told my doctor that no one in our family has diabetes, so how can I have it?”

She now firmly believes that the media can and should play a central role in increasing knowledge about diabetes. “A lot still needs to be done to raise awareness about diabetes,” she points out. “The doctors dealing with it should write more articles in newspapers and give talks on television. If everyone with diabetes knows more about their condition, they could take better care of themselves without any difficulty.” She adds: “Even if one does not have diabetes one should know what diabetes is as anyone may get it any time just the way it happened to me.”

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which would lead to the creation and medications and supplies, especially implementation of national diabetes insulin. A common information system programmes according to national health for diabetes to enable health services priorities. It also recognized the role of to monitor and control the quality of national organizations in the creation healthcare was also crucial. and implementation of national diabetes programmes and thus the need to Prevention of diabetes develop these organizations in order for and its complications them to participate in the process. Several courses of action were identified to meet the goals of the declaration In addition, the declaration emphasized including raising public awareness by all the need to develop and implement a possible means of the growing problems unique and comprehensive healthcare of diabetes and its complications. model, involving people with diabetes and healthcare professionals, that The declaration also called for the could be integrated with related non- allocation of adequate, appropriate and communicable disease programmes and sustainable resources to prevent diabetes the primary healthcare system. Such a where possible, and to make effective model should ensure universal access and efficient use of these resources for to quality care, training, and essential

Not long after diagnosis, Zehra had a frightening experience when she had a hypo [too low level of glucose in the blood] and had to be rushed to hospital. It made her realize the importance of having more knowledge about her condition. Her doctor, besides introducing her to self-monitoring, advised her to attend the education sessions organized under a diabetes care programme. She attended a series of lectures where she learned the basics of diabetes including the need for good blood sugar control, the complications of uncontrolled diabetes, the importance of exercise in controlling weight and blood sugar, and the need for regular follow-up. Says Zehra: “I think one does not need to know everything about the disease like doctors, but people with diabetes should have enough knowledge to be able to take care of themselves.”

Receiving education and learning self-monitoring has changed Zehra’s life. She is now in good control, regularly performing blood glucose monitoring at home and feeling much healthier. Although she still gets a hypo once in awhile but with her glucometer within reach she feels much more confident in dealing with it. She has also made it a routine to take regular exercise and go for a daily walk for an hour in the late afternoon.

Zehra believes that if one works sufficiently hard one can achieve anything in life. She married at 16 when she had just completed her matriculation. She resumed her education along with the responsibilities of married life and three children. She finally graduated with a master’s degree (MA) in economics at the age of 30. Zehra is now ready to fulfill another of her dreams and that is to open a day-care centre for working mothers so that they can pursue their careers without any hindrance.

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the development of a regional plan and activities.

The declaration emphasized the need to improve the detection and control of diabetes and impaired glucose tolerance (IGT), and reduce the onset of diabetic complications with special focus on gestational diabetes mellitus, and diabetes in the elderly and children.

Diabetes education Diabetes education for people with diabetes and healthcare professionals was another key area in the declaration. The declaration identified the promotion of health education for people with diabetes, health professionals and the public in the prevention and management of diabetes, and the setting up of standards and norms for education. It also called for the establishment of centres of excellence in diabetes education and research.

Diabetes education was also crucial to encouraging self-care for people with diabetes in order for them acquire knowledge and skills necessary for effective self-management of the disease.

Research Further, the declaration sought to encourage and promote research to allow for new knowledge, effective prevention and better healthcare and management as well as to collect epidemiological data through registry and screening.

Collaboration with stakeholders The declaration also recognized the importance of collaboration internationally as well as among the major stakeholders involved in diabetes healthcare.

Discrimination Discrimination against people with diabetes was another issue the declaration addressed and called for action for its removal.

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Diabetes Associations: Chapter 9 from Patients to Partners

At a glance

International Diabetes Federation

Number of member associations: 183

Number of member countries: 142

Number of people with diabetes represented: 2.7 million

iabetes associations play a crucial Drole in improving the quality of life of people with diabetes. It is not only in their position as advocate that diabetes associations have taken on a much more proactive role in enhancing the lives of people with diabetes. An example can be found in the provision of diabetes education, a cornerstone of diabetes management, by associations from all over the world. The results of the survey on diabetes associations around the world undertaken by the International Diabetes Federation (IDF) show a dynamic process at work.

The number of diabetes associations continues to grow worldwide as seen in the rise of membership in IDF. The number of people with diabetes that IDF member associations represent is well over two million. The growth in diabetes associations in the last 20 years possibly reflects the mounting numbers of people with diabetes as well as the gradual

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empowerment of those affected by the Results disease over the years. This was the second survey undertaken by IDF on diabetes associations. The It is significant to note that the majority survey questionnaire was sent to all of associations, which responded to the IDF member associations but was also survey, have both people with diabetes made available to non-members. The Stop discrimination, and healthcare professionals in their Federation received 92 questionnaires defend the rights and membership. This could be due to which represented a response rate of enhance the lives of the breakdown of traditional barriers approximately 50%. people with diabetes between healthcare professionals and Mission statement, their patients as well as a reflection of a The first survey conducted in 1999 Georgian Diabetes more collaborative approach to diabetes resulted in a 72.5% response rate. As a Federation care and management. result, there is no attempt to make any comparisons between the two surveys It would also seem that a new role has in this chapter as this could lead to emerged for diabetes associations. misinterpretations. Whereas previously, diabetes associations worked primarily on behalf of their However, the number of responses was members, more than 70% of those which sufficient to give a good representation of responded indicated that they now the structure, organization and activities engaged in activities for the primary of diabetes associations around the prevention of type 2 diabetes. world.

While diabetes associations vary in size IDF membership and influence, they nonetheless reflect Since its inception in 1950, IDF has the changing role of people with diabetes grown from 16 member associations in from being patients to being partners in 15 countries to 183 member associations the healthcare process. in 142 countries in 2003.

Figure 9.1 IDF membership growth, 1950 – 2003

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� ��

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The increase has been very steady in Figure 9.2 the last twenty five years, as shown Organizational structure of diabetes associations in Figure 9.1. This trend reflects the increasing number of people with �� diabetes as well as the need for people �� with diabetes, and their families, to play an active role in their care and management of the disease.

Goals The primary objective of most diabetes associations could be summarized as follows: to improve the quality of life of people with diabetes and their families. ��

To achieve this important mission, the efforts of the associations have focused on: Figure 9.3 Governing bodies and strategies • improving quality care and services; • promoting education of both �� people with diabetes and healthcare ��

professionals; �� • promoting self-management and

empowerment; �� • encouraging prevention and early

diagnosis of diabetes; �� • raising awareness on diabetes and its complications; � �� • providing assistance and protection, �� and defending the rights of people with diabetes; • establishing national diabetes programmes; and • influencing healthcare policies. while about 86% have elected bodies. In terms of strategy, close to 79% have a Organizational structure mission statement and 70% produce an The results of the survey indicated that action plan, as indicated in Figure 9.3. 88% of the respondents were national associations while 8% were national Type of membership federations, as shown in Figure 9.2. Some Diabetes associations with a mixed 4% declared a different structure, such as membership, ie both people with scientific societies, foundations, etc. diabetes and healthcare providers, represented 43% of the respondents. Some 84% of the associations charged a Some 33% of the respondents were membership fee while 38% offered free associations representing only people membership to people with diabetes. with diabetes and their families while 15% were organizations for healthcare Most diabetes associations have elected professionals only, as shown in Figure bodies governed by a constitution. Some 9.4. Healthcare centres make up 7% of 92% of the respondents indicated that the organizations which responded to the they have a constitution and by-laws survey.

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Figure 9.4 Figure 9.5 Type of membership Size of diabetes associations

��

Size of organizations and 49,999. Only 6% of the respondents The majority of associations, 48% of have more than 50,000 members, as respondents, have fewer than 999 shown in Figure 9.5. However, it is members. This was followed by medium- important to note that this small number sized associations of between 1,000 and of associations covers around 75% of all 9,999 members, 34%, while 12% were members represented by IDF diabetes large associations of between 10,000 associations.

Profile: Dijana Lukoseviciene

It came as a surprise to Dijana Lukoseviciene, 50, and to those who knew her, when she was diagnosed with type 2 diabetes. Dijana was energetic and active, and enjoyed gardening in the spring and going to the opera in the winter. She found out very quickly after her recent diagnosis that diabetes is not just a disease but a way of life. “The truth of this came to me on the first day home from the hospital,” she says. “A few times a day for the rest of my life I will have to control the level of blood glucose, observe a special diet, inject insulin before any substantial meal. What it means is that I will never have a chance to forget the disease, I will have to live in constant tension to a certain degree.”

Dijana, who works for the Vilnius municipality in Lithuania, also realized that she had to take responsibility to learn more about the disease in order to manage her diabetes in the best possible way. “Unfortunately the hospital personnel hardly helped in finding my way through the labyrinth of this complex disease,” she recalls. “The diabetes school was organized in such a way that only 15 to 20 minutes were allocated to each patient, this was not satisfactory.”

Instead Dijana turned to the Lithuanian Diabetes Association for support and used the internet as a resource. “I realized that it was necessary to communicate with people who

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Figure 9.5 Activities Figure 9.6 Size of diabetes associations Education, public awareness and the Activities undertaken by diabetes associations organization of meetings are the most common activities undertaken by the �� associations that responded to the �� survey, as indicated in Figure 9.6. ��

Education �� Of those who organized diabetes

education, 82% organized courses for �� people with diabetes while 67% had

courses for healthcare professionals, as �� shown in Figure 9.7. Some 67% produced their own education materials. ��

Public awareness �� Activities to raise public awareness

included World Diabetes Day, media � ��

events, other national campaigns and �� diabetes fairs, as shown in Figure 9.8.

It is also significant to note that almost 77% of respondents were involved in activities for the primary prevention of type 2 diabetes.

have the same illness, so I became a member of the Lithuanian Diabetes Association and subscribed to their quarterly magazine, Diabetas [Diabetes].”

Dijana found that she had to make several adjustments to her life: psychological, dietary and physical. She also had to learn to manage her insulin dosage, which she found the most difficult. “At the beginning I thought it would be enough to measure the level of blood glucose, and regulate the amount of insulin and carbohydrate intake,” she states, “today I know this understanding is quite limited.” Dijana found that her blood glucose level could rise in a stressful situation or during a complicated conversation with a colleague.

The diabetes association provided advice and helped answer her many questions. Says Dijana: “There were things that I did not understand due to my lack of experience with the disease. Practical suggestions helped a lot.” The association’s doctor gave her advice about diet, as well as an easy nutrition plan and a guide to principles of healthy nutrition. “He also taught me not to be afraid to reduce the insulin doses depending on fluctuations of the level of glucose.”

For the first two months following diagnosis Dijana found that she had more energy and strength than before. However, her doctor as well as the association’s doctor warned her that this was the so-called ‘honeymoon’ period. She was then prepared to meet what was to come – the fluctuations in her level of glucose, and to adjust her insulin dosage accordingly.

“It is vital to learn from my own mistakes,” emphasizes Dijana, “and to listen to suggestions from friends with a common fate, share our experiences and just to live on.”

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Figure 9.7 Meetings Diabetes education: type of activity Meetings organized by the associations were mostly seminars (80% of �� respondents) followed by workshops �� and congresses. These meetings were �� in most cases addressed to healthcare �� professionals and to a lesser extent to �� people with diabetes.

�� Advocacy �� The top three issues in advocacy were:

� �� 1 ensuring quality care; �� 2 defending the rights of people with diabetes; and 3 promoting education to people Figure 9.8 with diabetes and healthcare Public awareness activities professionals.

�� These top issues were fully in line with �� the goals set by the associations in their mission statements. Other major issues �� raised were prevention, screening, cost

�� of insulin, costs/reimbursement of care, �� insurance, driving licence, empowerment, and influencing public health policies �� through collaboration with governments, health organizations, other non- � �� governmental organizations (NGOs) and �� universities.

Magazines Figure 9.9 Magazines published by the diabetes Magazines: target groups associations are largely addressed to people with diabetes (92% of

�� respondents), while 80% targeted �� healthcare professionals and only 48%

�� focused on opinion leaders, as shown in �� Figure 9.9. Half of these magazines were addressed to all three target groups at �� the same time.

� �� National diabetes programmes �� More than half of the associations that responded, close to 58%, indicated that there is a national diabetes programme in their country. In 83% of the cases, the programme is being implemented with 73% of the associations involved in its implementation.

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More than 90% of the associations co- Figure 9.10 operate with a national health authority Services provided by healthcare centres in their country, this authority in many cases being the Ministry or Department �� of Health. �� Healthcare centres �� Activities undertaken by diabetes �� healthcare centres are multiple. All �� of them provide education for people �� with diabetes and a large majority offer

consultation, dietary guidance, foot care, �� eye examination as well as seminars �� for healthcare providers, as seen in �� Figure 9.10. ��

��

� ��

��

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Table 9.1 Structure and organization of diabetes associations, 2003

Free No. of membership Year of individual No. of full time No. of active Constitution for people with Region Country Name of organization establishment members employees volunteers and by-laws Elected bodies Action plan Membership fee diabetes AFR Cameroon Cameroon Diabetes Association (ACADIA) 1989 1,000 ü ü § § ü Central African Republic Association des Diabétiques en Centrafrique / Central Africa Diabetes Association Chad Association Tchadienne de lutte contre le Diabète / Chad Association for the Fight against Diabetes Congo, Democratic Republic of Association Nationale du Diabète de la République Démocratique du Congo Côte d’Ivoire Association des Diabétiques de Côte d’Ivoire (ADIACI) 1994 4,000 0 10 ü § § ü § Eritrea Eritrean Diabetes Association 1997 5,000 ü Ethiopia Ethiopian Diabetes Association 1985 5,000 1 10 ü ü § Gabon Association des Diabétiques du Gabon Gambia Gambia Diabetes Association 1993 600 0 6 ü ü § ü ü Ghana Ghana Diabetes Association 1,738 Guinea Association Guinéenne d’Education et d’Aide aux Diabétiques / Guinean Association for the Education and Help to Diabetics Kenya Diabetes Educators Association of Kenya 1999 65 0 65 ü ü ü ü § Kenya Diabetes Association 1971 10,524 0 6 ü § § ü § Madagascar Association Malgache contre le Diabète 1983 6,000 1 100 ü ü ü ü ü Mali Association Malienne de Lutte contre le Diabète (AMLD) 1991 Mozambique Associação Moçambicana dos Diabéticos Nigeria Diabetes Association of Nigeria 1982 3,000 5 15 ü ü ü ü § Senegal Association Sénégalaise de Soutien aux Diabétiques (ASSAD) 1967 19,928 10 19 ü § § ü ü South Africa Diabetes South Africa 1969 5,040 Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA) 1960 250 0 10 ü § § ü § Tanzania Diabetes Association of Zanzibar (DAZ) 1986 450 0 0 ü § ü ü § Tanzania Diabetes Association 1985 625 0 5 ü ü ü ü Togo Association Togolaise du Diabète (ATD) 1992 2,000 4 ü ü § ü § Uganda Uganda Diabetic Association Zambia Diabetes Association of Zambia 1989 1,000 0 10 ü ü ü ü § Zimbabwe Zimbabwe Diabetic Association 1989 1,500 2 8 ü ü ü ü § EMME Bahrain Bahrain Diabetes Association 1989 150 Egypt Egyptian Diabetes Association 1970 8,032 4 100 ü ü ü ü ü Iran Iranian Diabetes Society (IDS) 1968 14,599 12 80 ü ü ü § ü Iraq Iraqi Diabetes Association 1982 100 Jordan Jordanian Association for the Care of Diabetes 717 Kuwait Kuwait Diabetes Society 1996 1,086 8 20 ü ü ü ü Lebanon Lebanese Diabetes Association 1982 260 Libya Libyan Diabetic Association 400 Morocco Ligue Marocaine de Lutte contre le Diabète 1991 1,850 Pakistan Diabetic Association of Pakistan 1996 8,480 40 ü ü ü ü § Qatar Qatar Diabetes Association 1995 474 15 40 ü § ü § Saudi Arabia Saudi Diabetes and Endocrine Association 1993 3,850 Sudan Sudan Diabetic Association Syria Syrian Diabetes Association 1973 220 Tunisia Association Tunisienne des Diabétiques / Tunisian Diabetes Association 1971 3,500 United Arab Emirates Emirates Diabetes Society 124 EUR Albania Shoqata Shqipëtare Diabetike / Albanian Diabetes Association 1992 1,000 0 7 § ü § § ü Austria Österreichische Diabetes-Gesellschaft / Austrian Diabetes Society 1969 580 Österreichische Diabetiker Vereinigung / Austrian Diabetes Organization 5,900 Azerbaijan, Republic of Azerbaijan Diabetes Society 3,000 § ü ü Belarus Belarussian Humanitarian Organization ‘Children’s Diabetes’ 3,003 Belgium Association Belge du Diabète / Belgian Diabetes Association 1942 7,500 Vlaamse Diabetes Vereniging / Flemish Diabetes Association 1972 18,580 8 418 ü ü ü ü §

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Free No. of membership Year of individual No. of full time No. of active Constitution for people with Region Country Name of organization establishment members employees volunteers and by-laws Elected bodies Action plan Membership fee diabetes Bulgaria Bulgarian Diabetes Association 1990 15,300 5 250 § ü § § ü Bulgarian Society of Endocrinology and Gerontology 1954 160 Croatia Hrvatska Dijabeticka Udruga / Croatian Diabetes Association 1957 7,000 2 700 ü ü ü Cyprus Cyprus Diabetic Association 1979 6,000 1 50 ü ü § ü ü Czech Republic Ceska Diabetologicka Spolecnost / Czech Diabetes Society 1963 682 SVAZ Diabetiku Ceske Republiky / Union of Diabetics of the Czech Republic 1991 16,000 6 600 ü ü ü ü ü Denmark Diabetesforeningen / Danish Diabetes Association 1940 54,000 27 500 ü ü ü ü Estonia Estonian Diabetes Association 1992 0 All ü ü ü ü § Finland Finnish Diabetes Association 1955 52,000 60 1,500 ü ü ü France Association Française des Diabétiques (AFD) / French Diabetes Association 1938 26,000 Georgia, Republic of Georgian Diabetes Federation 1992 4,000 0 100 ü ü ü Germany Deutsche Diabetes-Union e V / German Diabetes Union 1990 46,136 Greece Hellenic Diabetologic Association 1974 2,086 Hellenic Federation of Diabetics 1997 300 1 10 ü ü ü Hungary Magyar Diabetes Tarsasag / Hungarian Diabetes Association 1971 1,480 0 0 ü ü ü ü § Iceland Samtök Sykursjúkra / Icelandic Diabetes Association 1971 750 Ireland Diabetes Federation of Ireland 1967 3,087 6 200 ü ü ü ü § Irish Endocrine Society 1984 165 Israel Israel Diabetes Association 1954 12,000 6 220 ü ü ü ü Italy Associazione Italiana Diabetici (AID) 1964 Associazione Medici Diabetologi (AMD) 1974 1,582 3 200 ü ü ü ü § FAND 1982 80,000 0 11 ü ü ü ü § Società Italiana di Diabetologia (SID) / Italian Society of Diabetology 1,943 Kazakhstan Diabetes Association of the Kazakhstan Republic 1995 3,000 10 ü ü ü ü ü Kyrgyzstan Diabetes Association of Kyrgyzstan Lithuania Lithuanian Diabetes Association 1989 5,000 4 52 ü ü ü ü ü Luxembourg Association Luxembourgeoise du Diabète / Luxembourg Diabetes Association 1979 906 0 15 ü ü ü ü § Macedonia Macedonian Diabetes Association 1991 2,500 Malta Ghaqda Kontra D-Dijabete / Maltese Diabetes Association 1983 900 0 ü ü § ü § Netherlands Diabetesvereniging Nederland (DVN) / Dutch Diabetes Association 1945 53,630 27 4,000 ü ü ü ü § Nederlandse Vereniging voor Diabetes Onderzoek (NVDO) / Dutch Association for 1974 300 Diabetes Research Norway Norges Diabetesforbund / Norwegian Diabetes Association 1948 33,000 18 1,200 ü ü ü ü § Poland Polskie Stowarzyszenie Diabetyków Zarzad Glowny / Polish Diabetes Association 1981 100,000 5 1,200 ü ü § ü ü Polskie Towarzystwo Diabetologiczne / Polish Diabetological Association 1983 500 Portugal Associação Protectora dos Diabeticos de Portugal (APDP) / Portuguese Diabetic 4,389 Association Sociedade Portuguesa de Diabetologia (SPD) 1926 452 Romania Association for the Protection of Romanian Children and Youth with Diabetes 750 Societatea Romana de Diabet, Nutritie si Boli Metabolice / Romanian Society of Diabetes, Nutrition and Metabolic Diseases Russian Federation Russian Diabetes Federation 1,000,000 Serbia and Montenegro Diabetes Association of Serbia and Montenegro 1997 7,000 0 3 ü ü ü § ü Slovakia Slovenska Diabetologicka Spolocnost / Slovak Diabetes Society 1968 ZVAZ Diabetikov Slovenska / Association of Diabetic Patients of Slovakia 1990 669 0 55 ü ü ü ü § Slovenia Zveza Društev Diabetikov Slovenije (SLODA) / Slovenian Diabetes Association 1956 3,000 Spain Asociación de Diabéticos de Tenerife 200 1 10 ü § § ü ü Federación Española de Diabetes / Spanish Federation of Diabetes 2,000 Sociedad Española de Diabetes / Spanish Diabetes Society 1954 830 1 0 ü ü § ü § Sweden Svenska Diabetes Förbundet / Swedish Diabetes Association 1943 35,500 14 ü ü ü ü § Swedish Society for Diabetology 1982 3,000 Switzerland Schweizerische Diabetes-Gesellschaft / Swiss Diabetes Association 1957 25,000 Turkey Türk Diabet Cemiyeti / Turkish Diabetes Association 1955 2,250 Turkish Diabetes Foundation 1996 750 3 10 ü ü ü ü ü Ukraine Ukrainian Diabetic Federation 1993 17,000 3 75 ü ü ü United Kingdom Diabetes UK 1934 183,000 170 ü ü ü ü § NA Anguilla Anguilla Diabetes Association Antigua and Barbuda Antigua and Barbuda Diabetes Association 1986 60 0 6 § ü

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Free No. of membership Year of individual No. of full time No. of active Constitution for people with Region Country Name of organization establishment members employees volunteers and by-laws Elected bodies Action plan Membership fee diabetes Bulgaria Bulgarian Diabetes Association 1990 15,300 5 250 § ü § § ü Bulgarian Society of Endocrinology and Gerontology 1954 160 Croatia Hrvatska Dijabeticka Udruga / Croatian Diabetes Association 1957 7,000 2 700 ü ü ü Cyprus Cyprus Diabetic Association 1979 6,000 1 50 ü ü § ü ü Czech Republic Ceska Diabetologicka Spolecnost / Czech Diabetes Society 1963 682 SVAZ Diabetiku Ceske Republiky / Union of Diabetics of the Czech Republic 1991 16,000 6 600 ü ü ü ü ü Denmark Diabetesforeningen / Danish Diabetes Association 1940 54,000 27 500 ü ü ü ü Estonia Estonian Diabetes Association 1992 0 All ü ü ü ü § Finland Finnish Diabetes Association 1955 52,000 60 1,500 ü ü ü France Association Française des Diabétiques (AFD) / French Diabetes Association 1938 26,000 Georgia, Republic of Georgian Diabetes Federation 1992 4,000 0 100 ü ü ü Germany Deutsche Diabetes-Union e V / German Diabetes Union 1990 46,136 Greece Hellenic Diabetologic Association 1974 2,086 Hellenic Federation of Diabetics 1997 300 1 10 ü ü ü Hungary Magyar Diabetes Tarsasag / Hungarian Diabetes Association 1971 1,480 0 0 ü ü ü ü § Iceland Samtök Sykursjúkra / Icelandic Diabetes Association 1971 750 Ireland Diabetes Federation of Ireland 1967 3,087 6 200 ü ü ü ü § Irish Endocrine Society 1984 165 Israel Israel Diabetes Association 1954 12,000 6 220 ü ü ü ü Italy Associazione Italiana Diabetici (AID) 1964 Associazione Medici Diabetologi (AMD) 1974 1,582 3 200 ü ü ü ü § FAND 1982 80,000 0 11 ü ü ü ü § Società Italiana di Diabetologia (SID) / Italian Society of Diabetology 1,943 Kazakhstan Diabetes Association of the Kazakhstan Republic 1995 3,000 10 ü ü ü ü ü Kyrgyzstan Diabetes Association of Kyrgyzstan Lithuania Lithuanian Diabetes Association 1989 5,000 4 52 ü ü ü ü ü Luxembourg Association Luxembourgeoise du Diabète / Luxembourg Diabetes Association 1979 906 0 15 ü ü ü ü § Macedonia Macedonian Diabetes Association 1991 2,500 Malta Ghaqda Kontra D-Dijabete / Maltese Diabetes Association 1983 900 0 ü ü § ü § Netherlands Diabetesvereniging Nederland (DVN) / Dutch Diabetes Association 1945 53,630 27 4,000 ü ü ü ü § Nederlandse Vereniging voor Diabetes Onderzoek (NVDO) / Dutch Association for 1974 300 Diabetes Research Norway Norges Diabetesforbund / Norwegian Diabetes Association 1948 33,000 18 1,200 ü ü ü ü § Poland Polskie Stowarzyszenie Diabetyków Zarzad Glowny / Polish Diabetes Association 1981 100,000 5 1,200 ü ü § ü ü Polskie Towarzystwo Diabetologiczne / Polish Diabetological Association 1983 500 Portugal Associação Protectora dos Diabeticos de Portugal (APDP) / Portuguese Diabetic 4,389 Association Sociedade Portuguesa de Diabetologia (SPD) 1926 452 Romania Association for the Protection of Romanian Children and Youth with Diabetes 750 Societatea Romana de Diabet, Nutritie si Boli Metabolice / Romanian Society of Diabetes, Nutrition and Metabolic Diseases Russian Federation Russian Diabetes Federation 1,000,000 Serbia and Montenegro Diabetes Association of Serbia and Montenegro 1997 7,000 0 3 ü ü ü § ü Slovakia Slovenska Diabetologicka Spolocnost / Slovak Diabetes Society 1968 ZVAZ Diabetikov Slovenska / Association of Diabetic Patients of Slovakia 1990 669 0 55 ü ü ü ü § Slovenia Zveza Društev Diabetikov Slovenije (SLODA) / Slovenian Diabetes Association 1956 3,000 Spain Asociación de Diabéticos de Tenerife 200 1 10 ü § § ü ü Federación Española de Diabetes / Spanish Federation of Diabetes 2,000 Sociedad Española de Diabetes / Spanish Diabetes Society 1954 830 1 0 ü ü § ü § Sweden Svenska Diabetes Förbundet / Swedish Diabetes Association 1943 35,500 14 ü ü ü ü § Swedish Society for Diabetology 1982 3,000 Switzerland Schweizerische Diabetes-Gesellschaft / Swiss Diabetes Association 1957 25,000 Turkey Türk Diabet Cemiyeti / Turkish Diabetes Association 1955 2,250 Turkish Diabetes Foundation 1996 750 3 10 ü ü ü ü ü Ukraine Ukrainian Diabetic Federation 1993 17,000 3 75 ü ü ü United Kingdom Diabetes UK 1934 183,000 170 ü ü ü ü § NA Anguilla Anguilla Diabetes Association Antigua and Barbuda Antigua and Barbuda Diabetes Association 1986 60 0 6 § ü

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Free No. of membership Year of individual No. of full time No. of active Constitution for people with Region Country Name of organization establishment members employees volunteers and by-laws Elected bodies Action plan Membership fee diabetes Aruba Aruba Diabetes Foundation 1975 50 0 15 ü ü ü § ü Bahamas Bahamas Diabetic Association 1986 350 1 20 ü ü § ü ü Barbados Diabetes Association of Barbados 1975 1,600 ü ü § ü ü Belize Belize Diabetes Association 1991 357 0 10 ü ü § ü ü Bermuda Bermuda Diabetes Association 1979 700 0 12 ü ü ü ü § British Virgin Islands British Virgin Islands Diabetes Association 1982 150 0 12 § ü § Canada Canadian Diabetes Association 1953 50,000 310 ü ü ü ü § Diabète Québec 1954 22,000 20 2,000 ü ü ü ü § Cayman Islands Cayman Islands Diabetic Association 2000 139 0 § ü § § ü Dominica, Commonwealth of Dominica Diabetes Association 300 Grenada Grenada Diabetes Association 1983 250 Guyana Guyana Diabetic Association 1973 100 0 7 ü ü ü ü § Haiti Fondation Haïtienne de Diabète et de Maladies Cardiovasculaires (FHADIMAC) 80 Jamaica Diabetes Association of Jamaica 1983 35,000 38 7 § ü § ü § Mexico Federación Mexicana de Diabetes / Mexican Diabetes Federation 1979 965 6 15 ü ü ü Sociedad Mexicana de Nutrición y Endocrinología / Mexican Society of Nutrition 500 and Endocrinology St Kitts and Nevis St Kitts Diabetes Association St Lucia St Lucia Diabetic and Hypertensive Association Trinidad and Tobago Diabetes Association of Trinidad and Tobago 1976 2,100 USA American Diabetes Association 1936 400,000 900 50,000 ü ü ü ü § SACA Argentina Liga Argentina de Protección al Diabético (LAPDI) / Argentine League for the 1964 2,000 3 10 ü ü ü ü ü Protection of Diabetics Mutual Integral Provincial de Ayuda al Diabético (MIPADI) 1994 310 Sociedad Argentina de Diabetes / Argentinian Diabetes Society 1954 765 Bolivia Sociedad Boliviana de Endocrinología, Metabolismo y Nutrición / Bolivian Society of 56 0 56 ü ü § ü § Endocrinology, Metabolism and Nutrition Brazil Associação de Diabetes Juvenil (ADJ) 1980 1,000 Federação Nacional de Associações de Diabéticos (FENAD) 1988 10 58 ü ü ü Sociedade Brasileira de Diabetes (SBD) / Brazilian Diabetes Society 1970 920 Chile Fundación Diabetes Juvenil de Chile / Juvenile Diabetes Foundation of Chile 1988 4,258 Sociedad Chilena de Endocrinología y Metabolismo / Chilean Society of 206 Endocrinology and Metabolism Colombia Asociación Colombiana de Diabetes 1954 8,000 Federación Diabetológica Colombiana (FDC) 1997 300 Costa Rica Asociación Costarricense de Endocrinología Diabetes y Nutrición (ACEDYN) 35 Cuba Sociedad Cubana de Diabetes / Cuban Society of Diabetes 1959 131 0 131 ü ü ü ü § Dominican Republic Instituto Nacional de Diabetes, Endocrinología y Nutrición (INDEN) 1972 343 Sociedad Dominicana de Diabetes (SODODIA) / Dominican Diabetes Society 1966 150 Ecuador Asociación Ecuatoriana de Diabeticos (AED) Federación Ecuatoriana de Diabetes (FEDIabetes) El Salvador Asociación Salvadoreña de Diabéticos (ASADI) 1988 3,200 10 40 ü § ü ü ü Guatemala Patronato de Pacientes Diabéticos de Guatemala Honduras Coordinadora Nacional de Lucha contra la Diabetes (CONALUDI) Netherlands Antilles Sociedat Kurasoleno di Diabetiko (SOKUDI) / Diabetic Association of Curaçao Nicaragua Fundación Pro Ayuda a Enfermos Crónicos (FUNPEC) 1994 600 ü ü ü § ü Panama Asociación Panameña de Diabeticos / Panamanian Diabetes Association 980 Paraguay Fundación Paraguaya de Diabetes Sociedad Paraguaya de Diabetología / Paraguayan Society of Diabetology 1970 40 ü ü ü ü § Peru Asociación de Diabéticos Juveniles del Péru (ADJ) / 1990 50 4 12 ü ü ü ü ü Juvenile Diabetes Association of Peru Asociación Peruana de Diabetes / Peruvian Diabetes Association 1973 1,000 Puerto Rico Asociación Puertorriqueña de Diabetes 1988 350 6 ü § § ü Asociación Puertorriqueña de Educadores en Diabetes / Puerto Rican Association of 47 Diabetes Educators Sociedad Puertorriqueña de Endocrinología y Diabetología (SPED) / Puerto Rican 1977 70 Society of Endocrinology and Diabetology Suriname Stichting Diabetes Educatie Suriname 1988 15 ü § §

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Free No. of membership Year of individual No. of full time No. of active Constitution for people with Region Country Name of organization establishment members employees volunteers and by-laws Elected bodies Action plan Membership fee diabetes Aruba Aruba Diabetes Foundation 1975 50 0 15 ü ü ü § ü Bahamas Bahamas Diabetic Association 1986 350 1 20 ü ü § ü ü Barbados Diabetes Association of Barbados 1975 1,600 ü ü § ü ü Belize Belize Diabetes Association 1991 357 0 10 ü ü § ü ü Bermuda Bermuda Diabetes Association 1979 700 0 12 ü ü ü ü § British Virgin Islands British Virgin Islands Diabetes Association 1982 150 0 12 § ü § Canada Canadian Diabetes Association 1953 50,000 310 ü ü ü ü § Diabète Québec 1954 22,000 20 2,000 ü ü ü ü § Cayman Islands Cayman Islands Diabetic Association 2000 139 0 § ü § § ü Dominica, Commonwealth of Dominica Diabetes Association 300 Grenada Grenada Diabetes Association 1983 250 Guyana Guyana Diabetic Association 1973 100 0 7 ü ü ü ü § Haiti Fondation Haïtienne de Diabète et de Maladies Cardiovasculaires (FHADIMAC) 80 Jamaica Diabetes Association of Jamaica 1983 35,000 38 7 § ü § ü § Mexico Federación Mexicana de Diabetes / Mexican Diabetes Federation 1979 965 6 15 ü ü ü Sociedad Mexicana de Nutrición y Endocrinología / Mexican Society of Nutrition 500 and Endocrinology St Kitts and Nevis St Kitts Diabetes Association St Lucia St Lucia Diabetic and Hypertensive Association Trinidad and Tobago Diabetes Association of Trinidad and Tobago 1976 2,100 USA American Diabetes Association 1936 400,000 900 50,000 ü ü ü ü § SACA Argentina Liga Argentina de Protección al Diabético (LAPDI) / Argentine League for the 1964 2,000 3 10 ü ü ü ü ü Protection of Diabetics Mutual Integral Provincial de Ayuda al Diabético (MIPADI) 1994 310 Sociedad Argentina de Diabetes / Argentinian Diabetes Society 1954 765 Bolivia Sociedad Boliviana de Endocrinología, Metabolismo y Nutrición / Bolivian Society of 56 0 56 ü ü § ü § Endocrinology, Metabolism and Nutrition Brazil Associação de Diabetes Juvenil (ADJ) 1980 1,000 Federação Nacional de Associações de Diabéticos (FENAD) 1988 10 58 ü ü ü Sociedade Brasileira de Diabetes (SBD) / Brazilian Diabetes Society 1970 920 Chile Fundación Diabetes Juvenil de Chile / Juvenile Diabetes Foundation of Chile 1988 4,258 Sociedad Chilena de Endocrinología y Metabolismo / Chilean Society of 206 Endocrinology and Metabolism Colombia Asociación Colombiana de Diabetes 1954 8,000 Federación Diabetológica Colombiana (FDC) 1997 300 Costa Rica Asociación Costarricense de Endocrinología Diabetes y Nutrición (ACEDYN) 35 Cuba Sociedad Cubana de Diabetes / Cuban Society of Diabetes 1959 131 0 131 ü ü ü ü § Dominican Republic Instituto Nacional de Diabetes, Endocrinología y Nutrición (INDEN) 1972 343 Sociedad Dominicana de Diabetes (SODODIA) / Dominican Diabetes Society 1966 150 Ecuador Asociación Ecuatoriana de Diabeticos (AED) Federación Ecuatoriana de Diabetes (FEDIabetes) El Salvador Asociación Salvadoreña de Diabéticos (ASADI) 1988 3,200 10 40 ü § ü ü ü Guatemala Patronato de Pacientes Diabéticos de Guatemala Honduras Coordinadora Nacional de Lucha contra la Diabetes (CONALUDI) Netherlands Antilles Sociedat Kurasoleno di Diabetiko (SOKUDI) / Diabetic Association of Curaçao Nicaragua Fundación Pro Ayuda a Enfermos Crónicos (FUNPEC) 1994 600 ü ü ü § ü Panama Asociación Panameña de Diabeticos / Panamanian Diabetes Association 980 Paraguay Fundación Paraguaya de Diabetes Sociedad Paraguaya de Diabetología / Paraguayan Society of Diabetology 1970 40 ü ü ü ü § Peru Asociación de Diabéticos Juveniles del Péru (ADJ) / 1990 50 4 12 ü ü ü ü ü Juvenile Diabetes Association of Peru Asociación Peruana de Diabetes / Peruvian Diabetes Association 1973 1,000 Puerto Rico Asociación Puertorriqueña de Diabetes 1988 350 6 ü § § ü Asociación Puertorriqueña de Educadores en Diabetes / Puerto Rican Association of 47 Diabetes Educators Sociedad Puertorriqueña de Endocrinología y Diabetología (SPED) / Puerto Rican 1977 70 Society of Endocrinology and Diabetology Suriname Stichting Diabetes Educatie Suriname 1988 15 ü § §

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Free No. of membership Year of individual No. of full time No. of active Constitution for people with Region Country Name of organization establishment members employees volunteers and by-laws Elected bodies Action plan Membership fee diabetes Uruguay Asociación de Diabéticos del Uruguay / Uruguayan Diabetes Association 1951 5,413 19 100 ü ü ü ü Sociedad de Diabetología y Nutrición del Uruguay 1978 250 Venezuela Asociación Venezolana de Diabetes / Venezuelan Diabetes Association Federación Venezolana de Asociaciones y Unidades de Diabetes (FENADIABETES) 1990 250 Fundación de Atención al Diabético (FUNDIABETES) 1,000 Sociedad Venezolana de Endocrinología y Metabolismo / Venezuelan Endocrinology 1957 150 and Metabolism Society SEA Bangladesh Diabetic Association of Bangladesh (DAB) 1956 569 India Diabetic Association of India 1955 12,270 ü ü ü ü § Mauritius Mauritius Diabetic Association 1981 300 1 24 ü ü ü ü § Nepal Nepal Diabetes Association 1990 300 3 10 ü ü ü ü ü Sri Lanka Diabetes Association of Sri Lanka 1984 494 18 48 ü ü ü ü § WP Australia Diabetes Australia 1952 94,044 South Eastern Sidney Division of General Practitioners 1992 205 6 0 ü ü § ü § Cambodia Cambodian Diabetes Association 1998 338 0 12 ü ü ü § ü China, Hong Kong Diabetes Hong Kong 1996 2,301 3 103 ü ü ü § ü Society for the Study of Endocrinology, Metabolism and Reproduction 1983 70 China, Macau Macau Diabetes Association 1997 328 0 5 ü ü ü § ü China, People’s Republic of Chinese Diabetes Society of the Chinese Medical Association (CMA) 1991 500 Fiji Fiji National Diabetes Foundation 1986 75 Indonesia Persatuan Diabetes Indonesia / Indonesian Diabetes Association 1986 5,000 Japan Japan Diabetes Society 1957 20,000 4 ü § ü ü § Korea, Republic of Korean Diabetes Association 1968 26,318 2 ü ü ü ü ü Malaysia Persatuan Diabetis Malaysia / Malaysian Diabetes Association 1981 2,800 New Zealand Diabetes New Zealand 1962 13,479 3 ü ü ü ü § Papua New Guinea Diabetic Association of Papua New Guinea 16 Philippines Philippine Diabetes Association 1958 500 1 ü ü § ü § Samoa Samoa Diabetes Association Singapore, Republic of Diabetic Society of Singapore 1971 3,500 12 10 ü § § ü § Taiwan Chinese Taipei Diabetes Association 1980 633 1 14 § § ü ü Thailand Diabetes Association of Thailand 1966 369 Tonga Tonga Diabetes Association 1997 700

Total 2,699,006 1,863 64,642 § § § § §

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Free No. of membership Year of individual No. of full time No. of active Constitution for people with Region Country Name of organization establishment members employees volunteers and by-laws Elected bodies Action plan Membership fee diabetes Uruguay Asociación de Diabéticos del Uruguay / Uruguayan Diabetes Association 1951 5,413 19 100 ü ü ü ü Sociedad de Diabetología y Nutrición del Uruguay 1978 250 Venezuela Asociación Venezolana de Diabetes / Venezuelan Diabetes Association Federación Venezolana de Asociaciones y Unidades de Diabetes (FENADIABETES) 1990 250 Fundación de Atención al Diabético (FUNDIABETES) 1,000 Sociedad Venezolana de Endocrinología y Metabolismo / Venezuelan Endocrinology 1957 150 and Metabolism Society SEA Bangladesh Diabetic Association of Bangladesh (DAB) 1956 569 India Diabetic Association of India 1955 12,270 ü ü ü ü § Mauritius Mauritius Diabetic Association 1981 300 1 24 ü ü ü ü § Nepal Nepal Diabetes Association 1990 300 3 10 ü ü ü ü ü Sri Lanka Diabetes Association of Sri Lanka 1984 494 18 48 ü ü ü ü § WP Australia Diabetes Australia 1952 94,044 South Eastern Sidney Division of General Practitioners 1992 205 6 0 ü ü § ü § Cambodia Cambodian Diabetes Association 1998 338 0 12 ü ü ü § ü China, Hong Kong Diabetes Hong Kong 1996 2,301 3 103 ü ü ü § ü Society for the Study of Endocrinology, Metabolism and Reproduction 1983 70 China, Macau Macau Diabetes Association 1997 328 0 5 ü ü ü § ü China, People’s Republic of Chinese Diabetes Society of the Chinese Medical Association (CMA) 1991 500 Fiji Fiji National Diabetes Foundation 1986 75 Indonesia Persatuan Diabetes Indonesia / Indonesian Diabetes Association 1986 5,000 Japan Japan Diabetes Society 1957 20,000 4 ü § ü ü § Korea, Republic of Korean Diabetes Association 1968 26,318 2 ü ü ü ü ü Malaysia Persatuan Diabetis Malaysia / Malaysian Diabetes Association 1981 2,800 New Zealand Diabetes New Zealand 1962 13,479 3 ü ü ü ü § Papua New Guinea Diabetic Association of Papua New Guinea 16 Philippines Philippine Diabetes Association 1958 500 1 ü ü § ü § Samoa Samoa Diabetes Association Singapore, Republic of Diabetic Society of Singapore 1971 3,500 12 10 ü § § ü § Taiwan Chinese Taipei Diabetes Association 1980 633 1 14 § § ü ü Thailand Diabetes Association of Thailand 1966 369 Tonga Tonga Diabetes Association 1997 700

Total 2,699,006 1,863 64,642 § § § § §

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Table 9.2 Number of registered patients and services provided by diabetes healthcare centres, 2003

Education for Seminar for Routine Total no. of Eye people with healthcare Dietary Magazine for laboratory Region Country Name of healthcare centre registered patients Consultation examination Hospitalization diabetes providers guidance Foot care patients test AFR Côte d’Ivoire Centre Antidiabétique d’Abidjan et Service d’Endocrino-Diabétologie du CHU de Yopougon 24,000 ü § ü ü ü ü ü § § Kenya Diabetes Care and Training Ltd 1,456 ü § § ü ü ü § ü ü Madagascar Maison du Diabète 5,500 ü ü § ü ü ü ü § ü Senegal Centre de Diabétologie Marc Sankale 19,928 EMME Libya National Centre for Diabetes and Endocrinology 16,094 ü ü ü ü § ü ü § ü Pakistan Diabetic Association of Pakistan 8,477 ü ü § ü ü ü ü ü § EUR Georgia, Republic of Georgian Diabetes Federation 1,500 ü ü § ü ü § § § § NA Bermuda BHB Diabetes Centre 1,500 ü § § ü ü ü ü § § Jamaica Diabetes Association of Jamaica 35,000 ü ü § ü ü ü ü ü ü SACA Nicaragua Fundación Pro Ayuda a Enfermos Crónicos Clinica 1,500 ü ü § ü ü ü ü ü ü Venezuela Fundación de Atención al Diabético 840 § § § ü ü ü ü § § SEA Bangladesh Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and 245,842 ü ü ü ü ü ü ü ü ü Metabolic Disorders (BIRDEM) India All India Institute of Diabetes 67,332 ü ü ü ü ü ü ü ü ü Sri Lanka National Diabetes Centre 130,000 ü ü § ü ü ü ü ü ü WP Singapore, Republic of Diabetes Education and Care Centre N/A ü ü § ü § ü ü § §

Total 558,969 § § § § § § § § §

N/A not available

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Total 558,969 § § § § § § § § §

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Prevention and Strategic Action Chapter 10

At a glance

Priorities

 Prevention of diabetes and its complications  Improve quality of life  Ensure affordable insulin and diabetes supplies  Raise global awareness  Promote education

he current mission of the TInternational Diabetes Federation (IDF) is “to work with its member associations to enhance the lives of people with diabetes”. To fulfil its mission and its role as the global advocate for people with diabetes, IDF has engaged in activities to advocate, educate and inform.

As such, for the last 50 years, the actions of the Federation have been targeted accordingly:

• recruiting more member associations; • organizing activities in the Federation’s seven regions; • raising public awareness about diabetes; • promoting solidarity through the associations’ twinning programmes; • defending the cause of people with diabetes at national, regional and international levels; • cooperating with the World Health Organization (WHO) and numerous non-governmental bodies;

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• helping to educate healthcare for satisfaction, and of a rise in incidence professionals to improve diabetes (number of new cases each year), a cause management through the Federation’s for concern. Education Foundation; • promoting diabetes education; Preventing type 1 diabetes to occur is still • evaluating the costs of diabetes; and a dream. However, the worldwide efforts • disseminating information about to better understand the mechanisms of diabetes through its newsletters, the disease, identify what is inherited and periodicals, non-serial publications, what may be due to the environment, triennial congresses, website and the and to recognize early those at risk offer Diabetes Atlas. great hopes that type 1 diabetes may one day be prevented, halted early in its By promoting diabetes The need for prevention progression and ultimately cured. prevention, IDF will ensure that those As evidenced by the information gathered Priorities for strategic action millions who already in this edition of the Diabetes Atlas, have diabetes will not the time has come to consider adding Type 1 diabetes mellitus face the nightmare of a diabetes prevention to the mission of The priority of the priorities today for regression in the quality the Federation. Indeed, estimations and the International Diabetes Federation of care they deserve projections all concur that the number is to ensure that insulin and blood while, on the contrary, of people with diabetes which may be glucose control materials are available there is a great need in reached in the next 25 years would and affordable everywhere in the world many parts of the world qualify diabetes as the largest epidemic for those who need them, an objective to improve it. humanity has ever experienced. followed assiduously by the IDF Task Force on Insulin. If this indeed occurs, and there is little reason to believe it will not if action is The contribution of IDF to the prevention not taken, there is a significant risk that of type 1 diabetes will be to maintain governments and social security systems pressure on raising awareness, encourage may fail to ensure the appropriate care to research in the field and support all those the some 333 million people who will be who, through innovative efforts, try to affected by diabetes in 2025. Some 90% better understand the mechanisms of this of these people will have type 2 diabetes complex disease. mellitus. Recent studies have shown that type 2 diabetes and its complications Type 2 diabetes mellitus may be prevented or delayed given the Pathways for direct action by IDF are right action. more obvious regarding type 2 diabetes mellitus, which affect some 90% of the By promoting diabetes prevention, IDF 194 million with diabetes today, and will ensure that those millions who probably even more than 90% tomorrow. already have diabetes will not face the As emphasized in a recent consensus nightmare of a regression in the quality statement (see Box 8.1 in Chapter 8) (1), of care they deserve while, on the there is strong evidence that genetics contrary, there is a great need in many plays an important role together with parts of the world to improve it. overweight or obesity resulting from excess caloric intake and reduction in Although representing only less than physical activity. 10% of all forms of diabetes, the absolute number of people with type 1 diabetes Furthermore, there is evidence that a low will definitely increase in the coming birth weight, as a consequence of poor years. This is due to the conjunction of nourishment of the foetus, significantly an increased life expectancy, a reason increases the risk of type 2 diabetes

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mellitus and the related ‘metabolic Improve quality of life syndrome’ in the offspring. In addition, The cornerstone of the action of the some mechanistic studies suggest a Federation remains helping all those relationship between stress and insulin affected by diabetes to improve resistance with predisposition to type 2 their quality of life, prevent diabetes diabetes mellitus. complications to occur and, if these occur, slowdown their progression, even Recent studies have shown that lifestyle if primary prevention of diabetes must changes (and also some medications) now be considered by IDF. are effective in preventing type 2 diabetes in individuals at risk, such as In our times of ‘evidence-based’ medicine, those with impaired glucose tolerance numerous studies performed over (2-5). IDF is committed to advancing the last 20 years (6) have provided concerted actions by governments and strong evidence that strict control of non-governmental organizations to blood glucose reduces the incidence of raise awareness about the seriousness retinopathy, nephropathy and neuropathy of type 2 diabetes, promote education in both type 1 and type 2 diabetes at all levels and exercise multisectoral mellitus, that control of blood pressure advocacy. reduces the risk of cardiovascular events and deaths, and that intensive treatment Global awareness, advocacy and of blood pressure reduces the risk of action in diabetes programme aggravation of nephropathy in people A major action in the coming years is the with microalbuminuria or incipiens renal ambitious ‘Global awareness, advocacy failure. and action in diabetes’ programme developed by the WHO Department of Noncommunicable Diseases Management in Geneva and the International Diabetes Federation. Supported by the World The time has come to act…NOW! Diabetes Foundation, this programme aims to enhance awareness about diabetes and its complications amongst the public, health professionals and As emphasized by Nathan (6), the net decision makers, with major emphasis effect of these controlled clinical trials on prevention, particularly in low income has been an expansion of lifespan and countries. an improvement in quality of life for persons affected by diabetes. IDF’s role is The programme is designed to support to disseminate the conclusions of these WHO/IDF regions and countries in the trials to its member associations, and reorganization of their health services raise awareness about the progress in in response to the current epidemic by this field among the public, healthcare developing coordinated programmes providers, social security authorities and to promote effective management of governments. people with diabetes as well as primary prevention of type 2 diabetes. In these Diabetes programmes programmes, emphasis will be put IDF recognizes some remarkable national on healthy dietary habits, promotion programmes for diabetes such as the of physical activity, and appropriate National Framework Programme on quantitative and qualitative nutrition of Diabetes in the United Kingdom, the the pregnant mother. 2000-2010 Development Programme for Prevention and Care in Finland, the

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National Plan against Diabetes in France, Conclusion and the coming National Prevention Programme for Diabetes in Sri Lanka, to Monitoring the global diabetes epidemic, mention only a few. evaluating the overall cost of the disease, assessing the access to insulin and Through its regions, IDF has contributed diabetes supplies worldwide, reviewing to major programmes through the the progress of diabetes education, and St Vincent Declaration in Europe, promoting the work and achievements of Declaration of the Americas on Diabetes its member associations are key features in North, South and Central America, of the present edition of the Diabetes Western Pacific Declaration on Diabetes in Atlas. However, to observe and report is the Western Pacific and EMME Declaration one course of action, to act to improve on Diabetes in the Eastern Mediterranean the condition of people with diabetes and Middle East. The Federation will and preventing the disease to affect continue to encourage similar initiatives millions is another. The time has come to in other parts of the world. act…NOW!

References

1. Diabetes in Asia 2002 Meeting. Consensus on the Aetiology of Type 2 Diabetes Mellitus and Development of a Primary Prevention Strategy for Type 2 Diabetes Mellitus. Colombo, Sri Lanka, July 2002. 2. Pan X-R, Li G-W, Wang J-X, et al. Effect of diet and exercise in preventing NIDDM in people with impaired glucose tolerance: the Da Quing IGT and Diabetes Study. Diabetes Care 1997; 20:537-544. 3. Tuomilehto J, Lindström J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001; 344:1343-1350. 4. Diabetes prevention programme research group. Reduction in the incidence of Type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346:393-403. 5. Chiasson J-L, Josse RG, Gomis R, Hanefeld M, Karasik A and Laakso M for the Stop-NIDDM Trial Research Group. Acarbose for prevention of type 2 diabetes mellitus: the STOP-NIDDM randomised trial. Lancet 2002; 359:2072-2077. 6. Nathan DM. The impact of clinical trials on the treatment of diabetes mellitus. J Clin Endocr Metab 2002; 87:1929-1937.

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