Diabetes atlas 3rd edtion

DIABETES ATLAS THIRD EDITION The mission of the International Diabetes Federation is to promote diabetes care, prevent...

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DIABETES ATLAS THIRD EDITION

The mission of the International Diabetes Federation is to promote diabetes care, prevention and a cure worldwide.

DIABETES ATLAS COMMITTEE Jean-Claude Mbanya (co-chair) Delice Gan (co-chair) Bjørnar Allgot Karel Bakker Jonathan Betz Brown Ambady Ramachandran Gojka Roglic Jonathan Shaw Martin Silink Linda Siminerio Gyula Soltèsz Rhys Williams Paul Zimmet Editor and project manager: Delice Gan Project coordinator: Olivier Jacqmain Diabetes Atlas, third edition, and other IDF publications are available from: International Diabetes Federation Executive Office 19 Avenue Emile de Mot B-1000 Brussels Belgium Tel +32 2 538 5511 Fax +32 2 538 5114 [email protected] www.idf.org Online version of Diabetes Atlas: www.eatlas.idf.org © International Diabetes Federation, 2006 No part of this publication may be reproduced or transmitted in any form or by any means without the prior written permission of the International Diabetes Federation. First published, 2000 Second edition, 2003 Third edition, 2006 Permission has been obtained from the United Nations, Population Division to use data from the World Population Prospects: The 2004 Revision. http://www.bms.com/ ISBN 2-930229-45-4

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ACKNOWLEDGEMENTS

CONTRIBUTIONS

The International Diabetes Federation (IDF) would like to express its

CHAPTER 1

thanks to its partners for their generous support in making the

1.1 Richard Sicree, Jonathan Shaw, Paul Zimmet

Diabetes Atlas, third edition, possible:


1.3 Robyn Tapp, Richard Sicree, Jonathan Shaw, Paul Zimmet

World Diabetes Foundation Sanofi-Aventis Groupe

CHAPTER 2

Merck and Co, Inc

2.1 Gyula Soltész, Chris Patterson, Gisela Dahlquist

Roche Diagnostics

2.2 Ravinder Singh, Jonathan Shaw, Paul Zimmet

Novartis Bristol Myers-Squibb

CHAPTER 3

Astra Zeneca

A publication such as this would not have been possible without

CHAPTER 4

the commitment and contribution of many people around the

Boyd Metzger

Gojka Roglic

world. IDF would like to thank and express its deep appreciation of the contributions of the following authors:

CHAPTER 5

Jonathan Betz Brown, Dorte Vistisen, Richard Sicree,

Jonathan Shaw, Gregory Nichols, Ping Zhang

CHAPTER 6


6.2 David Beran, John Yudkin

CHAPTER 7

Ravinder Singh, Jonathan Shaw, Paul Zimmet

CHAPTER 8

Paul Zimmet, KGMM Alberti, Jonathan Shaw

CHAPTER 9

Rhys Williams, Jonathan Shaw

CHAPTER 10

Martin Silink

IN TOUCH WITH Sylvia Brunoldi, Marguerite de Clerk, Fatema Jawad, Ambady Ramachandran Special thanks to Shirley Murray for coordinating the work at the International Diabetes Institute, and to Morten Agergaard for the design of this publication. Special thanks also to the IDF Regional Chairs for assistance: Morsi Arab, Gordon Bunyan, Susana Feria de Campanella, Debbie Jones, Kaushik Ramaiya, Wim Wientjens, Mahen Wijesuriya

_

ACKNOWLEDGEMENTS IDF also gratefully acknowledges the help of the following for their contribution to the publication: IDF member associations Zulfiqarali G Abbas, Carlos A Aguilar-Salinas, Nizar Albache, Mansour M Al-Nozha, Maha Al-Till, Karolina Antonov, Fereidoun Azizi, Michael Barry, Lee-Ming Chuang, Aynina Cisse, Kirsten Coppell, Max de Courten, Wendy Davis, John Day, Anne FagotCampagna, Juan Jose Gagliardino, Geoff Gill, Dan Hackam, Markolf Hanefeld, Hans Hauner, Günther Heller, Lex Herreburgh, Julia Hippisley-Cox, Akhtar Hussain, Tazeen Jafar, Jak Jervell, Harry Keen, Hilary King, Ross Lawrenson, Warren Lee, Theodoros G Loizou, Berit Lundman, Rachid Malek, Jaana Martakainen, Arne Melander, V Mohan, Errol Morrison, Henrietta Mulnier, Bruce Neal, Annemette Nielsen, Cynthia Perez, Catherine Regniers, Antti Reunanen, Shaukat M Sadikot, Helmut Schröder, Ulrich Schwabe, Laidon Shapo, Claudia P Sánchez-Castillo, Mohammed Tazi, Lesley Tilson, Tom Walley, Peter Watkins, Kumudu Wijewardene

CONTENTS Foreword Introduction Executive Summary What is Diabetes?

1 3 5 7

PART 1 THE GLOBAL BURDEN OF DIABETES Diabetes and Impaired Glucose Tolerance 10 CHAPTER 1 1.1 Prevalence and Projections 15 1.2 Known and Newly Diagnosed Diabetes 105 1.3 Complications of Diabetes 111

Diabetes in the Young: a Global Perspective

CHAPTER 2 2.1 Global Trends in Childhood Type 1 Diabetes 153

2.2 Type 2 Diabetes in the Young

193

CHAPTER 3 Gestational Diabetes Mellitus

CHAPTER 4

CHAPTER 5 The Economic Impacts of Diabetes

211

Diabetes Mortality

219 237

PART 2 THE CHALLENGES Access to Insulin, Medication and Diabetes Supplies CHAPTER 6 6.1 Diabetes Medication Use: International Prescription Patterns 6.2 Managing Insulin-Requiring Diabetes in Sub-Saharan Africa

267 271 288

CHAPTER 7 Mental Health, Antipsychotic Drugs and Hyperglycaemia

CHAPTER 8

PART 3 PREVENTION AND ACTION Prevention and action CHAPTER 9 Prevention and Diabetes: Possibilities for Success and Consequences of Inaction

CHAPTER 10 From Vision to Action 329

299

The Metabolic Syndrome

307

APPENDICES Appendix 1.1 Methodology for Chapter 1.1 Appendix 1.2 Methodology for Chapter 1.3 Appendix 2 Methodology for Chapter 2.1 Appendix 3 Methodology for Chapter 5 Glossary Acronyms References World Diabetes Foundation

313 317

335 339 341 343 350 352 354 376

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FOREWORD

D

iabetes is no longer an epidemic that can be ignored. Each new edition of the Diabetes Atlas, strengthened by the latest prevalence studies, confirms the fact that diabetes is increasing – and increasing rapidly – in every part of the world. At the same time, there is now good evidence showing that type 2 diabetes can be prevented in many cases, and that there are cost-effective measures for preventing diabetic complications. The third edition of the Diabetes Atlas firmly confounds what many have believed for so long. Once thought of as a disease of affluent countries, type 2 diabetes is now a growing burden on developing economies. More than 80% of the 246 million people with diabetes live in low- and middle-income countries, where health resources are needed to combat both contagious and chronic diseases. Once thought of as a disease of the elderly, people in younger age groups now form the bulk of those with diabetes. Some 46% of adults with diabetes are in the 40–59 age group. Once thought of ‘as a touch of sugar’, studies show that diabetes at any age, if not properly managed, will lead to serious outcomes, and, in some cases, death. It is estimated that 3.8 million men and women will die from diabetes in 2007, more than 6% of total world mortality.

these issues and challenges. It is now up to us to take up the challenge and find cost-effective ways to tackle one of the largest health problems we now face. We must unite – governments, organizations, individuals – to prevent diabetes, to improve diabetes care for the millions affected and to, ultimately, find a cure. I would like to express my appreciation and thanks to the many colleagues around the world whose invaluable contribution has made this edition of the Diabetes Atlas possible. I would also like thank our sponsoring partners who have given their support in so many ways. The Diabetes Atlas will be a significant resource for all of us who are working to improve the lives of millions touched by diabetes.

Pierre Lefèbvre IDF President 2003 - 2006

If left unchecked, the number of people with diabetes will reach 380 million in less than 20 years. This is more than the current adult population of the African Region or of the North American Region. This will mean that 1 out of 14 adults worldwide will have diabetes in the year 2025. The loss of earnings and lives because of diabetes will be hard to bear. This edition of the Diabetes Atlas brings us face to face with

FOREWORD

INTRODUCTION

C

hronic diseases account for a large proportion of the global burden of disease and are the major cause of death in almost all countries. It is estimated that diabetes, cardiovascular disease, cancer and other chronic, noncommunicable diseases caused 35 million deaths in 2005. Total deaths from infectious diseases, maternal and perinatal conditions and nutritional deficiencies are projected to decline by 3% by 2015. At the same time, deaths due to chronic diseases are projected to increase by 17%. According to the recent report from the World Health Organization, Preventing Chronic Disease: a vital investment, each year at least 4.9 million people die as a result of tobacco use, 2.6 million people die as a result of being overweight or obese, 4.4 million die as a result of raised total cholesterol levels and 7.1 million die as a result of raised blood pressure. The same report stresses that common and modifiable risk factors that underlie the major chronic diseases are widespread, and that the global response to address them is inadequate. The inadequate response is in large part due to misconceptions regarding the major chronic diseases and their shared risk factors. Chronic diseases do not affect only rich people. In all but the least-developed countries, poor people are more likely to develop chronic diseases and more likely to die from them. Chronic diseases are increasingly affecting younger people. Childhood obesity is a growing problem even in poor countries and the incidence of type 2 diabetes in children and adolescents is increasing. Although we have been extremely vigilant towards the spread of infectious diseases, such as SARS and avian influenza in recent years, we have failed to keep in check the ‘silent killers’ like diabetes, cardiovascular disease and cancer. These are widely perceived to be the result of voluntary choice of an unhealthy lifestyle. However, the choice of lifestyle is very limited among the young and the poor, and government action is needed to improve every person’s access to a healthy life. INTRODUCTION

The world has also been slow to recognize that there are interventions that have been proven cost-effective in chronic disease prevention and control. Many of these interventions are feasible and inexpensive, even in the poorest countries. The World Health Organization is developing a framework for assisting diverse countries in developing, implementing and evaluating national policies and programmes for the prevention and control of chronic diseases. It supports an integrated, comprehensive, stepwise and multisectoral approach focused on the common risk factors. An integrated approach to public health prevention and control of chronic disease is necessary to achieve the global goal of reducing death rates by 2% per year over the next 10 years; achievement of this goal will prevent 36 million premature deaths by 2015. Diabetes presents major challenges to patients, health systems and national economies. The World Health Organization together with the International Diabetes Federation is working to raise awareness of diabetes worldwide along with improving the quality of care. This latest edition of the Diabetes Atlas is a welcome update of the trends in the global burden of diabetes and its related economic implications. It also spotlights recentlydocumented dimensions of the disease — such as the increase in diabetes in children and the often underestimated mortality attributable to diabetes. I am confident that the Diabetes Atlas will continue to be a valuable resource for advocates, policy-makers, researchers and healthcare providers.

Robert Beaglehole Director Department of Chronic Diseases and Health Promotion Noncommunicable Diseases and Mental Health Cluster World Health Organization Geneva

EXECUTIVE SUMMARY Global projections for the number of people with diabetes (20-79 age group), 2007-2025 (millions)

53.2 64.1 +21%

28.3 40.5 +43%

67.0 99.4 +48% 24.5 44.5 +81%

10.4 18.7 +80%

16.2 32.7 +102%

Africa Eastern Mediterranean and Middle East Europe North America South and Central America South-East Asia Western Pacific

T

he third edition of the Diabetes Atlas confirms beyond all doubt that the diabetes epidemic is real and that its magnitude is larger than previous projections had anticipated. It reveals that the major burden of diabetes falls on the developing world where it threatens not only to subvert the gains of economic development but also the gains brought about by international humanitarian programmes addressing the UN Millennium Development Goals. The third edition of the Diabetes Atlas has been structured on four key messages: • • • •

Diabetes is common and getting commoner Diabetes is a life-threatening condition A full and healthy life is possible with diabetes In many cases, type 2 diabetes may be prevented

The book is thus divided into three parts: the global burden, the challenges, and prevention and action. Part 1 of the Diabetes Atlas looks at the global burden of diabetes. It describes the diabetes pandemic and shows the evidence that is hard to ignore. It points out the consequences of inaction by revealing the mortality caused by diabetes as well as the mounting health expenditures in countries EXECUTIVE SUMMARY

46.5 80.3 +73%

World 2007: 2025: Increase:

246 380 +55%

around the world. There is also a closer examination of type 1 and type 2 diabetes in the young, as well as gestational diabetes mellitus. Data are provided for 215 countries and territories for the years 2007 and 2025. Estimates show that there will be some 246 million people with diabetes in 2007. This figure already outstrips an estimate made in 1994 in which it was predicted that there would be 239 million people with diabetes in the year 2010. New studies have allowed us to revise the estimate for 2025 from the second edition of the Atlas. If action is not taken to put preventive measures in place, some 380 million people are expected to have diabetes in 2025. This would be more than the current adult population of the African region. Two sets of prevalence estimates have been provided in this edition: national or regional prevalence, and comparative prevalence. The national or regional prevalence rate is ideal for assessing the burden of diabetes for each country or region, while the comparative prevalence is ideal for making comparisons between countries or regions. The data underline once again that the burden of diabetes is greatest in the developing world, where some 80% of

those with diabetes live. The world is expected to spend at least USD232 billion in 2007 to treat and prevent diabetes and its complications. However, estimates in the Diabetes Atlas show that more than 80% of expenditures for medical care for diabetes are made in the world’s economically richest countries, not in the low- and middle-income countries. In the world’s poorest countries, not enough is spent to provide even the least expensive lifesaving diabetes drugs. For the first time, country by country estimates of mortality attributable to diabetes are presented in the Diabetes Atlas. It is estimated that there will be 3.8 million deaths attributable to diabetes in 2007, similar in magnitude to those reported for HIV/AIDS in the year 2002. The number of deaths attributable to diabetes calculated here is three to four times greater than those given in the conventional international statistical reports largely based on diabetes given as an underlying cause on death certificates. Although these mortality estimates may not be accurate, given the assumptions on which the calculations are based, they do provide a more realistic estimate of diabetes-attributable mortality than currently exist.

public health strategies to improve nutrition, prevent overweight and obesity, increase physical activity and reduce smoking, as these strategies will prevent not only diabetes but many of the chronic diseases. Part three also describes IDF’s lead to put diabetes on the global agenda through its Unite for Diabetes campaign and World Diabetes Day. It reinforces the message that the epidemic of diabetes is one of the most serious challenges facing the modern world. Diabetes is largely a hidden, silent epidemic causing much hardship, but it has not as yet received serious consideration from the world community. Prevention of diabetes is essential, as millions, especially in low- and middle-income countries, develop the disease each year. To do nothing is not an option and is morally indefensible.

Part two focuses on some of the major challenges facing people with diabetes. It examines the access to insulin, medication and diabetes supplies, as well the association between mental health, antipsychotic drugs and hyperglycaemia. The issue of the metabolic syndrome is also addressed here. Access to insulin, medication and diabetes supplies remains a major challenge for millions of people with diabetes around the world. Part two provides a description of the pattern of use of diabetes therapies, both pharmacological and dietary, in as many countries as data are available. Describing the use of hypoglycaemic treatments is valuable in gaining an understanding of how therapies are actually used in practice, as against the advice given in various published guidelines. This edition of the Atlas also takes a closer look at the access to diabetes care in three sub-Saharan countries as examples of where solutions for better access could be found for people with diabetes in the poorer countries. Part three is a call for action. It provides the evidence that much of type 2 diabetes can be prevented, and underlines the need to implement cost-effective strategies to reduce or prevent diabetic complications. Governments are encouraged to take stock of the evidence and to implement

EXECUTIVE SUMMARY


WHAT IS DIABETES ?

D

iabetes is recognized as a group of heterogeneous disorders with the common elements of hyperglycaemia and glucose intolerance, due to insulin deficiency, impaired effectiveness of insulin action, or both1. Diabetes mellitus is classified on the basis of aetiology and clinical presentation of the disorder into four types:

need injections of insulin every day in order to control the levels of glucose in their blood. Without insulin, people with type 1 diabetes will die.

• • • •

• • • • • • • •

type 1 diabetes type 2 diabetes gestational diabetes mellitus (GDM) other specific types

Type 1 diabetes Type 1 diabetes is sometimes called insulin-dependent, immune-mediated or juvenile-onset diabetes. It is caused by an auto-immune reaction, where the body’s defence system attacks the insulin-producing cells. The beta cells of the pancreas therefore produce little or no insulin, the hormone that allows glucose to enter body cells. The reason why this occurs is not fully understood. The disease can affect people of any age, but usually occurs in children or young adults. People with this form of diabetes WHAT IS DIABETES ?

The onset of type 1 diabetes is often sudden and dramatic and can include symptoms such as: abnormal thirst and a dry mouth frequent urination extreme tiredness/lack of energy constant hunger sudden weight loss slow-healing wounds recurrent infections blurred vision

Studies now show that while incidence is on the increase among children, it is not increasing among young adults. This indicates a shift to a younger age at onset. The causes of the changes over time are unknown and although migration might slowly change the genetic background within a population, the rapid changes in incidence rate reported 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 destruction2. These risk factors include: Early events

Potential risk factors which may initiate the autoimmune process include early fetal events e.g. blood group incompatibility; maternal viral infections during pregnancy; and early exposure to cow’s milk components and other nutritional factors. Population-based case-control studies have identified some protective factors, including a long duration of breast feeding3, early vitamin D supplementation4, pre-school day care (as a proxy measure of infections)5 and atopic diseases6. Lifestyle

Since type 1 diabetes in childhood is associated with estimates of general wealth such as GDP, it has been suggested that lifestyle habits related to welfare might be responsible for the changes in trend. Wealth is a well-known determinant of birth weight and childhood growth. Weight and growth

Different estimates of child growth such as high birth weight, an increased height, weight, weight for height and body mass index (BMI) have repeatedly been shown to be risk factors for childhood onset diabetes7-11. Rapid growth is associated with high growth hormone levels and an increased number of fat cells both leading to insulin resistance and thereby an overloading of the beta cell. Although autoimmune mechanisms are responsible for the beta cell destruction leading to type 1 diabetes, overload factors may accelerate this process.

Type 2 diabetes Type 2 diabetes is characterized by insulin resistance and relative insulin deficiency, either of which may be present at the time that diabetes becomes clinically manifest. The specific reasons for the development of these abnormalities are not yet known. The diagnosis of type 2 diabetes usually occurs after the age of 40 years but could occur earlier, especially in populations with a high diabetes prevalence. Type 2 diabetes can remain undetected, i.e. asymptomatic, for many years and the diagnosis is often made from associated complications or incidentally through an abnormal blood or urine glucose test.

Type 2 diabetes is often, but not always, associated with obesity, which itself can cause insulin resistance and lead to elevated blood sugar levels. It is strongly familial, but major susceptibility genes have not yet been identified. There are several possible factors in the development of type 2 diabetes. These include: • • • • •

ethnicity obesity, diet and inactivity insulin resistance family history intrauterine environment

In contrast to type 1 diabetes, persons with type 2 diabetes are not dependent on exogenous insulin and are not ketosisprone, but may require insulin for control of hyperglycaemia if this is not achieved with diet alone or with oral hypoglycaemic agents. Type 2 diabetes constitutes about 85 to 95% of all diabetes in developed countries, and accounts for an even higher percentage in developing countries.

Gestational diabetes Gestational diabetes mellitus (GDM) is a carbohydrate intolerance of varying degrees of severity which starts or is first recognized during pregnancy. The definition applies regardless of whether insulin is used for treatment or if the condition persists after pregnancy. It does not exclude the possibility that unrecognized glucose intolerance may have antedated the pregnancy. Increased maternal glucose (blood sugar) levels are associated with an increased rate of complications in the baby, including large size at birth, birth trauma, hypoglycaemia (low blood sugar), and jaundice. Maintaining control of blood sugar levels significantly reduces the risk to the baby. Women who have had GDM have an increased risk of developing type 2 diabetes in later years. GDM is also associated with increased risk of obesity and abnormal glucose metabolism during childhood and adult life in the offspring.

Impaired glucose tolerance Impaired glucose tolerance (IGT) is an asymptomatic condition defined by elevated (though not diabetic) levels of blood DIABETES ATLAS THIRD EDITION

Insulin production and action

Raises Blood Sugar

High Blood Sugar Promotes insulin release

Glucagon Liver

Glycogen

Glycose

Stimulates breakdown of glycogen Stimulates formation of glycogen

Pancreas

Insulin Stimulates glucose uptake from blood Tissue Cells (muscle, brain, fat, etc)

Lowers Blood Sugar

Promotes glucagon release

Low Blood Sugar

Insulin is a hormone produced by the pancreas that is necessary for cells to be able to use blood sugar. In response to high levels of glucose in the blood, the insulinproducing cells in the pancreas secrete the hormone insulin. Type I diabetes occurs when these cells are destroyed by the body’s own immune system. People with type 2 diabetes produce insulin but cannot use it effectively.

glucose two hours after a 75g oral glucose challenge. Along with impaired fasting glucose (IFG), it is now recognized as being a stage in the transition from normality to diabetes.

survival. Insulin may also be used by people with type 2 diabetes. In type 2 diabetes, the body needs more insulin than it can produce.

Thus, individuals with IGT are at high risk of progressing to type 2 diabetes, although such progression is not inevitable, and probably over 30% of individuals with IGT will return to normal glucose tolerance over a period of several years. Not surprisingly, IGT shares many characteristics with type 2 diabetes, being associated with obesity, advancing age, insulin resistance and an insulin secretory defect.

Since the landmark discovery of insulin by Frederick Banting and Charles Best in 1921, huge steps forward have been made in research and development in creating genetically engineered human insulin. Until recently insulin was derived from a limited resource of the pancreas of cattle and pigs.

Insulin Insulin is the internal secretion of the pancreas formed by groups of beta cells in the islets of Langerhans in this organ. It is the hormone needed to enable glucose to enter the cells and provide energy. Insulin is also important in keeping blood glucose levels within the acceptable limits. Insulin is injected into the body by people with type 1 diabetes in whom the cells that produce insulin have been destroyed. This is the most common form of diabetes in children and young adults, and they depend on insulin for WHAT IS DIABETES ?

PART 1 THE GLOBAL BURDEN It is now recognized that it is the developing countries that presently face the greatest burden of diabetes. However, many governments and public health planners still remain largely unaware of the current magnitude, or, more importantly, the future potential for increases in diabetes and its serious complications in their own countries.

D

iabetes is now one of the most common noncommunicable 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. The number of studies describing the epidemiology of diabetes over the last 20 years has been extraordinary. It is now recognized that it is the developing countries that presently face the greatest burden of diabetes. However, many governments and public health planners still remain largely unaware of the current magnitude, or, more importantly, the future potential for increases in diabetes and its serious complications in their own countries. In addition to diabetes, the condition of impaired glucose tolerance (IGT ) also constitutes a major public health 10

PART 1

problem, both because of its association with diabetes incidence and its own association with an increased risk of the development of cardiovascular disease. Part 1 of the Diabetes Atlas looks at the global burden of diabetes. It describes the diabetes pandemic and shows the evidence that is hard to ignore. It points out the consequences of inaction by revealing the mortality caused by diabetes as well as the mounting health expenditures in countries around the world. Chapter 1 presents estimates of the prevalence of diabetes mellitus and IGT for 215 countries and territories for the years 2007 and 2025, which should provide some concept of the current and likely future burden. This chapter also provides a review of studies which allow an estimate of the proportion of cases of diabetes that are undiagnosed. Data are also provided on the prevalence of many of the complications of diabetes, which illustrate the seriousness of the disease. Chapter 2 looks at the global trends in childhood type 1 diabetes and provides estimates for type 1 diabetes in children and adolescents. This chapter also reviews the available epidemiological data on type 2 diabetes in the DIABETES ATLAS THIRD EDITION

young from around the world. By focusing on such data it is hoped that deficiencies in our knowledge of the disease will be highlighted, and that strategies to deal with it will be developed. Chapter 3 highlights the rising trend of gestational diabetes and the increased risk of developing type 2 diabetes in later years in both the mother and the offspring. Chapter 4 provides estimates of mortality attributable to diabetes for 193 countries for the year 2007, which underlines the need for preventive measures for diabetes and its complications worldwide. Chapter 5 examines the economic impact of diabetes and estimates national health expenditures to treat and prevent diabetes and its complications in 193 countries and territories for the years 2007 and 2025. The results show that more than 80% of expenditures for medical care for diabetes are made in the world’s economically richest countries, not in the lowand middle-income countries where 80% of persons with diabetes will soon live. In the world’s poorest countries, not enough is spent to provide even the least expensive lifesaving diabetes drugs. THE GLOBAL BURDEN

PART 1

11

CHAPTER 1 DIABETES AND IMPAIRED GLUCOSE TOLERANCE

The number of people with diabetes in Tanzania is expected to increase by 50% within the next 20 years. 14

CHAPTER 1


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

D

iabetes is recognised as a group of heterogeneous disorders with the common elements of hyperglycaemia and glucose intolerance, due to insulin deficiency, impaired effectiveness of insulin action, or both. Diabetes mellitus is classified on the basis of aetiology and clinical presentation of the disorder into four types: type 1 diabetes, type 2 diabetes, gestational diabetes, and other specific types. Impaired glucose tolerance (IGT ) is an asymptomatic condition defined by elevated (though not diabetic) levels of blood glucose two hours after a 75g oral glucose challenge. Along with impaired fasting glucose, it is now recognized as being a stage in the transition from normality to diabetes. Thus, individuals with IGT are at high risk of progressing to type 2 diabetes, although such progression is not inevitable, and probably over 30% of individuals with IGT will return to normal glucose tolerance over a period of several years.

should be used when interpreting data and their limitations will be discussed further throughout the text. Comparison 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 to always be considered, and the reader must realize that the key purpose of reports such as these is to stimulate action in the form of preventive and management programmes, as well as further research.

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

CHAPTER 1

15

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

Introduction

D

iabetes mellitus and lesser forms of glucose intolerance, particularly impaired glucose tolerance (IGT), can now be found in almost every population in the world and epidemiological evidence suggests that, without effective prevention and control programmes, diabetes will likely continue to increase globally1.

Figure 1.1 highlights the large range of type 2 diabetes prevalences even within the same or similar ethnic groups, when living under different conditions. Clearly, many of the differences between these rates reflect underlying behavioural, environmental and social risk factors, such as diet, level of obesity and physical activity.

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. Type 1 diabetes is increasing in incidence in both developing and developed countries, and there is an indication of a shift towards type 1 diabetes developing in children at earlier ages (see Chapter 2).

Within ethnic groups, high rates of type 2 diabetes are usually found in migrant or urbanized populations that may have experienced a greater degree of lifestyle change. The lowest rates are generally found in rural communities where people have lifestyles incorporating high levels of physical activity.

Type 2 diabetes constitutes about 85 to 95% of all diabetes in developed countries1, and accounts for an even higher percentage in developing countries. Type 2 diabetes is now a common and serious global health problem, which, for most countries, has evolved in association with rapid cultural and social changes, ageing populations, increasing urbanization, dietary changes, reduced physical activity 16

and other unhealthy lifestyle and behavioural patterns 1.

CHAPTER 1

The incidence and prevalence of type 2 diabetes is also reported to be increasing in children. Studies from America and Japan have demonstrated an increasing incidence2,3, while other ethnic groups with high adult diabetes prevalence such as the Pima Indians4 are also reporting increasing adolescent prevalences (see Chapter 2). The importance of this problem and the need for further research are emphasized by the authors of this chapter. DIABETES ATLAS THIRD EDITION

Figure 1.1 Differences in the prevalence of type 2 diabetes among selected ethnic groups, 2007

Rural Bangladesh

Asian Indian

Arab

Singapore Indian Rural Tunisia United Arab Emirates

Hispanic

Chinese

African

Oceania

Rural Colombia Urban Mexican China Singapore Chinese Rural Tanzania African Jamaican Rural Fiji Nauru Prevalence (%)

0

5

10

2007 2025

In addition to estimating the prevalence of diabetes for the years 2007 and 2025, data on case numbers and national prevalence of impaired glucose tolerance (IGT) are presented for both years. The decision to include data on IGT was based on two major factors associated with its presence: it greatly increases the risk of developing diabetes5, and it is associated with the development of cardiovascular disease6,7.

Classification criteria and reporting standards Standardization of methods and reporting in diabetes epidemiology promotes comparison between studies and may permit the pooling of results from different studies8,9. Standardized criteria for detecting and reporting glucose intolerance have evolved greatly since the 1960s10. In the late 1970s both the US National Diabetes Data Group (NDDG) and the World Health Organization (WHO) produced new criteria on which to diagnose diabetes mellitus. In 1985, WHO modified their criteria to be more consistent with NDDG values. More recently, the American Diabetes Association (ADA) 11 and WHO 12 have produced new recommendations for the diagnosis of diabetes. The major PREVALENCE AND PROJECTIONS

15

20

25

30

35

40

45

Prevalence rates are age standardized to Segi’s World Population for ages 30-64 year

change recommended is the lowering of the diagnostic value of the fasting plasma glucose concentration to 7.0 mmol/l. For glucose tested in whole blood, the new recommended threshold is 6.1 mmol/l12. In many population studies, individuals have been categorized as having diabetes mellitus based on blood glucose values measured after an overnight fast and/or two hours after a 75g oral glucose load. Whilst WHO still recommends the oral glucose tolerance test (OGTT) as being the single best choice, they also state that “if it is not possible to perform the OGTT (e.g. for logistical or economic reasons), the fasting plasma glucose alone may be used for epidemiological purposes” 12. It is important to realize that different screening and diagnostic criteria may have been used for different studies in this report. The impact that the recent diagnostic cut-off level changes have on prevalence estimates seems to vary from country to country13. In this section, the criteria used will be reported when they are known.

Global estimates of diabetes The global burden of diabetes has been estimated several CHAPTER 1

17

Estimates for 2025

Why two prevalence estimates?

The estimates for 2025 of this edition are slightly different to those published most recently in 2003. There are two main reasons for this. Most importantly 30 new studies, applied to 70 countries, have been used. New studies were only used when it was felt that they improved the assessment of prevalence.

Prevalences have been calculated for each country and region in two ways:

Secondly, the 2004 edition of the United Nations Population Prospects, rather than the 2000 edition for the population of each country, was used. This has only very marginally changed the estimate of world adult population for 2025, but for individual countries the changes are occasionally important. For example, the population estimate (age 20–79 years) for Bangladesh has been reduced by nine million, while that for Ethiopia has increased by seven million.

National or regional prevalence The national or regional prevalence indicates the percentage of each country’s or region’s population that has diabetes. It is ideal for assessing the burden of diabetes for each country or region. However, because the prevalence of diabetes increases with age, it cannot be used for comparing prevalences between countries or regions which have different age structures. For example, the national prevalence of diabetes is higher in Japan (7.2%) than in Samoa (6.5%), but we cannot tell if this is just because Japan has an older population or because Japanese are more prone to develop diabetes than are Samoans.

times14-17. In 1994, the International Diabetes Federation (IDF) Directory14 included type 1 and type 2 diabetes estimates supplied by member nations. Using these data IDF estimated that over 100 million people worldwide had diabetes. Also in 1994, McCarty et al15 used data from population-based epidemiological studies and estimated that the global burden of diabetes was 110 million in 1994 and that it would likely more than double to 239 million by 2010.

obtaining age-specific prevalences for those countries with adequate data are given.

WHO16 also produced a report using epidemiological information and estimated the global burden at 135 million in 1995, with the number reaching 299 million by the year 2025. In 1997, Amos et al17 estimated the global burden of diabetes to be 124 million people, and projected that this would increase to 221 million people by the year 2010. Despite using different methodologies, and at times showing large differences in country-specific estimates, these reports have arrived at remarkably similar global figures of diabetes.

2. Employing the methodology indicated in Appendix 1.1 to create smoothed curves for prevalence (with respect to age).

Methodology The principal details of the methodology are provided in Appendix 1.1, where details of the rationale and process of 18

1. National or regional prevalence 2. Comparative prevalence

CHAPTER 1

The principal aspects of the determination of prevalence were: 1. Identification of studies through a detailed literature search, and contact with IDF member organizations.

3. Applying the prevalence rates to the population distribution of that country, and where no data for those countries were available, to those other countries of similar ethnicity and economic circumstances, for which no local data were available. 4. Assuming an urban/rural prevalence ratio of 2:1 for diabetes (but not IGT ), except in those countries classified by WHO16 as market economies, or former socialist economies. The urban proportion of the population was derived from UN estimates18. DIABETES ATLAS THIRD EDITION

At a glance

Comparative prevalence The comparative prevalence has been calculated by assuming that every country and region has the same age profile (the age profile of the world population has been used). This removes the differences of age between countries and regions, and makes this figure ideal for making comparisons, for example, the comparative prevalence shows that Samoans (7.5%) are in fact more prone to have diabetes than are Japanese (4.9%). The comparative prevalence should not be used for assessing the proportion of people within a country or region who have diabetes.

5. The data for diabetes rates include both type 1 and type 2 diabetes, with a separate chapter providing estimates on type 1 diabetes in children and adolescents (see Chapter 2). 6. The prevalence of diabetes throughout the Diabetes Atlas includes both undiagnosed and previously diagnosed diabetes. This section contains prevalence estimates of diabetes and IGT for the years 2007 and 2025, and although the Tables contain data listed to one decimal point, it should not be inferred that this indicates the degree of precision, but rather to facilitate calculations and the appearance of the Tables. In general, no predictions of diabetes or IGT numbers should be taken as having reliability of more than one significant figure. The consequence of applying current age and gender specific prevalence rates to estimate prevalences and number of cases for the year 2025 is that only changes in the age and urban/rural distribution of the population will affect the estimates. Since it is likely that the age specific prevalence rates (the prevalence at any given age) will rise due to increasing obesity, the figures are probably underestimates. PREVALENCE AND PROJECTIONS

Total world population (billions) Adult population (age 20-79, billions)

2007 2025 6.6 4.1

7.9 5.2

WORLD DIABETES AND IGT (20-79 age group) Diabetes Comparative prevalence (%) 6.0 Number of people with diabetes (millions) 246

7.3 380

IGT Comparative prevalence (%) Number of people with IGT (millions)

8.0 418

7.5 308

Results The main aim of this section is to estimate the prevalence of diabetes mellitus and IGT for each country for the years 2007 and 2025. Data are provided for 215 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 the Western Pacific (WP). The prevalence of diabetes and IGT has been calculated in two ways: 1. National prevalence: the age and sex structure of each specific country has been used to provide an accurate estimate of the percentage of adults affected within each country. 2. Comparative prevalence: the age and sex structure of the world population has been used to provide a prevalence estimate for each country that can readily be compared to other countries. CHAPTER 1

19

MAP 1.1 Prevalence estimates of diabetes, 2007

>20% 14% 10% 8% 6% 4% 20% 14% 10% 8% 6% 4% 20% 14% 10% 8% 6% 4% 20% 14% 10% 8% 6% 4% 10% SR or HBA1c > 10% SR or HBA1c > 10% SR or HBA1c > 10% SR or HBA1c > 10% OGTT SR or HBA1c > 10% SR or HBA1c > 10% Registry SR or HBA1c > 10% OGTT OGTT SR or FPG > 8.0 OGTT OGTT OGTT SR or FPG > 8.0 OGTT/FBG OGTT OGTT SR or HBA1c > 10% OGTT FBG OGTT

Diagnostic criteria Sample size Age (yrs) Known diabetes Known diabetes Known diabetes Known diabetes Known diabetes WHO - 1980 Known diabetes Known diabetes Known diabetes Known diabetes WHO - 1980 WHO - 1980 WHO - 1980 WHO - 1980 WHO - 1980 WHO - 1980 WHO - 1980 ADA - 1997 WHO - 1980 WHO - 1980 Known diabetes WHO - 1980 ADA - 1997 WHO - 1980

4,104 4,104 4,104 4,104 4,104 1,303 4,104 4,104 N/A 4,104 1,303 1,303 1,036 1,303 1,303 1,303 1,036 84,054 1,303 1,303 4,104 1,303 4,761 1,303

40-79 40-79 40-79 40-79 40-79 25-74 40-79 40-79 20+ 40-79 25-74 25-74 18+ 25-74 25-74 25-74 18+ 20+ 25-74 25-74 40-79 25-74 20+ 25-74

PREVALENCE AND PROJECTIONS

CHAPTER 1

79

Table 1.27

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

DM prevalence (%) Country/territory Population (20-79) (000’s) National Comparative* R

Argentina 24,952 6.0 5.6 Bolivia 4,910 5.1 5.8 Brazil 119,519 5.8 6.2 Chile 10,883 5.9 5.6 Colombia 27,860 4.6 5.0 Costa Rica 2,746 8.5 9.3 Cuba 8,117 10.4 9.3 Dominican Republic 5,219 7.3 8.7 Ecuador 7,792 5.2 5.7 El Salvador 3,980 7.7 9.0 French Guiana 111 11.5 11.8 Guatemala 6,034 7.2 8.6 Honduras 3,764 7.1 9.1 Netherlands Antilles 126 13.7 11.3 Nicaragua 2,870 7.6 10.1 Panama 2,002 9.0 9.7 Paraguay 3,344 4.0 4.8 Peru 16,642 5.4 6.0 Puerto Rico 2,704 12.8 10.7 Suriname 274 9.7 10.2 Uruguay 2,280 6.4 5.6 Venezuela 16,297 4.9 5.4 SACA Total 272,427 6.0 6.3

* All comparisons between countries should be done using the comparative prevalence, which is adjusted to the world population

80

CHAPTER 1


Number of people with DM (000’s) in the 20-79 age group Rural Urban Male Female

20-39

40-59

60-79 Total

143.1 1,344.7 695.9 791.9 121.7 736.1 629.9 1,487.8 46.4 201.7 113.9 134.2 36.3 126.3 85.6 248.1 620.4 6,292.9 3,101.0 3,812.3 919.5 3,245.7 2,748.1 6,913.3 73.9 571.6 310.4 335.1 80.4 349.1 216.0 645.5 166.6 1,111.2 571.5 706.3 122.7 729.7 425.3 1,277.8 68.6 165.2 98.4 135.3 37.5 114.0 82.3 233.8 95.2 749.5 309.9 534.8 100.8 447.3 296.6 844.7 72.8 310.7 147.4 236.1 66.3 219.5 97.7 383.5 84.3 320.6 191.1 213.7 55.1 209.1 140.6 404.8 106.4 201.3 119.5 188.3 59.6 130.2 117.9 307.7 1.4 11.3 5.6 7.2 2.5 7.6 2.7 12.8 176.1 259.7 171.3 264.5 82.6 183.6 169.6 435.8 89.1 178.6 110.7 157.1 56.2 119.1 92.5 267.8 2.8 14.4 6.3 10.9 2.0 10.0 5.2 17.2 42.8 174.0 87.6 129.2 48.5 99.3 69.0 216.8 45.1 135.4 75.8 104.7 29.8 82.3 68.4 180.4 33.9 98.8 59.5 73.2 24.1 69.1 39.5 132.7 130.2 763.8 425.0 469.0 126.8 464.0 303.2 894.0 45.0 300.3 129.2 216.1 35.3 140.6 169.4 345.3 7.7 19.0 10.6 16.0 5.3 14.3 7.1 26.7 11.5 134.9 67.5 78.9 10.7 69.0 66.7 146.4 48.1 746.9 371.6 423.3 74.2 440.6 280.1 795.0 2,111 14,106 7,180 9,038 2,098 8,007 6,113 16,218


CHAPTER 1

81

Table 1.28

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

DM prevalence (%) N Country/territory Population (20-79) (000’s) National Comparative* R



82

CHAPTER 1



20-39

40-59

60-79 Total

143.3 1,852.4 944.0 1,051.8 149.2 975.6 871.0 1,995.7 55.7 375.0 199.2 231.4 56.6 217.0 157.0 430.6 1,111.2 16,516.3 9,588.6 8,038.8 2,166.8 7,837.6 7,623.0 17,627.5 82.0 863.3 457.4 487.9 93.1 434.1 418.1 945.3 215.2 2,036.1 1,014.6 1,236.7 153.0 1,117.4 980.8 2,251.3 91.9 345.7 183.6 254.0 51.7 180.3 205.5 437.6 90.0 1,006.2 393.9 702.3 78.6 537.9 479.7 1,096.2 89.5 576.2 244.8 421.0 86.9 360.9 218.0 665.8 103.0 599.1 326.6 375.5 74.7 341.5 285.9 702.1 142.8 416.7 217.2 342.3 77.6 264.6 217.2 559.4 1.8 20.9 9.3 13.3 4.0 11.1 7.6 22.6 239.2 572.2 303.1 508.3 154.3 351.7 305.4 811.4 127.7 409.1 223.1 313.7 94.3 243.0 199.5 536.8 2.5 18.3 8.2 12.6 3.9 6.1 10.8 20.8 63.2 378.5 178.7 263.0 78.1 206.9 156.6 441.7 57.8 262.3 132.3 187.9 37.5 138.4 144.3 320.1 46.3 210.6 110.2 146.7 40.4 119.9 96.6 256.9 165.1 1,378.9 724.3 819.6 169.8 778.5 595.7 1,544.0 42.1 396.3 162.6 275.8 38.4 160.1 239.9 438.4 8.1 31.3 15.7 23.7 5.7 20.1 13.6 39.4 10.8 168.2 84.8 94.2 11.6 84.3 83.0 179.0 61.5 1,326.1 648.1 739.6 101.3 680.3 606.0 1,387.6 2,951 29,759 16,170 16,540 3,728 15,067 13,915 32,710


CHAPTER 1

83

Table 1.29

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

IGT prevalence (%) N Country/territory Population (20-79) (000’s) National Comparative* M



84

CHAPTER 1


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

20-39

40-59

60-79 Total

837.3 1,627.9 528.3 1,244.7 692.2 2,465.2 141.2 214.6 110.9 130.6 114.2 355.7 3,427.4 4,932.2 2,582.8 3,527.5 2,249.3 8,359.5 380.7 714.3 230.1 606.3 258.7 1,095.0 464.2 723.1 446.5 479.6 261.1 1,187.3 81.9 106.7 59.0 81.5 48.1 188.7 432.5 584.2 221.0 423.1 372.5 1,016.7 208.6 324.7 180.3 222.5 130.5 533.3 242.2 341.4 168.5 219.6 195.5 583.6 108.8 156.8 97.2 96.9 71.5 265.6 2.9 5.4 2.9 4.0 1.4 8.3 162.3 234.2 146.8 142.0 107.8 396.5 103.1 134.5 93.7 88.2 55.6 237.6 3.2 7.6 2.4 5.6 2.8 10.8 75.3 101.4 73.4 66.0 37.2 176.7 60.3 79.3 44.1 56.8 38.7 139.6 103.2 182.9 81.8 154.9 49.5 286.1 503.9 717.2 365.1 462.6 393.4 1,221.1 86.1 134.1 47.6 86.4 86.1 220.1 6.8 13.6 7.3 8.9 4.3 20.5 78.9 157.1 45.7 117.1 73.3 236.0 315.8 465.0 296.4 303.8 180.6 780.8 7,827 11,958 5,832 8,529 5,424 19,785


CHAPTER 1

85

Table 1.30

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

IGT prevalence (%) N Country/territory Population (20-79) (000’s) National Comparative* M



86

CHAPTER 1



20-39

40-59

60-79 Total

1,112.5 1,979.3 633.1 1,627.8 830.9 3,091.8 234.9 319.8 161.8 207.9 184.9 554.6 4,934.4 6,525.3 2,798.6 4,727.0 3,934.0 11,459.6 517.2 923.3 267.5 718.8 454.1 1,440.4 680.3 1,019.2 536.2 659.3 503.9 1,699.5 130.7 173.0 74.0 120.5 109.2 303.6 568.1 659.4 181.0 487.7 558.8 1,227.5 339.7 474.0 219.3 338.7 255.7 813.7 400.7 500.8 210.8 331.8 358.8 901.4 170.8 224.8 117.3 174.0 104.4 395.6 4.9 9.1 4.7 5.6 3.8 14.0 269.7 341.8 237.7 217.6 156.2 611.5 180.1 234.4 143.0 166.9 104.5 414.5 4.2 7.3 3.0 4.1 4.4 11.4 133.6 174.5 106.8 127.6 73.7 308.1 92.8 122.4 53.4 88.4 73.4 215.2 177.3 313.0 130.0 250.4 110.0 490.3 836.8 1,070.8 460.1 740.1 707.5 1,907.7 102.6 134.6 49.4 90.7 97.1 237.3 8.7 16.7 7.4 11.2 6.8 25.4 96.7 172.4 50.0 140.1 79.0 269.1 471.6 708.1 374.0 446.9 358.8 1,179.7 11,468 16,104 6,819 11,683 9,070 27,572


CHAPTER 1

87

Table 1.31 Data sources: prevalence estimates of diabetes mellitus (DM) and impaired glucose tolerance (IGT)

Country/territory

Data used S

Argentinaa,b Bolivia Brazil Chile Colombia Costa Ricac Cuba Dominican Republic Ecuador El Salvadorc French Guiana Guatemalac Hondurasc Netherlands Antillesb Nicaraguac Panamac Paraguay Peru Puerto Rico Suriname Uruguay Venezuela

Argentina (de Sereday et al, 2004)80 Bolivia (Barceló et al, 2001)141 Brazil (Oliveira et al, 1996; Malerbi et al, 1992 and Torquato et al, 2003)81,139,140 Chile (Baechler et al, 2002)82 Colombia (Aschner et al, 1993)142 Mexico (Aguilar-Salinas et al, 2003 and Sanchez-Castillo et al, 2005)78,79 Jamaica (Wilks et al, 1999)76 Jamaica (Wilks et al, 1999)76 Bolivia (Barceló et al, 2001)141 Mexico (Aguilar-Salinas et al, 2003 and Sanchez-Castillo et al, 2005)78,79 Suriname (Schaad et al, 1985)143 Mexico (Aguilar-Salinas et al, 2003 and Sanchez-Castillo et al, 2005)78,79 Mexico (Aguilar-Salinas et al, 2003 and Sanchez-Castillo et al, 2005)78,79 Suriname (Schaad et al, 1985)143 Mexico (Aguilar-Salinas et al, 2003 and Sanchez-Castillo et al, 2005)78,79 Mexico (Aguilar-Salinas et al, 2003 and Sanchez-Castillo et al, 2005)78,79 Paraguay (Jimenez et al, 1998)144 Bolivia (Barceló et al, 2001)141 Jamaica (Wilks et al, 1999)76 Suriname (Schaad et al, 1985)143 Argentina (de Sereday et al, 2004)80 Brazil (Oliveira et al, 1996; Malerbi et al, 1992 and Torquato et al, 2003)81,139,140

a. Persons with previously diagnosed diabetes were excluded from the study, and obtained prevalence doubled b. Because of the absence of data for IGT in the Argentinian and Barbados studies, the following countries had IGT prevalence determined from the study indicated below: Argentina: Paraguay (Jimenez et al, 1998)144 Netherland Antilles: Jamaica (Wilks et al, 1999)76 c. Diabetes prevalence was derived by combining the data of the two studies indicated; IGT prevalence was calculated from Brazilian data

88

CHAPTER 1


- South and Central American Region

d Screening method OGTT 2hBG OGTT OGTT 2hBG OGTT/FBG OGTT OGTT 2hBG OGTT/FBG OGTT OGTT/FBG OGTT/FBG OGTT OGTT/FBG OGTT/FBG OGTT 2hBG OGTT OGTT OGTT OGTT

Diagnostic criteria Sample size Age (yrs) WHO - 1999 WHO - 1985 WHO - 1985 WHO - 1999 WHO - 1985 ADA - 1997 WHO - 1980 WHO - 1980 WHO - 1985 ADA - 1997 WHO - 1980 ADA - 1997 ADA - 1997 WHO - 1980 ADA - 1997 ADA - 1997 WHO - 1985 WHO - 1985 WHO - 1980 WHO - 1980 WHO - 1999 WHO - 1985

2,397 2,948 25,371 1,315 670 84,054 1,303 1,303 2,948 84,054 1,218 84,054 84,054 1,218 84,054 84,054 1,606 2,948 1,303 1,218 2,397 25,371

20-69 25+ 30-69 20+ 30-79 20+ 25-74 25-74 25+ 20+ 30+ 20+ 20+ 30+ 20+ 20+ 20-74 25+ 25-74 30+ 20-69 30-69


CHAPTER 1

89

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


Bangladesh 80,196 4.8 5.3 Bhutan 1,145 4.7 5.4 India 659,570 6.2 6.7 Maldives 167 6.2 7.1 Mauritius 847 11.3 11.1 Nepal 14,288 3.5 4.2 Sri Lanka 14,136 8.4 8.4 SEA Total 770,350 6.0 6.5 * All comparisons between countries should be done using the comparative prevalence, which is adjusted to the world population

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


Bangladesh 120,909 6.1 6.6 Bhutan 1,858 3.6 4.5 India 918,761 7.6 8.2 Maldives 294 9.8 11.2 Mauritius 1,019 14.6 13.4 Nepal 22,915 4.4 5.8 Sri Lanka 16,746 10.7 10.2 SEA Total 1,082,501 7.4 8.0 * All comparisons between countries should be done using the comparative prevalence, which is adjusted to the world population

Table 1.34

Prevalence estimates of impaired glucose tolerance (IGT), 2007 - South-East Asian Region

IGT prevalence (%) Country/territory Population (20-79) (000’s) National Comparative* M Bangladesh Bhutan India Maldives Mauritius Nepal Sri Lanka SEA Total

80,196 8.5 1,145 3.0 659,570 5.4 167 12.2 847 16.5 14,288 3.8 14,136 12.1 770,350 5.9

8.9 3.2 5.6 12.4 16.3 4.1 12.1 6.0


90

CHAPTER 1



20-39

40-59

60-79 Total

1,935.0 1,913.1 1,844.2 2,003.9 1,487.3 1,644.6 716.2 3,848.1 45.2 9.2 29.2 25.2 12.9 22.4 19.0 54.3 20,871.3 19,979.5 22,189.6 18,661.2 8,418.0 19,645.4 12,787.5 40,850.8 3.8 6.6 5.2 5.2 4.5 4.1 1.7 10.4 38.3 57.6 46.9 49.0 15.1 53.4 27.3 95.9 313.6 183.5 186.6 310.5 77.9 233.7 185.5 497.1 645.9 540.7 519.1 667.5 325.0 519.3 342.3 1,186.6 23,853 22,690 24,821 21,722 10,341 22,123 14,079 46,543


20-39

40-59

60-79 Total

2,614.4 4,804.8 3,440.5 3,978.7 2,354.9 3,436.9 1,627.4 38.7 28.5 35.0 32.2 14.3 32.8 20.2 26,755.7 43,125.9 37,726.1 32,155.5 11,713.0 33,162.1 25,006.5 11.5 17.4 14.5 14.4 11.5 12.0 5.4 43.5 105.1 70.7 77.9 16.3 68.8 63.6 474.1 535.3 369.5 640.0 160.6 454.0 394.8 729.0 1,057.2 774.0 1,012.2 361.3 774.7 650.3 30,667 49,674 42,430 37,911 14,632 37,941 27,768

7,419.2 67.2 69,881.6 28.9 148.6 1,009.4 1,786.2 80,341


3,443.1 17.1 18,286.5 11.3 55.5 191.7 920.9 22,926


20-39

40-59

60-79 Total

3,376.2 3,455.2 2,404.9 959.1 6,819.3 17.2 14.0 9.9 10.4 34.3 17,619.6 15,852.7 12,959.3 7,094.0 35,906.1 9.0 12.2 5.1 2.9 20.3 84.2 47.5 66.2 26.0 139.7 350.6 246.2 153.2 143.0 542.3 786.6 783.8 541.2 382.6 1,707.5 22,244 20,412 16,140 8,618 45,169

CHAPTER 1

91

Table 1.35

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

IGT prevalence (%) Country/territory Population (20-79) (000’s) National Comparative* M

Bangladesh 120,909 8.8 9.2 Bhutan 1,858 3.2 3.6 India 918,761 6.1 6.3 Maldives 294 12.9 13.7 Mauritius 1,019 17.7 17.0 Nepal 22,915 4.8 5.5 Sri Lanka 16,746 13.6 13.4 SEA Total 1,082,501 6.5 6.7 * All comparisons between countries should be done using the comparative prevalence, which is adjusted to the world population


92

Country/territory

Data used S

Bangladesh Bhutan India Maldives Mauritius Nepal Sri Lanka

Bangladesh (Hussain et al, 2005)91 Bangladesh (Sayeed et al, 2003)145 India (Sadikot et al, 2004)85 India (Shah et al, 2006)86 India (Ramachandran et al, 2001)84 India (Sadikot et al, 2004)85 India (Shah et al, 2006)86 Sri Lanka (Fernando et al, 1994)146 Mauritius (Dowse et al, 1990)109 Nepal (Singh et al, 2003)90 Nepal (Karki et al, 2000)89 Sri Lanka (Wijewardene et al, 2005)92

CHAPTER 1



20-39

40-59

60-79 Total

5,287.7 5,359.6 4,611.2 4,063.6 1,972.5 29.5 29.4 23.0 19.4 16.4 28,515.3 27,712.9 21,773.2 21,158.9 13,296.1 20.8 17.2 20.9 10.8 6.3 72.9 107.2 46.9 77.2 56.0 394.7 705.6 463.9 320.8 315.7 1,206.3 1,065.8 765.8 764.1 742.2 35,527 34,998 27,705 26,415 16,405

10,647.3 58.9 56,228.2 38.0 180.1 1,100.4 2,272.1 70,525

- South-East Asian Region

d Screening method

OGTT FBG OGTT SR OGTT OGTT SR OGTT OGTT FBG OGTT FBG


Diagnostic criteria Sample size Age (yrs) WHO - 1999 ADA - 1997 WHO - 1999 Known Diabetes WHO - 1999 WHO - 1999 Known Diabetes WHO - 1985 WHO - 1985 WHO - 1999 WHO - 1985 ADA - 1997

6,312 4,923 18,363 39,429 11,216 18,363 39,429 633 5,080 1,841 1,840 6,047

20+ 20+ 25+ 15-64 20+ 25+ 15-64 30-64 25-74 20+ 30+ 30-65

CHAPTER 1

93

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

DM prevalence (%) Country/territory Population (20-79) (000’s) National Comparative* R Australia Brunei Darussalam Cambodia China China, Hong Kong China, Macau Cook Islandsa Fiji French Polynesia Guam Indonesia Japan Kiribatia Korea, Democratic People’s Republic of Korea, Republic of Lao People’s Democratic Republic Malaysia Marshall Islandsa Micronesia, Federated States ofa Mongolia Myanmar Naurua New Caledoniab New Zealandc Niuea Palaua Papua New Guinea Philippines Samoa Singapore Solomon Islands Taiwana Thailand Timor-Leste Tokelaua Tongaa Tuvalua Vanuatu Viet Nam WP Total

14,504 242 7,599 929,432 5,560 349 13 510 165 107 142,635 97,326 67 15,114 35,704 2,991 15,390 38 55 1,598 31,394 8 154 2,790 1 13 3,043 47,038 90 3,245 246 14,340 44,194 501 1 55 7 109 51,972

6.4 9.3 4.3 4.3 9.5 8.5 5.5 8.5 13.1 6.7 2.0 7.2 6.4 5.3 8.6 2.5 9.9 8.8 5.2 1.6 2.8 30.7 3.2 7.7 4.5 8.9 1.9 6.5 6.5 11.9 2.0 5.7 7.2 1.3 8.5 11.9 13.4 2.2 2.5

5.0 12.2 5.0 4.1 8.2 8.2 5.5 9.2 13.5 6.5 2.3 4.9 6.4 5.2 7.8 3.1 10.7 8.8 5.9 1.9 3.2 30.7 4.4 6.4 4.5 8.9 2.9 7.6 7.5 10.1 3.0 7.4 6.9 1.7 8.5 12.9 13.4 3.0 2.9

1,468,598

4.6

4.4

a. Population number as described in the CIA World Factbook 2005108, with growth and age distribution adjustment to that of world population from 2005 to 2007, except Taiwan (developed world population) b. For New Caledonia, the Melanesian population was ascribed as having the national urban/rural population distribution, whereas the French population was deemed as having the diabetes prevalence of Metropolitan France, and assigned to the urban component, and each assigned 50% of the total population c. New Zealand data only self-reported * All comparisons between countries should be done using the comparative prevalence, which is adjusted to the world population

94

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20-39

40-59

60-79 Total

3.3 178.7 20,705.1 0.2 20.2 5.7 2.3 1,102.8 1.4 173.1 42.8 394.1 0.4 1.2 5.2 467.9 0.0 1.0 0.0 0.1 27.6 1,053.6 4.0 2.1 2,213.8 5.6 0.1 2.1 0.3 1.1 852.3

19.3 147.4 19,104.5 0.6 23.4 15.9 4.9 1,785.0 2.8 633.5 30.7 1,136.6 3.0 1.6 20.1 404.8 2.6 3.9 0.0 1.0 31.6 2,001.5 1.9 2.9 948.6 0.9 0.0 4.4 0.7 1.4 442.3

515.8 10.0 141.6 20,531.5 238.7 14.3 0.3 20.2 9.8 3.7 1,353.7 3,599.1 2.1 446.0 1,647.8 31.3 625.8 1.7 1.4 11.3 369.9 1.3 0.8 106.3 0.0 0.6 25.1 920.6 2.7 201.6 2.1 324.5 1,436.0 3.3 0.0 2.9 0.4 1.0 557.6

410.1 12.6 184.6 19,278.2 287.3 15.6 0.4 23.3 11.8 3.5 1,534.1 3,379.3 2.1 360.6 1,426.0 42.3 904.8 1.7 1.5 14.0 502.8 1.3 4.1 109.8 0.0 0.6 34.1 2,134.4 3.1 183.2 3.0 487.8 1,726.4 3.3 0.0 3.6 0.5 1.4 737.1

40.0 3.1 65.9 6,421.0 41.6 2.6 0.2 7.0 4.2 1.4 261.4 376.9 0.9 145.2 427.3 13.3 149.7 0.6 0.7 5.3 141.4 0.5 1.0 20.0 0.0 0.2 5.7 553.2 0.6 21.6 0.5 95.8 497.7 0.6 0.0 1.3 0.2 0.2 217.5

346.4 14.1 191.7 21,531.4 236.6 15.9 0.4 26.8 12.6 4.0 1,408.3 2,497.1 2.2 388.6 1,463.0 34.1 875.8 1.8 1.6 15.1 412.5 1.5 2.2 95.7 0.0 0.6 31.6 1,627.6 3.1 184.4 2.5 355.3 1,577.1 3.5 0.0 3.4 0.5 1.2 613.7

539.5 5.4 68.6 11,857.3 247.8 11.3 0.2 9.7 4.8 1.9 1,218.1 4,104.3 1.2 272.8 1,183.4 26.1 505.1 1.0 0.5 4.9 318.8 0.6 1.7 100.3 0.0 0.3 21.9 874.2 2.2 178.8 2.0 361.3 1,087.6 2.5 0.0 1.8 0.3 1.0 463.4

925.9 22.6 326.2 39,809.6 526.0 29.9 0.7 43.6 21.6 7.2 2,887.8 6,978.4 4.2 806.6 3,073.8 73.5 1,530.6 3.4 2.8 25.3 872.7 2.6 4.9 216.1 0.1 1.1 59.2 3,055.1 5.9 384.8 5.0 812.3 3,162.4 6.6 0.1 6.5 1.0 2.4 1,294.6

27,268

26,778

33,163

33,830

9,526

33,984

23,483

66,993


CHAPTER 1

95

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


Australia 17,547 7.7 6.0 Brunei Darussalam 366 12.7 14.5 Cambodia 11,743 5.2 6.1 China 1,067,160 5.6 4.8 China, Hong Kong 6,604 13.0 9.6 China, Macau 425 12.8 9.6 Cook Islandsa 17 6.3 6.4 Fiji 626 10.2 10.5 French Polynesia 220 16.0 15.6 Guam 145 8.2 7.9 Indonesia 183,541 2.8 2.9 Japan 90,209 7.9 5.7 Kiribatia 106 7.0 6.9 Korea, Democratic People’s Republic of 17,307 6.3 5.8 Korea, Republic of 38,604 10.8 8.8 Lao People’s Democratic Republic 4,927 2.9 4.0 Malaysia 22,293 12.3 13.1 Marshall Islandsa 61 10.3 10.1 Micronesia, Federated States of a 64 8.2 7.3 Mongolia 2,252 2.2 2.2 Myanmar 41,444 3.8 4.1 Naurua 12 33.0 32.3 New Caledoniab 216 3.9 4.3 New Zealandc 3,244 8.8 7.3 Niuea 1 5.3 5.3 Palaua 18 10.3 10.1 Papua New Guinea 4,901 2.8 4.1 Philippines 70,161 7.9 9.3 Samoa 114 8.1 9.1 Singapore 4,054 17.1 11.9 Solomon Islands 415 3.0 4.4 Taiwana 17,140 6.6 8.4 Thailand 52,258 8.9 8.0 Timor-Leste 882 1.4 2.1 Tokelaua 1 9.4 9.3 Tongaa 63 14.4 15.2 Tuvalua 10 15.8 15.7 Vanuatu 172 3.2 4.3 Viet Nam 72,238 3.5 3.7 WP Total 1,731,564 5.7 5.1

a. Population number as described in the CIA World Factbook 2005108, with growth and age distribution adjustment to that of world population from 2005 to 2025 , except Taiwan (developed world population) b. For New Caledonia, the Melanesian population was ascribed as having the national urban/rural population distribution, whereas the French population was deemed as having the diabetes prevalence of Metropolitan France, and assigned to the urban component, and each assigned 50% of the total population c. New Zealand data only self-reported; total diabetes calculated as twice the self-reported prevalence * All comparisons between countries should be done using the comparative prevalence, which is adjusted to the world population

96

CHAPTER 1



20-39

40-59

60-79 Total

744.2 601.8 44.6 390.5 911.0 1,346.0 4.8 41.8 19.8 26.9 4.2 25.2 17.3 46.6 239.2 368.9 281.0 327.0 132.1 313.9 162.1 608.1 22,105.6 37,164.0 29,474.2 29,795.5 5,854.7 29,076.2 24,338.7 59,269.7 347.7 511.7 39.0 264.9 555.6 859.4 22.9 31.3 3.0 15.7 35.5 54.3 0.2 0.9 0.4 0.7 0.2 0.5 0.4 1.1 21.6 42.5 30.0 34.1 7.6 36.5 20.1 64.2 6.8 28.3 15.4 19.7 5.5 18.7 11.0 35.1 2.6 9.2 6.0 5.8 1.8 5.6 4.5 11.9 1,352.7 3,776.3 2,457.0 2,672.0 309.6 2,499.6 2,319.9 5,129.0 3,674.7 3,496.7 265.2 2,512.2 4,393.9 7,171.4 2.5 4.9 3.7 3.7 1.2 3.7 2.5 7.4 169.3 912.4 598.8 483.0 145.7 567.2 368.8 1,081.8 2,119.8 2,043.5 336.4 1,715.4 2,111.5 4,163.3 62.3 80.7 61.5 81.5 24.3 65.7 53.0 143.0 473.3 2,269.6 1,127.6 1,615.2 204.2 1,345.3 1,193.3 2,742.9 0.5 5.8 3.2 3.1 0.9 3.1 2.2 6.3 1.5 3.8 2.6 2.6 0.9 2.6 1.8 5.3 7.2 41.7 21.5 27.4 7.2 29.4 12.3 48.9 619.2 947.3 636.4 930.1 180.7 713.8 671.9 1,566.4 0.0 4.1 2.1 2.0 0.7 2.2 1.1 4.1 1.2 7.2 1.2 7.2 1.2 3.5 3.7 8.4 138.9 146.7 22.7 96.6 166.4 285.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.1 1.7 0.9 0.9 0.3 0.9 0.6 1.8 48.0 90.0 53.6 84.4 12.8 71.0 54.1 137.9 1,565.9 4,006.8 1,620.5 3,952.2 780.7 2,855.0 1,937.0 5,572.7 5.1 4.2 4.4 4.8 0.6 4.7 3.9 9.2 348.8 343.6 22.2 183.2 487.0 692.4 3.6 8.9 4.8 7.7 1.3 6.6 4.6 12.5 433.8 690.0 104.8 449.9 569.1 1,123.9 2,630.4 2,029.8 2,114.4 2,545.8 507.4 2,013.4 2,139.4 4,660.2 9.8 2.9 6.3 6.4 1.4 6.0 5.3 12.7 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.1 2.1 7.0 4.1 5.0 1.4 5.1 2.6 9.1 0.3 1.3 0.7 0.9 0.2 0.9 0.5 1.6 1.7 3.7 2.1 3.3 0.5 2.6 2.3 5.5 1,333.8 1,166.8 1,046.5 1,454.2 290.5 1,132.0 1,078.2 2,500.7 30,672 53,033 47,432 51,969 9,318 46,439 43,643 99,401


CHAPTER 1

97

Table 1.39

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

IGT prevalence (%) N Country/territory Population (20-79) (000’s) National Comparative* M Australia Brunei Darussalam Cambodia China China, Hong Kong China, Macau Cook Islandsa Fiji French Polynesia Guam Indonesia Japan Kiribatia Korea, Democratic People’s Republic of Korea, Republic of Lao People’s Democratic Republic Malaysia Marshall Islandsa Micronesia, Federated States ofa Mongolia Myanmar Naurua New Caledonia New Zealand Niuea Palaua Papua New Guinea Philippines Samoa Singapore Solomon Islands Taiwana Thailand Timor-Leste Tokelaua Tongaa Tuvalua Vanuatu Viet Nam WP Total

14,504 242 7,599 929,432 5,560 349 13 510 165 107 142,635 97,326 67 15,114 35,704 2,991 15,390 38 55 1,598 31,394 8 154 2,790 1 13 3,043 47,038 90 3,245 246 14,340 44,194 501 1 55 7 109 51,972

9.6 19.6 9.4 6.9 12.2 11.7 10.1 10.1 12.9 17.7 9.9 13.2 17.3 8.5 9.0 2.2 18.9 17.3 21.0 9.2 2.3 20.4 4.9 9.6 6.9 17.3 7.7 9.4 6.0 17.2 7.7 3.8 4.3 9.1 13.0 12.0 13.0 8.0 2.3

8.2 17.6 10.4 6.9 10.9 10.9 10.1 10.7 13.0 17.3 10.6 10.9 17.3 8.2 8.2 2.5 14.9 17.3 17.3 10.3 2.5 20.4 4.8 8.2 6.9 17.3 9.3 10.7 6.5 18.7 9.4 4.6 4.2 10.6 13.0 13.0 13.0 9.4 2.5

1,468,598

7.6

7.5

a. Population number as described in the CIA World Factbook 2005108, with growth and age distribution adjustment to that of world population from 2005 to 2007, except Taiwan (developed world population) * All comparisons between countries should be done using the comparative prevalence, which is adjusted to the world population

98

CHAPTER 1



20-39

40-59

60-79 Total

601.5 25.0 306.8 40,001.1 307.5 19.2 0.6 21.6 10.0 8.8 7,594.0 5,706.6 5.2 651.9 1,644.5 24.9 1,460.3 3.0 5.2 53.6 279.9 0.8 3.0 115.2 0.0 1.0 93.7 1,264.0 2.3 279.3 7.4 249.0 1,025.3 25.2 0.1 2.9 0.4 3.4 459.4

785.2 22.4 407.3 24,322.5 368.9 21.7 0.7 29.9 11.3 10.2 6,550.5 7,185.0 6.3 631.7 1,579.2 39.8 1,454.6 3.6 6.3 92.7 444.9 0.9 4.5 152.2 0.0 1.2 142.0 3,146.3 3.1 279.0 11.4 302.7 870.3 20.6 0.1 3.7 0.5 5.3 715.8

215.0 22.2 304.5 24,566.4 133.4 8.4 0.3 18.2 5.6 5.9 4,583.1 2,276.2 3.8 266.0 556.1 21.9 1,120.8 2.2 3.8 66.3 223.0 0.7 1.7 40.4 0.0 0.7 90.7 1,135.7 1.5 121.8 7.7 135.5 552.8 16.1 0.0 1.8 0.2 3.3 370.1

595.3 21.4 268.5 25,358.4 350.5 23.6 0.6 23.1 12.1 9.4 5,490.3 4,837.4 5.3 577.0 1,554.1 30.4 1,425.6 3.0 5.3 52.9 352.6 0.7 3.7 116.4 0.0 1.0 104.9 2,134.6 2.6 329.3 7.6 228.0 977.2 18.5 0.1 3.4 0.5 3.6 578.6

576.4 3.7 141.1 14,398.8 192.5 9.0 0.5 10.1 3.6 3.7 4,071.1 5,777.9 2.4 440.6 1,113.5 12.5 368.5 1.4 2.4 27.2 149.1 0.4 2.0 110.6 0.0 0.5 40.0 1,140.0 1.3 107.3 3.5 188.2 365.6 11.2 0.0 1.4 0.2 1.8 226.5

1,386.7 47.4 714.1 64,323.6 676.4 41.0 1.3 51.4 21.3 19.0 14,144.4 12,891.6 11.5 1,283.6 3,223.7 64.7 2,914.9 6.6 11.5 146.3 724.7 1.7 7.5 267.4 0.1 2.2 235.6 4,410.3 5.4 558.3 18.8 551.7 1,895.6 45.8 0.1 6.6 0.9 8.8 1,175.1

62,263

49,634

36,884

45,507

29,507

111,898


CHAPTER 1

99

Table 1.40

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

IGT prevalence (%) N Country/territory Population (20-79) (000’s) National Comparative* M Australia Brunei Darussalam Cambodia China China, Hong Kong China, Macau Cook Islandsa Fiji French Polynesia Guam Indonesia Japan Kiribatia Korea, Democratic People’s Republic of Korea, Republic of Lao People’s Democratic Republic Malaysia Marshall Islandsa Micronesia, Federated States ofa Mongolia Myanmar Naurua New Caledonia New Zealand Niuea Palaua Papua New Guinea Philippines Samoa Singapore Solomon Islands Taiwana Thailand Timor-Leste Tokelaua Tongaa Tuvalua Vanuatu Viet Nam WP Total

17,547 366 11,743 1,067,160 6,604 425 17 626 220 145 183,541 90,209 106 17,307 38,604 4,927 22,293 61 64 2,252 41,444 12 216 3,244 1 18 4,901 70,161 114 4,054 415 17,140 52,258 882 1 63 10 172 72,238

10.6 20.5 10.4 7.4 14.1 14.0 11.2 11.2 14.1 18.1 11.2 14.1 18.1 9.4 11.0 2.3 19.9 18.1 29.9 10.2 2.6 21.2 5.3 10.6 7.4 18.1 8.6 10.8 6.4 17.6 8.7 4.2 4.6 9.5 13.8 13.3 13.8 9.0 2.6

9.1 18.7 11.6 6.9 11.9 11.9 11.2 11.6 13.8 18.1 11.6 11.7 18.1 9.1 9.1 2.7 16.3 18.1 18.1 11.0 2.7 21.2 5.2 9.1 7.4 18.1 10.4 12.1 7.1 19.7 10.5 5.1 4.4 11.6 13.8 13.8 13.8 10.5 2.7

1,731,564

8.2

7.8

a. Population number as described in the CIA World Factbook 2005108, with growth and age distribution adjustment to that of world population from 2005 to 2025, except Taiwan (developed world population) * All comparisons between countries should be done using the comparative prevalence, which is adjusted to the world population

100

CHAPTER 1



20-39

40-59

60-79 Total

825.5 38.0 533.3 45,482.7 406.9 26.5 0.9 28.8 14.5 12.3 11,572.2 5,691.4 8.9 821.1 2,177.5 43.8 2,237.5 5.1 8.9 94.2 409.4 1.3 5.3 150.7 0.1 1.5 161.3 2,168.7 3.3 370.9 13.9 332.0 1,291.8 45.9 0.1 4.0 0.7 5.8 736.9

1,042.8 37.1 688.3 33,576.0 526.3 32.9 1.1 41.2 16.6 14.0 9,024.9 7,013.1 10.4 803.2 2,062.3 67.8 2,204.0 6.0 10.4 136.2 677.0 1.4 6.2 193.7 0.1 1.7 260.6 5,413.7 4.0 344.2 22.3 395.8 1,107.0 38.0 0.1 4.4 0.8 9.7 1,165.5

234.9 28.4 493.3 19,175.3 119.0 8.9 0.4 19.9 6.7 7.3 4,787.6 1,628.4 5.5 256.8 436.3 35.6 1,486.7 3.2 5.5 75.2 253.6 0.9 2.1 44.5 0.0 0.9 146.0 1,560.4 1.7 130.1 12.6 145.9 545.4 30.1 0.0 1.9 0.3 5.2 444.2

663.2 35.0 430.3 31,709.5 377.6 22.3 0.8 30.3 16.6 11.2 8,643.7 4,885.1 8.6 797.5 1,798.7 52.8 2,097.0 5.0 8.6 95.8 548.8 1.0 5.5 116.2 0.0 1.4 186.0 3,611.8 3.3 300.3 16.3 284.5 1,164.9 30.8 0.1 4.7 0.8 6.5 953.4

970.1 11.7 297.9 28,173.8 436.6 28.2 0.8 19.8 7.8 7.7 7,165.8 6,191.0 5.1 570.1 2,004.8 23.2 857.8 2.9 5.1 59.3 284.1 0.7 4.0 183.7 0.0 0.9 89.8 2,410.1 2.4 284.7 7.3 297.4 688.5 23.0 0.0 1.9 0.4 3.8 504.8

1,868.2 75.1 1,221.5 79,058.6 933.1 59.4 1.9 70.0 31.1 26.3 20,597.1 12,704.5 19.3 1,624.3 4,239.8 111.6 4,441.5 11.1 19.3 230.4 1,086.4 2.6 11.5 344.3 0.1 3.2 421.8 7,582.3 7.3 715.1 36.2 727.8 2,398.8 83.9 0.1 8.4 1.4 15.4 1,902.4

75,733

66,960

32,141

58,926

51,627

142,693


CHAPTER 1

101


Country/territory

Data used S

Australia Brunei Darussalam Cambodiaa China China, Hong Kongb China, Macau Cook Islands Fiji French Polynesia Guam Indonesia Japanb Kiribati Korea, Democratic People’s Republic of Korea, Republic of c Lao People’s Democratic Republic Malaysia Marshall Islands Micronesia, Federated States of Mongolia Myanmar Nauru New Caledonia New Zealandd Niue Palau Papua New Guinea Philippines Samoa Singapore Solomon Islands Taiwanb Thailanda Timor-Lested Tokelau Tonga Tuvalu Vanuatu Viet Nam

Australia (Dunstan et al, 2002)107 Singapore (Ministry of Health Survey, 1998)103 Cambodia (King et al, 2005)93 China (Gu et al, 2003)99 Hong Kong (Janus et al, 2000 and Cockram et al, 1993)147,148 Hong Kong (Janus et al, 2000 and Cockram et al, 1993)147,148 Rarotonga (King et al, 1986)149 Fiji (Zimmet et al, 1983)150 Tonga (Colaguiri et al, 2002)151 Kiribati (King et al, 1984)152 Indonesia (Waspadji et al, 1983)153 Japan (Ohmura et al, 1993 and Sekikawa et al, 2000)154,155 Kiribati (King et al, 1984)152 Republic of Korea (Park et al, 1995)102 Republic of Korea (Kim et al, 2006)96 Viet Nam (Duc Son et al, 2004)97 Singapore (Ministry of Health Survey, 1998)103 Kiribati (King et al, 1984)152 Kiribati (King et al, 1984)152 Mongolia (Suvd et al, 2002)156 Viet Nam (Duc Son et al, 2004)97 Nauru (Zimmet et al, 1984)157 New Caledonia (Zimmet et al, 1982)158 New Zealand (Ministry of Health, 2002)159 Niue (King et al, 1986)149 Kiribati (King et al, 1984)152 Fiji Melanesians (Zimmet et al, 1983)150 Philippines (Baltazar et al, 2004)94 Samoa (Collins et al, 1994)160 Singapore (Ministry of Health Survey, 2004)98 Fiji Melanesians (Zimmet et al, 1983)150 Taiwan (Chou et al, 1992, 1994)161,162 Thailand (Aekplakorn et al, 2003)95 Indonesia (Waspadji et al, 1983)153 Tonga (Colaguiri et al, 2002)151 Tonga (Colaguiri et al, 2002)151 Tonga (Colaguiri et al, 2002)151 Fiji Melanesians (Zimmet et al, 1983)150 Viet Nam (Duc Son et al, 2004)97

a. Because of the absence of data for IGT in the study used for diabetes, IGT figures were calculated from unpublished Indonesian data163 (862 participants) b. The prevalences for the studies based on the Hong Kong, Japanese and Taiwanese studies were obtained by combining the data from the two studies respectively c. IGT figures were calculated using data from Park et al, 1995102 d. Because of the absence of data for IGT in the study used for diabetes, IGT figures were calculated from Australian data

102

CHAPTER 1


- Western Pacific Region

d Screening method OGTT OGTT OGTT FBG OGTT OGTT OGTT OGTT OGTT OGTT OGTT OGTT OGTT OGTT FBG FBG OGTT OGTT OGTT OGTT FBG OGTT OGTT SR OGTT OGTT OGTT OGTT OGTT OGTT OGTT OGTT FBG OGTT OGTT OGTT OGTT OGTT FBG

Diagnostic criteria Sample size Age (yrs) WHO - 1999 WHO - 1985 WHO - 1999 ADA - 1997 WHO - 1985 WHO - 1985 WHO - 1985 WHO - 1980 WHO - 1999 WHO - 1980 WHO - 1980 WHO - 1985 WHO - 1980 WHO - 1985 ADA - 1997 WHO - 1999 WHO - 1985 WHO - 1980 WHO - 1980 WHO - 1999 WHO - 1999 WHO - 1980 WHO - 1980 Known Diabetes WHO - 1985 WHO - 1980 WHO - 1980 WHO - 1999 WHO - 1985 WHO – 1999 WHO - 1980 WHO - 1985 ADA - 1997 WHO - 1980 WHO - 1999 WHO - 1999 WHO - 1999 WHO - 1980 WHO - 1999

11,247 3,568 2,246 15,838 4,413 4,413 1,127 2,638 1,024 2,938 2,704 5,211 2,938 2,520 5,844 2,932 3,568 2,938 2,938 2,996 2,932 1,583 707 7,862 1,149 2,938 1,340 7,044 1,776 4,168 1,340 4,287 5,350 2,704 1,024 1,024 1,024 1,340 2,932

25+ 18-69 25+ 35-74 20-79 20-79 20+ 20+ 15+ 20+ 15+ 40+ 20+ 30+ 20+ 15+ 18-69 20+ 20+ 35+ 15+ 20+ 20+ 25+ 20+ 20+ 20+ 20-65 25-74 18-69 20+ 30-79 35+ 15+ 15+ 15+ 15+ 20+ 15+


CHAPTER 1

103

1.2 Known and Newly Diagnosed Diabetes Studies have shown that a substantial proportion of all people found to have diabetes had not been previously diagnosed.

Introduction

I

t has been a consistent finding of population-based diabetes studies that a substantial proportion of all people found to have diabetes had not been previously diagnosed. Thus, diabetes surveys identify people with previously diagnosed, or known, diabetes (KDM), as well as those with newly diagnosed diabetes, whose diabetes is only found through blood tests undertaken in the survey. The uncovering of new cases of diabetes when mass blood testing is undertaken is primarily because of the lack of symptoms associated with the early years of type 2 diabetes, meaning that those with diabetes may be unaware of their condition and therefore not seek medical attention for it. However, it should also be noted that since the clinical diagnosis of diabetes requires diagnostic blood glucose levels on two separate days, a proportion of those labelled as having undiagnosed diabetes in research studies may not in fact have diabetes if re-tested. In any survey, the percentage of all people with diabetes, whose diabetes has been previously diagnosed, is often taken as a measure of how well the standard clinical services are managing to screen for and identify people with diabetes. A high KNOWN AND NEWLY DIAGNOSED DIABETES

percentage indicates successful screening, while a low number reflects an inability of medical services to screen for diabetes, and is often seen in developing countries where resources are limited.

Studies Tables 1.42-1.48 show the numbers with KDM as a percentage of all those with diabetes in over 80 studies. In general, the lowest percentages were seen in studies from developing countries, and the highest from developed countries. In Tanzania, rural India, Nepal, Tonga and China only 20-25% of all people with diabetes had been previously diagnosed. Overall, across all the surveys, approximately 50% of all people with diabetes were undiagnosed. It should be noted that in some studies that report a high percentage of previously diagnosed cases, there may have been some bias in study design, which resulted in this finding. For example, the study from Ireland127 only undertook blood glucose testing on those individuals with symptoms or risk factors for diabetes. This is likely to have underestimated the numbers of individuals with newly diagnosed diabetes, as some of these individuals may not have had risk factors or symptoms. CHAPTER 1

105

Table 1.42 Proportion of known diabetes (KDM) in studies - African Region Country/territory Author Journal Total KDM diabetes (n) (n)

KDM proportion of total diabetes (%)

Cameroon Mbanya, 200629 Unpublished 489 101 Ghana Amoah et al, 200228 Diabetes Research and Clinical Practice 300 91 South Africa Levitt et al, 199325 Diabetes Care 46 24 Omar et al, 199326 South African Medical Journal 20 12 Motala, 200627 Unpublished 488 101 Tanzania, United Republic of McLarty et al, 198921 Lancet 53 7 Mean Median

21 30 52 60 21 13 33 26

Table 1.43 Proportion of known diabetes (KDM) in studies - Eastern Mediterranean and Middle East Region Country/territory Author Journal Total KDM KDM proportion of diabetes total diabetes (n) (n) (%) Algeria Malek et al, 200150 Diabetes and Metabolism 120 54 45 Bahrain al-Mahroos et al,199832 Diabetes Care 604 393 65 Egypt Herman et al, 199533 Diabetic Medicine N/A N/A 57 Iran, Islamic Republic of Azizi et al, 2003164 Eastern Mediterranean Health Journal 21,637 12,024 56 Jordan Ajlouni et al, 1998110 Journal of Internal Medicine 379 N/A 67a Kuwait Abdella et al, 199835 Diabetes Research and Clinical Practice 443 N/A 50a Lebanon Salti et al, 1997111 Eastern Mediterranean Health Journal 331 259 78 Occupied Palestinian Territory Abdul-Rahim et al, 200153 Eastern Mediterranean Health Journal 59 46 78 Husseini et al, 2003165 Medical Science Monitor 49 35 71 Oman Al-Lawati et al, 200236 Diabetic Medicine 677 N/A 33a Pakistan Shera et al, 199548 Diabetic Medicine 131 72 55 Shera et al, 199947 Diabetes Research and Clinical Practice 127 69 54 Shera et al, 199949 Journal of the Pakistan Medical Association 115 42 37 Saudi Arabia Al-Nuiam, 199739 Diabetic Medicine 41 21 51 Al-Nozha, 200438 Saudi Medical Journal 4,004 2,888 72 Sudan Elbagir,199630 Diabetes Care 44 16 36 Tunisia Papoz et al, 1988114 International Journal of Epidemiology 168 97 58 United Arab Emirates Malik et al, 200541 Diabetes Research and Clinical Practice 505 299 59 Mean 57 Median 57

a. These figures were quoted in the original papers as simple fractions (e.g. 1/2, 2/3), or provided only separate prevalences of new and known diabetes, so that the ratio could be deduced N/A not available

106

CHAPTER 1


Table 1.44 Proportion of known diabetes (KDM) in studies – European Region Country/territory Author Journal Total KDM diabetes (n) (n)


Albania Shapo et al, 2004117 Diabetic Medicine 70 38 54 Cyprus Loizou et al, 2006121 Diabetes Care 123 84 68 Denmark Glumer et al, 2003122 Diabetes Care 404 139 34 Finland Ylihärsilä et al, 2005124 Diabetic Medicine 188 83 44 France Gourdy et al, 200170 Diabetes and Metabolism 230 121 53 Lecomte et al, 2002166 Diabetes and Metabolism 1,675 993 59 Germany Rathmann et al, 200371 Diabetologia 253 128 51 Greece Panagiotakos et al, 2005125 Diabetic Medicine 210 154 73 Iceland Vilbergsson et al, 1997126 Diabetic Medicine 467 282 60 Ireland Smith et al, 2003127 Diabetic Medicine 353 270 76 Israel Stern et al, 1988167 Diabetes 192 113 59 Stern et al, 1999129 Acta Diabetologica 345 310 90 Bar-On et al, 1992128 Nutrition, Metabolism and Cardiovascular Diseases 100 N/A 67a Italy Garancini et al, 1995134 Diabetologia 476 213 45 Netherlands Mooy et al, 199572 Diabetes Care 184 78 42 Poland Lopatynski et al, 200161 Polskie Archiwum Medycyny Wewnetrznej 586 204 35 Szurkowska et al, 200160 Polskie Archiwum Medycyny Wewnetrznej 321 161 50 Spain Botas et al, 2003168 Diabetic Medicine 120 47 39 Castell et al, 1999118 Diabetes Research and Clinical Practice 258 167 65 Sweden Eliasson et al, 2002133 Diabetic Medicine 214 N/A 50a 169 Turkey Kelestimur et al, 1999 Acta Diabetologica 99 58 59 Satman et al, 200258 Diabetes Care 1,792 578 32 United Kingdom Forrest et al, 1986170 Diabetic Medicine N/A N/A 45a Uzbekistan King et al, 1998130 Diabetic Medicine 162 49 30 King et al, 2002131 Diabetes Research and Clinical Practice 61 26 43 Mean 53 Median 51

Table 1.45 Proportion of known diabetes (KDM) in studies – North American Region Country/territory Author Journal Total KDM diabetes (n) (n)


Guadeloupe Costagliola et al, 199138 Diabetes Research and Clinical Practice 81 66 81 Jamaica Ragoobirsingh et al, 1995171 Diabetes Care 378 196 52 Mexico Aguilar-Salinas et al, 200378 Diabetes Care 3,597 2,878 80 United States of America CDC, 200374 Morbidity and Mortality Weekly Report N/A 288 71a Mean 71 Median 76


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107

Table 1.46 Proportion of known diabetes (KDM) in studies – South and Central American Region Country/territory Author Journal Total KDM diabetes (n) (n)


Bolivia Barceló et al, 2001141 Revista Panamericana de Salud Pública 185 132 Brazil Malerbi et al, 1992140 Diabetes Care 1,660 896 Chile Baechler et al, 200282 Revista Medica de Chile 115 63 Colombia Aschner, 1993142 Diabetes Care 34 22 Paraguay Jimenez et al, 1998144 Diabetic Medicine 99 44 Mean Median

71 54 55 65 45 58 55

Table 1.47 Proportion of known diabetes (KDM) in studies – South-East Asian Region Country/ Author Journal Total KDM territory diabetes (n) (n)


Bangladesh Abu Sayeed et al, 1997172 Diabetes Care 123 35 28 India Ramachandran et al (large cities), 200184 Diabetologia 1,684 1,175 70 Sadikot et al (urban), 200485 Diabetes Research and Clinical Practice 624 199 32 Sadikot et al (rural), 200485 Diabetes Research and Clinical Practice 193 37 19 Mauritius Dowse et al, 1990109 Diabetes 633 269 42 Soderberg et al, 2005173 Diabetic Medicine 1,317 671 51 Nepal Karki et al, 200089 Southeast Asian Journal of Tropical 116 30 25 Medicine and Public Health Mean 38 Median 32

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


Australia Dunstan et al, 2002107 Diabetes Care 943 475 50 Cambodia King et al, 200593 Lancet 185 66 36 China Gu et al, 200399 Diabetologia N/A N/A 24 China, Hong Kong Cockram et al, 1993148 Diabetes Research and Clinical Practice 41 16 38 Janus, 2000147 Diabetic Medicine 269 77 29 Japan Sekikawa et al, 1993174 Diabetes Care 109 52 48 Korea, Republic of Kim et al, 200696 Diabetes Care N/A N/A 57a Mongolia Suvd et al, 2002156 Diabetic Medicine 72 46 64 Nauru Zimmet et al, 1984157 Diabetes Research 374 221 59 Philippines Baltazar, 200494 Diabetes Research and Clinical Practice 362 N/A 67a Samoa Collins et al, 1994160 Diabetes Care 203 101 50 Singapore Ministry of Health, Singapore, 1999103 Government Report N/A N/A 38 Taiwan Chou et al, 1992161 Diabetes Care 143 77 54 Chou et al, 1994162 Diabetes Care 209 63 30 Thailand Aekplakorn et al, 200395 Diabetes Care 607 N/A 50a Tonga Colagiuri et al, 2002151 Diabetes Care 106 N/A 20a 97 Viet Nam Duc Son et al, 2004 Diabetic Medicine 194 118 61 Mean 46 Median 50


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1.3 Complications of Diabetes Diabetic complications account for much of the social and financial burden of diabetes. Diabetes is ranked among the leading causes of blindness, renal failure and lower limb amputation in many countries, while some 50% of people with diabetes die of cardiovascular disease.

Introduction

O

ver the last 30 years, type 2 diabetes has changed from being seen as a relatively mild ailment associated with ageing and the elderly (‘just a touch of sugar’) to one of the major contemporary causes of premature mortality and morbidity in most countries. In virtually every developed society, diabetes is ranked among the leading causes of blindness, renal failure and lower limb amputation. Through its effects on cardiovascular disease (50% of people with diabetes die of cardiovascular disease), it is also now one of the leading causes of death. The changing perceptions of diabetes relate partly to a better appreciation of its devastating complications, but mainly to the rapid rise in its prevalence that has occurred in the last few decades. The main relevance of diabetic complications in a public health perspective is the relationship to human suffering and disability, and the huge socio-economic costs through premature morbidity and mortality175. Chronic elevation of blood glucose, even when no symptoms are present to alert the individual to the presence of diabetes, will eventually lead to tissue damage, with consequent, and COMPLICATIONS OF DIABETES

often serious, disease. Whilst evidence of tissue damage can be found in many organ systems, it is the kidneys, eyes, peripheral nerves and vascular tree, which manifest the most significant, and sometimes fatal, diabetic complications. Indeed, diabetic complications are those aspects of the disease that are most feared (such as blindness and amputation), and account 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 coronary heart disease (CHD), 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. CHAPTER 1

111

THE MAJOR DIABETIC COMPLICATIONS

Figure 1.14 Heart attacks in people with and without diabetes over a period of seven years

Eyes (retinopathy)

Brain and cerebral circulation (cerebrovascular disease)

Incidence (%) 50 45 40

Heart and coronary circulation (coronary heart disease)

35 30

Kidney (nephropathy)

25 20 15 10 Peripheral nervous system (neuropathy)

Lower limbs (peripheral vascular disease)

Major diabetic complications Over the last two or three decades, there has been an increasing awareness of the magnitude of the problem presented by diabetic complications. The major complications are: • cardiovascular disease (CVD); • nephropathy; • neuropathy; • amputation; and • retinopathy.

Cardiovascular disease Cardiovascular disease is the major cause of death in diabetes, accounting for some 50% of all diabetes fatalities, and much disability. The kinds of CVD that accompany diabetes include angina, myocardial infarction (heart attack), stroke, peripheral artery disease, and congestive heart failure (CHF). Angina is the pain that arises when the blood supply to the heart muscle itself is temporarily insufficient. This is usually due to narrowing of the arteries feeding the heart muscle. When one of these arteries becomes fully blocked, a myocardial infarction occurs, which kills heart muscle and is CHAPTER 1

0 People without diabetes

Diabetic foot (ulceration and amputation)

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5

People with diabetes

No prior heart attack Prior heart attack

Adapted from Haffner et al, 1998176

often fatal. People with diabetes without previous heart attacks have been shown to have as high a risk of heart attacks as have non-diabetic persons with previous heart attacks (see Figure 1.14)176. Strokes occur when areas of the brain die from arterial blockage or arterial breakage and bleeding. Strokes are also sometimes fatal but they also often cause paralysis and loss of speech, and other problems. Peripheral artery disease results from blockages in arteries that feed the legs; it causes pain while walking and can lead to major surgery and the need for amputation. Heart failure results when the heart cannot pump strongly and fluid backs up in the legs, lungs and other tissues. Smoking, high cholesterol, high blood pressure, stress from social inequality and oppressive work environments, poor diet, high blood sugar and abdominal fat all increase the likelihood of cardiovascular disease events in persons living with diabetes and impaired glucose tolerance. Several interventions, some of which are relatively inexpensive, can dramatically reduce the risk of CVD, including stopping smoking, general blood pressure control, low-dose daily aspirin, ACE-inhibitor pills, and statin drugs, which improve DIABETES ATLAS THIRD EDITION

Figure 1.15 Numbers of people with diabetes entering the Australian dialysis register 1980-2004178

People with diabetes (n) 600

500

400

300

200

100

0 80

81

82

83

84

85

86

87

88

89

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00

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Year of entry

cholesterol in the blood. More information on diabetes and CVD can be found online at www.cvd.idf.org.

Nephropathy Diabetes is an increasingly important cause of renal failure (see Figure 1.15), and indeed has now become the single most common cause of end stage renal disease, i.e. that which requires either dialysis or kidney transplantation, in the USA177, and in other countries. A more detailed discussion of diabetic nephropathy can be found in the publication Diabetes and Kidney Disease: Time to Act, International Diabetes Federation, 2003.

cause tingling, burning, and stabbing pain, extreme sensitivity to touch, aching and numbness. Both pain and loss of feeling can occur at the same time. Loss of feeling (loss of protective sensation) is a particular risk because it can allow foot injuries to escape notice and treatment, leading to major infections and amputation. Good blood sugar and blood pressure control can help prevent peripheral neuropathy; smoking and heavy drinking make it much more likely. Regular inspection of the feet, careful nail trimming, avoidance of ill-fitting footwear, and wearing shoes or sandals rather than going barefoot can all prevent foot injury, ulceration and amputation.

Neuropathy

Amputation

When blood sugar and blood pressure are not controlled, diabetes can harm nerves throughout the body. Problems with digestion and urination, impotence, and many other functions can result, but the most commonly affected area is the feet and legs. Nerve damage in these areas is called peripheral neuropathy, and leads to loss of feeling in the feet and toes.

Through effects on peripheral nerves and arteries, diabetes can lead to foot ulceration, infection and the need for amputation. People with diabetes carry a risk of amputation that may be more than 25 times greater than that seen in those without diabetes179. A recent publication, Diabetes and Foot Care: Time to Act, International Diabetes Federation, 2005, takes a closer look at the diabetic foot and ways in which complications can be prevented.

Peripheral neuropathy is frequently asymptomatic, but can COMPLICATIONS OF DIABETES

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Retinopathy Diabetes can harm sight and cause blindness in several ways. The most common cause of blindness in diabetes is macular oedema, caused by fluid build-up behind the retina of the eye. A more common complication is background and proliferative retinopathy, which can cause blindness as a result of repeated haemorrhages at the back of the eye. Diabetes also increases the risk of cataracts and glaucoma. However, the risk of blindness in diabetes can be greatly reduced by strict control of blood sugar and blood pressure; and regular eye exams can detect macular oedema and proliferative retinopathy so that laser treatments can be used to control these conditions before they cause visual loss.

114

2. Studies with ≥100 participants were included; where more than one study was available for a country, preference was given to larger and population-based studies, those published after 1989, and those with the fewest restrictions. 3. Prevalences are reported for coronary heart disease, stroke, nephropathy, neuropathy, retinopathy, and incidence and prevalence for lower extremity amputations. 4. Where possible, the age ranges of the populations are reported. Where the age range of the population was not available, the mean or median age is reported.

Methods

5. Diagnostic criteria for each complication are recorded, as variation in definitions can affect the prevalences reported.

Details of the methods used in this report on diabetic complications are found in Appendix 1.2. The main principles in collating available prevalence data were:

6. For some countries, results from more than one study are presented. This is usually because they cover different aspects of the diabetic population.

1. Studies were identified through a detailed literature search, as well as contact with IDF member organizations.

There are some important differences between this section and Chapter 1.1 on diabetes prevalence and IGT. The total

CHAPTER 1


numbers of individuals within a country who may have complications are not estimated, nor is a national prevalence. Furthermore, data have not been projected from one country onto other countries. This is for two reasons: firstly, such calculations require knowledge of the age and sex structure of both the original study population, and of the target (national diabetic) population. In most cases, neither of these is known. Secondly, many studies are clinic-based, and so their generalizability is limited.

Results The results are provided in Tables 1.49 - 1.58. A brief summary of results for each complication is presented below. The interquartile range was used to describe the middle fifty percent of prevalences for each complication.

Cardiovascular disease The prevalence of coronary heart disease in those with diabetes (both type 1 and type 2) ranged from 1.0% to 25.2% in clinic-based populations and from 1.8% to 43.4% in population-based studies (see Table 1.49). The prevalence of stroke in those with type 1 and type 2 diabetes ranged from 1.0% to 11.3% in clinic-based populations and from 2.8% to 12.5% in population-based studies. For CHD, the middle fifty percent of the prevalences were between 4.0% and 13.5%. For stroke, the middle fifty percent of the prevalences were between 4.0% and 6.2%.

Nephropathy The prevalence of microalbuminuria in those with type 1 diabetes ranged from 4.3% to 37.6% in clinic-based populations and from 12.3% to 27.2% in population-based studies (see Table 1.51). Among those with type 2 diabetes, the prevalence of microalbuminuria ranged from 2.5% to 57.0% in clinic-based populations and from 19.4% to 42.1% in population-based studies. The prevalence of overt nephropathy in those with type 1 diabetes ranged from 0.7% to 27.0% in clinic-based populations, and from 0.3% to 24.0% in population-based studies. Among those with type 2 diabetes, the prevalence of overt nephropathy ranged from 5.4% to 20.0% in clinic-based populations, and from 9.2% to 32.9% in population-based studies. For microalbuminuria, the middle fifty percent of the COMPLICATIONS OF DIABETES

prevalences were between 17.9% and 23.8% for type 1 diabetes, and between 19.4% and 42.0% for type 2 diabetes. For overt nephropathy, the middle fifty percent of the prevalences in type 1 diabetes were between 6.1% and 13.8%, and between 10.1% and 18.2% for type 2 diabetes.

Neuropathy The prevalence of neuropathy in those with type 1 diabetes ranged from 3.0% to 65.8% in clinic-based populations and from 12.8% to 54.0% in population-based studies (see Table 1.53). Among those with type 2 diabetes, the prevalence of neuropathy ranged from 7.6% to 68.0% in clinic-based populations, and from 13.1% to 45.0% in population-based studies. The middle fifty percent of the neuropathy prevalences for type 1 diabetes were between 21.2% and 29.3%, and between 19.7% and 37.5% for type 2 diabetes.

Amputations The prevalence of lower extremity amputations ranged from 0.2% to 4.8%, and the annual incidence ranged from 46.1 to 936 per 100,000 diabetic population (see Table 1.55). The middle fifty percent of the amputation prevalences were between 0.9% and 2.4%, and between 181 per 100,000 diabetic population and 463 per 100,000 diabetic population for the incidence of amputations.

Retinopathy The prevalence of retinopathy in those with type 1 diabetes ranged from 10.8% to 60.0 % in clinic-based populations and from 14.5% to 79.0% in population-based studies (see Table 1.57). Among those with type 2 diabetes, the prevalence of retinopathy ranged from 10.6% to 65.4% in clinic-based populations and from 10.1% to 55.0% in population-based studies. The middle fifty percent of the retinopathy prevalences for type 1 diabetes were between 34.1% and 53.0%, and between 23.7% and 36.2% for type 2 diabetes.

Discussion The aims of this section were to describe the burden of diabetic complications, and to be able to examine the differences existing between countries and between ethnic CHAPTER 1

115

IN TOUCH WITH: RAMÓN AGUIRRE People with diabetes are at an increased risk of developing a number of complications associated with the disease. Diabetes is among the leading causes of blindness, renal failure and lower limb amputation. Many complications have the potential to reduce the quality of life of people with diabetes and their families. However, diabetic complications may be prevented or delayed by good diabetes management by the person with diabetes and the healthcare team.

Ramón Aguirre, 52, was born in Argentina, and took his first job in a bakery when he was eight years old, after his mother’s death. Eight years ago, while working as a pastry cook, he started feeling ill and went to the doctor. He was diagnosed with a discus hernia, tuberculosis and type 2 diabetes. He started treatment but was soon without a job or income, and could not afford to continue with the insulin and medication his doctor had prescribed. It was not long before Ramón developed complications. His feet problems brought him to a podologist who recommended an urgent consultation with a doctor specialized in diabetes. Ramón rejected the idea because he did not want to lose a day’s work which he now had, but after some months he started having symptoms of blindness: he could not see his hands, so needed for his work.

groups. In order to do this with confidence, it is necessary that there is a degree of uniformity in the methodology of the different studies. This, however, was not the case. For each of the complications, a wide range of results was found, but understanding the underlying causes of this diversity is difficult. For example, the low prevalence of neuropathy seen in Mauritius180 could be due to a low inherent risk for neuropathy in that population, the availability of high quality diabetes care, the relative youth of a population in a developing country, the methods used in the study for defining neuropathy or the population-based study design. In the absence of similar studies, it is almost impossible to determine which of these explanations may be correct. The problem of accurately describing the burden and making comparisons is made particularly difficult by the relative lack of population-based studies. Studies based on secondary care tend to over-represent those with advanced disease, as those requiring more intensive treatment are generally referred on for specialist care. Furthermore, prevalences in clinic populations will depend on local referral patterns, which are likely to vary widely around the world.

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Neither the diagnostic tools nor diagnostic thresholds used to define a complication were equivalent across studies. For example, neuropathy was defined as the absence of ankle reflexes in one study181, and as the presence of symptoms and clinical signs (using validated scales) in another182. The inconsistent use of diagnostic tools to classify a complication has been shown to dramatically affect the prevalence reported. The Diabetes Control and Complications Trial (DCCT) compared the prevalence of neuropathy using 11 different criteria and found that within the one population, the prevalence of neuropathy varied from 0.3%, using sensory examination, reflexes and symptoms, through to 21.8% using nerve conduction tests183. Another example of the variability brought about by changing methodology is highlighted by a study on amputation. The study compared the incidence of lower extremity amputations in one population, when primary or all amputations were included184. The incidence of lower extremity amputations varied from 276 per 100,000 person years (primary amputation) to 388 per 100,000 person years (all amputations). Further differences in amputation incidences are likely to be due to the (rather imprecise) method of estimating the total diabetic population from DIABETES ATLAS THIRD EDITION

With the help of Estela, his wife, Ramón went to see the recommended diabetologist, Dra María Teresa Enrico. Ramón’s retinopathy had developed to an advanced stage and the retina in one eye had loosened. He was given an appointment for surgery in a year’s time at the Ophthalmology Hospital. However, with his condition, Ramón could not wait. But without money he could not pay for the intervention elsewhere. Dr Enrico put him in contact with the ‘Fundación de Cirugía Ocular Dr. Zambrano’ and with the diabetes association, Liga Argentina de Protección al Diabético (LAPDI). These associations helped Ramón obtain the surgery he so needed and paid half of the hospital costs. Once his sight was regained, he would pay the rest.

new house that the Government of Buenos Aires plans to give the community where he has lived for 10 years. Ramón reminds people with diabetes “not to lose time, because diabetes is controllable and everything depends on oneself”.

Today, with the help of his family, Ramon has bought the necessary machines to start again as a pastry cook. He works from home making bread and pastries that his wife and his mother-in-law sell every day. He keeps his diabetes under control with the free medication from the hospital. His dream is to open a bakery and move with Estela to a

which those with amputations were drawn. One large study, EURODIAB, examined the prevalence of retinopathy, neuropathy and nephropathy in type 1 diabetes across several European countries185,186. This study used standard methodology, making it possible to gain some insight into whether observed differences in prevalence estimates are due to methodological problems or represent actual differences. The study found the prevalence of complications did vary between countries. The prevalence of retinopathy ranged from 21% in Germany to 60% in Portugal. However, much less variation was seen for neuropathy and microalbuminuria, for which the prevalences clustered fairly tightly around 25% and 23%, respectively. 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.

COMPLICATIONS OF DIABETES

• Of the seven population-based studies giving figures for neuropathy in type 2 diabetes, two of the three highest prevalences were from the USA. • Populations from Europe had high rates of heart disease and stroke, while migrant Indian populations (Mauritius and Fiji) 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 populationbased 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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Table 1.49 Prevalence of cardiovascular disease Region Country/territory

Data used U

AFR South Africa Rotchford et al, 2002187 EMME Egypt Arab et al, 2002188 Pakistan Hashim et al, 1999189 Sudan Elmahdi et al, 1991190 EUR Austria Muhlhauser et al, 1992191 Belgium Van Acker et al, 2001192 Denmark Gall et al, 1991193 Estonia Vides et al, 2001194 Finland Isomaa et al, 2001195 Hu, 2003a,196 France Delcourt et al, 1998197 Le Floch et al, 2000198 Germany Liebl et al, 2002199 Italy DAI Study Group, 2004200 Netherlands Verhoeven et al, 1991201 Reenders et al, 1993202 de Visser et al, 2002203 Spijkerman et al, 2004204 Serbia and Montenegro Vlajinac et al, 1992205 Miljus, 2002206 Slovakia Slovakian Diabetes Society, 2002a,207 Spain Esmatjes et al, 1996208 Diamante, 1997209 Arteagoitia et al, 2003210 Sweden Lundman et al, 1998211 Wandell, 2004212 United Kingdom Morgan et al, 2000213 NA United States of America Maser et al, 1991214 Qureshi et al, 1998215 Alexander et al, 2000216 Barzilay et al, 2001217 Alexander et al, 2003218 Malik et al, 2005219 SEA Bangladesh Sayeed et al, 1998220 Chuang et al, 2002b,221 India Ramachandran et al, 1999b,222 Ramachandran et al, 2000223 Mauritius Collins et al, 1993224 Sri Lanka Fernando et al, 1993225 Chuang et al, 2002b,221 WP China Chi et al, 2001226 Chuang et al, 2002b,221 Fiji (Asian Indian) Tuomilehto et al, 1988227 Indonesia Chuang et al, 2002b,221 Japan Kuzuya et al, 1994228 Korea, Republic of Lee et al, 1995229 Chuang et al, 2002b,221 Malaysia Chuang et al, 2002b,221 Nauru Collins et al, 1993224 New Zealand (European) Simmons et al, 1996230 New Zealand (Maori) Simmons et al, 1996230 New Zealand (Pacific Islanders) Simmons et al, 1996230 Philippines Chuang et al, 2002b,221

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Coronary heart disease (%) Stroke (%) d UnDM Type 1 DM Type 2 DM Total DM UnDM Type 1 DM Type 2 DM Total DM

• • • • • • • • • • • 5.1 • • • • 6.2 30.8 • • 26.4 • • • • • 13.4 • • • • • 8.4 • 16.3 13.3 • • 10.6 • • • • • 40.0 • • 9.0 • • • 13.3 • 13.4 • • 35.5 • • • • • • • • 11.0 • 0.5 • • • 12.4 • 4.7 12.3 • • 12.1 • • • • 3.4 • • • • • • • • • • • • • • • • 18.6 • • • • • • • 11.4 • 0.5 • • • • • • 12.0 • • • • • • • • • • • • • • • • • • • • 7.8 • • • • • • • • • • • • • • • • • • • • •


• • • • 7.5 15.0 • • • • 19.8 • • • 6.2 • • • 4.4 • 11.3 • • • 6.2 21.0 • • • • • • • • • 7.7 • • • 2.8 • • • 5.2 • 8.1 • • • 7.6 • • • • • 13.5 • 4.3 4.1 4.1 • • • 6.7 • 9.9 • • • • • • • • • • • • 5.0 • 20.9 • • • 9.1 • • • • • • • • • • 3.3 • • • • 6.0 • • • 5.6 • • • 5.0 • • • 0.5 • • • • • 9.8 • 11.5 • 3.1 12.3 11.3 • • 5.4 • 25.2 • • • 9.6 • • • • • 10.7 • • • 5.0 (incl UnDM) (incl UnDM) 9.8 • • • • 43.4 • • • 12.5 17.6 • • • • 26.7 • • • • • • • • • 2.0 • • • 1.0 • • • • • • • • • • Male 22.0 • • • • Female 33.7 • • • 3.6 • 6.0 • • • 2.0 8.7 • • • 3.4 1.0 • • • 5.0 31.3 • • • • 5.0 • • • 4.0 2.1 • • • 5.7 • • • 8.4 • 3.0 • • • 6.0 12.0 • • • 6.0 15.8 • • • • 11.0 • • • • 11.0 • • • • 6.0 • • • • 3.0 • • • 6.0

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Table 1.49 Prevalence of cardiovascular disease

Region Country/territory Data used U

WP Singapore Thai et al, 1990231 Chuang et al, 2002b,221 Taiwan Chuang et al, 2002b,221 Fuh, 2002a,232 Tseng et al, 2005233 Thailand Thai Multicenter Group, 1994234 Tatsanavivat et al, 1998235 Tandhanand et al, 2001236 Viet Nam Chuang et al, 2002b,221

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

a. Unpublished data b. Extra details supplied by authors

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Coronary heart disease (%) Stroke (%) d UnDM Type 1 DM Type 2 DM Total DM UnDM Type 1 DM Type 2 DM Total DM

• • • 12.8 • • • • (incl UnDM) • • • 5.0 • • • 3.0 • • • 4.0 • • • 6.0 • • 18.1 • • • 4.7 • • • • • • 7.5 • • • 10.5 • • • 3.7 • • • • 1.8 • • • • • • • 3.0 • • • 3.0 • • • 1.0 • • • 3.0


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Table 1.50 Data sources: prevalence of cardiovascular disease Region Country/territory

Data used Study type Sample size A

AFR South Africa Rotchford et al, 2002187 Clinic (secondary care) 253 EMME Egypt Arab et al, 2002188 Clinic (primary care) 2,000 Pakistan Hashim et al, 1999189 Clinic (primary care) 805 Sudan Elmahdi et al, 1991190 Clinic (secondary care) 413 EUR Austria Muhlhauser et al, 1992191 Clinic (primary care) 375 Belgium Van Acker et al, 2001192 Clinic (secondary care) 1,653 Denmark Gall et al, 1991193 Clinic (secondary care) 549 Estonia Vides et al, 2001194 Register 181 Finland Isomaa et al, 2001195 Clinic (primary care) 1,697 Hu, 2003a,196 Population based 172 France Delcourt et al, 1998197 Clinic (secondary care) 427 Le Floch et al, 2000198 Clinic (primary care) 7,391 Germany Liebl et al, 2002199 Clinic (primary and secondary care) 2,701 Italy DAI Study Group, 2004200 Clinic (secondary care) 19,468 Netherlands Verhoeven et al, 1991201 Clinic (primary care) 137 Reenders et al, 1993202 Clinic (primary care) 387 de Visser et al, 2002203 Population based 281 Spijkerman et al, 2004204 Population based 255 Serbia and Montenegro Vlajinac et al, 1992205 Population based 152 Miljus, 2002206 N/A N/A Slovakia Slovakian Diabetes Society, 2002a,207 Clinic (secondary care) N/A Spain Esmatjes et al, 1996208 Clinic (primary and secondary care) 1,157 Diamante, 1997209 Clinic (secondary care) 1,822 Arteagoitia et al, 2003210 Clinic (primary care) 2,920 Sweden Lundman et al, 1998211 Clinic (primary and secondary care) 4,027 Wandell, 2004212 Clinic (primary care) 389 United Kingdom Morgan et al, 2000213 Clinic (primary and secondary care) 10,287 NA United States of America Maser et al, 1991214 Clinic (secondary care) 657 Qureshi et al, 1998215 Population based 1,532 Alexander et al, 2000216 Population based N/A Barzilay et al, 2001217 Population based 479 Alexander et al, 2003218 Population based 600 Malik et al, 2005219 Population based 465 SEA Bangladesh Sayeed et al, 1998220 Clinic (secondary care) 693 Chuang et al, 2002b,221 Clinic (secondary care) 1,607 India Ramachandran et al, 1999b,222 Clinic (secondary care) 3,010 Ramachandran et al, 2000223 Clinic (secondary care) 617 Mauritius Collins et al, 1993224 Population based 259 Sri Lanka Fernando et al, 1993225 Clinic (secondary care) 500 Chuang et al, 2002b,221 Clinic (secondary care) 1,213 WP China Chi et al, 2001226 Clinic (secondary care) 447 Chuang et al, 2002b,221 Clinic (secondary care) 2,430 Fiji (Asian Indian) Tuomilehto et al, 1988227 Population based 151 Indonesia Chuang et al, 2002b,221 Clinic (secondary care) 2,093 Japan Kuzuya et al, 1994228 Clinic (secondary care) 2,120 Korea, Republic of Lee et al, 1995229 Clinic (secondary care) 631 Chuang et al, 2002b,221 Clinic (secondary care) 952 Malaysia Chuang et al, 2002b,221 Clinic (secondary care) 1,045 Nauru Collins et al, 1993224 Population based 215 New Zealand (European) Simmons et al, 1996230 Population based 176 New Zealand (Maori) Simmons et al, 1996230 Population based 286 New Zealand (Pacific Islanders) Simmons et al, 1996230 Population based 495 Philippines Chuang et al, 2002b,221 Clinic (secondary care) 2,657 Singapore Thai et al, 1990231 Population based 117

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Age (yrs)

Duration DM (yrs)

21-81 4 ± N/A N/A N/A 31->70 N/A 20+ 15 median=67 median=6 21-69 range 5-27 18 14 ± 9 68 (11) 8.1 (5.4) ≥18 10 ± 7 54.6 (6.9) 6.5 (5.3) mean=61 N/A mean=28 19 ± 8 40-74 N/A ≥20 N/A ≥65 N/A 55 N/A 52.8 (>18) N/A 30-60 0-2 10-91 8 ± 6 mean=52 8 ± 6 10-50 median=4 35-74 N/A mean=52 8 ± N/A 14-91 8 ± 7 35-54 range 300mg/la mean=51 5 ± 1 N/A 41.3 (17.2) 5.9 (5.6) • mean=54 6 ± 6 A/CR >19.9 mg/mmol 20-85 8 ± 8 N/A 21-81 4 ± N/A A/CR ≥20 mg/mmol mean=49 9 ± 6 Grade 2 proteinuria 20+ N/A A/CR ≥300 mg/g 54.9 (10.2) 10.2 (6.6) A/CR >300 mg/g 56 10 ± 5 Dipstick proteinuria 20+ 15 Proteinuria >0.5g/24h or blood urea of >40mg%a median=67 median=6 Albuminuria >200 mg/l 15-60 16 ± 10 AER ≥200 µg/min 15-60 15 ± 9 AER ≥200 µg/min mean=37 15 ± 10 N/A 21-69 range 5-27 N/A 15-60 14 ± 9 AER ≥200 µg/min >18 N/A N/A N/A N/A N/A 150µg/mina 300 mg/24hr or proteinuria >0.5g/24h 15-60 15 ± 10 AER ≥200 µg/min N/A N/A A/CR ≥300 mg/g 15-60 13 ± 8 AER ≥200 µg/min 15-60 15 ± 9 AER ≥200 µg/min 15-60 15 ± 9 AER ≥200 µg/min 31+ 12 ± 9 Proteinuria >30mg/dla 15-60 14 ± 9 AER ≥200 µg/min 67.5 (10.2) • AER > 200 µg/min 69.7 (10.2) 11.7 ± 8.6 AER ≥ 200 µg/min 15-60 14 ± 9 AER >200 µg/min mean=68 8 ± 7 Proteinuria >0.5 g/24h mean=68 8 ± 6 AER >200 mg/la 15-60 16 ± 10 AER ≥200 µg/min 62.9 (7.0) Not relevant • 8-30 10 ± 3 AER >200 µg/mina 15-60 15 ± 10 AER ≥200 µg/min N/A N/A A/CR ≥300 mg/g 15-60 15 ± 10 AER ≥200 µg/min 15-60 13 ± 8 AER ≥200 µg/min N/A N/A N/A 45-70 9 ± 7 AER >200 µg/mina >18 14 ± 9 AER >200 µg/mina 68 (11) 8.1 (5.4) N/A 18+ 10 ± 7 Proteinuria ≥300mg/ga 54.6 (6.9) 6.5 (5.3) AER >200 µg/min 14-75 N/A N/A 6-92 11 ± N/A Albustix reading ≥0.3 g/l 15-60 17 ± 10 AER ≥200 µg/min 3-80 N/A AER >200 µg/mina

Albuminuria > 30 mg/24hr Albuminuria 30-299 mg/la Albuminuria 20-199 µg/mina Albuminuria > 30mg/l A/CR 3.0-19.9 mg/mmol A/CR >3.4 mg/mmola Men A/CR 2.6-19.9 mg/mmol, women A/CR 3.6-19.9 mg/mmol N/A A/CR 100-299 mg/g A/CR 30-300 mg/g AER 30-300 mg/24hr N/A Albuminuria 21-200 mg/l AER 20-199 µg/min AER 20-199 µg/min AER 20-200 µg/mina Albuminuria ≥ 30mg/dl AER 20-199 µg/min N/A N/A AER >20-150µg/mina AER 31-299 mg/24hr AER 20-199 µg/min AER 20-199 µg/min AER 31-300mg/24hr AER 20-199 µg/min A/CR 30-299 mg/g AER 20-199 µg/min AER 20-199 µg/min AER 20-199 µg/min N/A AER 20-199 µg/min AER 20-200 µg/min AER 20-199 µg/min AER 20-199 µg/min Albuminuria 20-200 µg/min AER 20-200 mg/la AER 20-199 µg/min A/CR ≥ 2.0 mg/mmol AER 16 -200 µg/mina AER 20-199 µg/min A/CR 30-299 mg/g AER 20-199 µg/min AER 20-199 µg/min N/A AER 20-200 µg/mina AER 20-200 µg/mina AER ≥20 mg/l or albuminuria >30 mg/24 h N/A AER 20-200 µg/mina Albuminuria ≥20 mg/la A/CR ≥2.5 mg/mmol AER 20-199 µg/min AER 20-200 µg/mina


CHAPTER 1

131

Table 1.52 Data sources: Prevalence of diabetic nephropathy Region Country/territory


NA Mexico Cueto-Manzano et al, 2005262 Clinic (primary care) 756 United States of America Orchard et al, 1990263 Clinic (secondary care) 592 Garg et al, 2002264 Population based 1,192 SACA Brazil Foss et al, 1989265 Clinic (secondary care) 546 SEA India Ramachandran et al, 1999b,222 Clinic (secondary care) 3,010 Mohan et al, 2000266 Clinic (secondary care) 1,848 Ramachandran et al, 2000223 Clinic (secondary care) 617 Mauritius Dowse et al, 1998267 Population based 746 Sri Lanka Weerasuriya et al, 1998268 Clinic (primary care) 597 WP Australia Tapp et al, 2004269 Population based 879 China Chi et al, 2001226 Clinic (secondary care) 447 China, Hong Kong Chan et al, 1993270 Clinic (secondary care) 397 Ko et al, 1999271 Clinic (secondary care) 150 Tam et al, 2004272 Clinic (primary care) 1,161 Indonesia Diabcare Asia, 2003d,273 Clinic (primary care) 717 Japan Kuzuya et al, 1994228 Clinic (secondary care) 2,120 Kawano et al, 2001181 Clinic 6,472 Korea, Republic of Lee et al, 1995229 Clinic (secondary care) 631 Malaysia Shriwas et al, 1996274 Clinic (secondary care) 131 Nauru Collins et al, 1989275 Population based 318 New Zealand (European) Simmons et al, 1994276 Clinic (primary and secondary care) 297 New Zealand (Pacific Islanders) Simmons et al, 1994276 Clinic (primary and secondary care) 123 Philippines Lantion-Ang, 2000277 Clinic (primary care) 359 Samoa Collins et al, 1995278 Population based 141 Singapore Thai et al, 1990231 Population based 117 Taiwan Fuh, 2002d,232 Clinic (secondary care) 4,535 Thailand Thai Multicenter Group, 1994234 Clinic (secondary care) 2,060 Viet Nam Diabcare Asia, 2003d,273 Clinic (primary care) 521

A/CR AER DM N/A

albumin/creatinine ratio albumin excretion rate diabetes mellitus not available

a. Diagnosis of nephropathy required two or more urine samples b. Extra details supplied by authors c. Abstract only d. Unpublished data e. More than one centre used to derive prevalence figure

132

CHAPTER 1


Age (yrs)

Duration DM (yrs) Overt diagnostic criteria Microalbuminuria diagnostic criteria

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


CHAPTER 1

133

Table 1.53 Prevalence of diabetic neuropathy

Prevalence of diabetic neuropathy (%)

134

Region Country/territory

Data used UnDM Type 1 DM Type 2 DM Total DM

AFR South Africa Tanzania, United Republic of Zambia EMME Egypt Saudi Arabia Sudan EUR Austria Belgium Croatia Czech Republic Finland France Germany Greece Hungary Ireland Israel Italy Luxembourg Netherlands Poland Portugal Romania Spain Sweden Turkey Ukraine United Kingdom NA United States of America SACA Brazil

Levitt et al, 1997243 Wikblad et al, 1997280 Rolfe, 1988245 Herman et al, 1998246 Arab et al, 2002188 Nielsen, 1998281 Akbar et al, 2000282 Elmahdi et al, 1991190 Muhlhauser et al, 1992191 EuroDiab, 1996a,283 Kastenbauer et al, 2004284 EuroDiab, 1996a,283 Van Acker et al, 2001192 EuroDiab, 1996a,283 Perusicova et al, 1993b,250 Partanen et al, 1995285 EuroDiab, 1996a,283 EuroDiab, 1996a,283 Delcourt et al, 1998197 Detournay et al, 2000286 EuroDiab, 1996a,c,283 EuroDiab, 1996a,c,283 Manes et al, 2002287 EuroDiab, 1996a,283 EuroDiab, 1996a,283 Norymberg et al, 1991254 Veglio et al, 1993288 EuroDiab, 1996a,c,283 Fedele et al, 1997289 EuroDiab, 1996a,283 Verhoeven et al, 1991201 Reenders et al, 1993202 EuroDiab, 1996a,283 Spijkerman et al, 2003257 EuroDiab, 1996a,283 EuroDiab, 1996a,283 EuroDiab, 1996a,283 Esmatjes et al, 1996208 Cabezas-Cerrato, 1998290 Arteagoitia et al, 2003210 Lundman et al, 1998211 Bolukbasi, 1998b,291 Bürö et al, 2004292 Kravchenko et al, 1996259 Walters et al, 1992293 Young et al, 1993294 Kumar et al, 1994295 EuroDiab, 1996a,283 Abbott et al, 2005296 Orchard et al, 1990263 Franklin et al, 1990297 Dyck et al, 1993182 Lavery et al, 2003298 Gregg et al, 2004299 Foss et al, 1989a,b,265

CHAPTER 1

• • • 13.6 • • • • • • • • • • • 8.3 • • • • • • • • • • • • • • • • • 48.1 • • • • • • • • • • • • • • • • • • • • •

• • • • • • • • • 23.3 16.0 29.3 25.7 57.6 32.8 • 26.1 21.2 • • 20.1 25.5 • 29.0 24.1 • 28.5 26.0 • 21.5 • • 23.9 • 25.6 36.9 65.8 • 12.9 • 22.8 • • • 12.8 22.7 • 22.7 • 32.4 • 54.0 • • •

• • • • • 19.7 • 31.5 • • 37.5 • 38.3 • • • • • 28.8 8.8 • • • • • 23.4 • • • • 18.0 68.0 • • • • • 20.0 24.1 19.0 27.9 • 60.0 • 17.2 32.1 41.6 • • • 27.8 45.0 • • 50.9

27.6 28.1 31.2 21.9 55.0 • 56.0 • 26.0 • • • 33.7 • • • • • • • • • 33.5 • • • • • 32.3 • • • • • • • • • 22.7 • 27.3 26.9 • 27.9 16.8 28.5 • • 21.2 • • 47.6 41.4 28.5 •


Prevalence of diabetic neuropathy (%) Region Country/territory

Data used UnDM Type 1 DM Type 2 DM Total DM

SEA Bangladesh India Mauritius Sri Lanka WP Australia China China, Hong Kong Indonesia Japan Korea, Republic of Malaysia Philippines Singapore Taiwan Thailand Viet Nam

Chuang et al, 2002a,221 Ramachandran et al, 1999222 Ramachandran et al, 2000223 Shaw et al, 1998180 Fernando, 1996300 Weerasuriya et al, 1998268 Tapp et al, 2004269 Chuang et al, 2002a,221 Ko et al, 1999271 Chuang et al, 2002a,221 Kawano et al, 2001181 Chuang et al, 2002a,221 Chuang et al, 2002a,221 Chuang et al, 2002a,221 Thai et al, 1990231 Chuang et al, 2002a,221 Wang et al, 2000301 Fuh, 2002d,232 Hsu et al, 2005302 Tandhanand et al, 2001236 Chuang et al, 2002a,221

• • • 3.6 • 10.0 7.1 • • • • • • • • • • • • • •

• • 3.0 • • • • • • • • • • • • • • • • • •

• 15.0 27.5 • • • • 12.7 30.6 • • • 13.1 • • 31.0 7.6 7.3 • 55.0 • 41.4 • 33.0 • 61.0 • 42.0 • (incl UnDM)15.9 • 12.0 • 32.4 24.4 • 32.4 • • 27.0 • 44.0

DM Total DM UnDM

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

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


CHAPTER 1

135

Table 1.54 Data sources: Prevalence of diabetic neuropathy Region Country/territory


AFR South Africa Tanzania, United Republic of Zambia EMME Egypt Saudi Arabia Sudan EUR Austria Belgium Croatia Czech Republic Finland France Germany Greece Hungary Ireland Israel Italy Luxembourg Netherlands Poland Portugal Romania Spain Sweden Turkey Ukraine United Kingdom NA United States of America SACA Brazil

Levitt et al, 1997243 Wikblad et al, 1997280 Rolfe, 1988245 Herman et al, 1998246 Arab et al, 2002188 Nielsen, 1998281 Akbar et al, 2000282 Elmahdi et al, 1991190 Mühlhauser et al, 1992191 EuroDiab, 1996a,283 Kastenbauer et al, 2004284 EuroDiab, 1996a,283 Van Acker et al, 2001192 EuroDiab, 1996a,283 Perusicova et al, 1993b,250 Partanen et al, 1995285 EuroDiab, 1996a,283 EuroDiab, 1996a,283 Delcourt et al, 1998197 Detournay et al, 2000286 EuroDiab, 1996a,c,283 EuroDiab, 1996a,c,283 Manes et al, 2002287 EuroDiab, 1996a,283 EuroDiab, 1996a,283 Norymberg et al, 1991254 Veglio et al, 1993288 EuroDiab, 1996a,c,283 Fedele et al, 1997289 EuroDiab, 1996a,283 Verhoeven et al, 1991201 Reenders et al, 1993202 EuroDiab, 1996a,283 Spijkerman et al, 2003257 EuroDiab, 1996a,283 EuroDiab, 1996a,283 EuroDiab, 1996a,283 Esmatjes et al, 1996208 Cabezas-Cerrato, 1998290 Arteagoitia et al, 2003210 Lundman et al, 1998211 Bolukbasi, 1998b,291 Börü et al, 2004292 Kravchenko et al, 1996259 Walters et al, 1992293 Young et al, 1993294 Kumar et al, 1994295 EuroDiab, 1996a,283 Abbott et al, 2005296 Orchard et al, 1990263 Franklin et al, 1990297 Dyck et al, 1993182 Lavery et al, 2003298 Gregg et al, 2004299 Foss et al, 1989a,b,265

Clinic (primary care) Clinic (secondary care) Clinic (secondary care) Population based Clinic (primary care) Clinic (secondary care) Clinic (secondary care) Clinic (secondary care) Clinic (primary care) Clinic (secondary care) Clinic (secondary care) Clinic (secondary care) Clinic (secondary care) Clinic (secondary care) Register Clinic Clinic (secondary care) Clinic (secondary care) Clinic (secondary care) Clinic (primary and secondary care) Clinic (secondary care) Clinic (secondary care) Population based Clinic (secondary care) Clinic (secondary care) Clinic (secondary care) Clinic (secondary care) Clinic (secondary care) Clinic (secondary care) Clinic (secondary care) Population based Clinic (primary care) Clinic (secondary care) Clinic (primary care) and population based Clinic (secondary care) Clinic (secondary care) Clinic (secondary care) Clinic (primary and secondary care) Population based Clinic (primary care) Clinic (primary and secondary care) Clinic (secondary care) Clinic (secondary care) Clinic (secondary care) Population based Clinic (secondary care) Clinic (primary care) Clinic (secondary care) Population based Clinic (secondary care) Population based Population based Clinic (primary and secondary care) Population based (NHANES) Clinic (secondary care)

243 153 600 509 2,000 375 237 413 395 116 350 116 1,653 132 1,443 132 138 104 427 4,119 229 216 821 138 116 1,019 379 894 8,757 107 137 387 134 255 117 130 114 1,157 2,644 2,920 4,027 297 866 4,123 1,077 6,487 811 181 15,692 588 279 359 1,666 419 546

136

CHAPTER 1


Age (yrs)

Duration DM (yrs)

20-85 mean=44 ≥35 ≥20 20-70 median=50 mean=54 20+ mean=67 15-60 57.1 (11.9) 15-60 21-69 15-60 >18 45-65 15-60 15-60 35-74 mean=66 15-60 15-60 18-70 15-60 15-60 ≥31 15-59 15-60 18-70 15-60 mean=68 mean=68 15-60 62.9 (7.0) 15-60 15-60 15-60 45-70 15-74 68 (11) ≥18 N/A 57.2 (10.3) 14-75 30-80+ 18-90 34-96 15-60 61.4 (13.8) mean=24 20-74 57 69.1 (11.1) 40+ 25-84

Diagnostic tool

8 ± 8 Clinical score 5 ± 6 Clinical score (NDS, NSS), quantitative sensory testing 7 ± 6 Clinical score N/A Quantitative sensory testing N/A Clinical score median=8 Clinical score 11 ± 7 Clinical score (DNI) N/A Clinical score N/A Quantitative sensory testing 16 ± 10 Clinical score, quantitative sensory testing, autonomic function tests 11.8 (9.7) NSS (Michigan Neuropathy Screening Instrument) 15 ± 9 Clinical score, quantitative sensory testing, autonomic function tests range 5-27 Quantitative sensory testing 14 ± 9 Clinical score, quantitative sensory testing, autonomic function tests N/A N/A 0 ± 0 Clinical score, electrophysiology 15 ± 10 Clinical score, quantitative sensory testing, autonomic function tests 16 ± 10 Clinical score, quantitative sensory testing, autonomic function tests 11 ± 7 Clinical score, quantitative sensory testing 9 ± N/A Medical record review 15 ± 10 Clinical score, quantitative sensory testing, autonomic function tests 13 ± 8 Clinical score, quantitative sensory testing, autonomic function tests 8 ± 7 Clinical score (NDS, NSS), quantitative sensory testing 15 ± 9 Clinical score, quantitative sensory testing, autonomic function tests 15 ± 9 Clinical score, quantitative sensory testing, autonomic function tests 12 ± 9 Clinical score N/A Clinical score, autonomic function tests 14 ± 9 Clinical score, quantitative sensory testing, autonomic function tests 12 ± 9 Clinical score (DNI) 14 ± 9 Clinical score, quantitative sensory testing, autonomic function tests 8 ± 7 Clinical score 8 ± 6 Clinical score, autonomic function tests 16 ± 10 Clinical score, quantitative sensory testing, autonomic function tests 0 Quantitative sensory testing (monofilament) 15 ± 10 Clinical score, quantitative sensory testing, autonomic function tests 15 ± 10 Clinical score, quantitative sensory testing, autonomic function tests 13 ± 8 Clinical score, quantitative sensory testing, autonomic function tests 9 ± 7 Clinical score 10 ± 0 Clinical score (NDS, NSS) 8.1 (5.4) Clinical score, quantitative sensory testing 10 ± 7 Clinical score, quantitative sensory testing N/A Clinical score, electrophysiology 8.5 (7.1) NDS, NSS N/A Clinical score N/A Clinical score, quantitative sensory testing range 0-62 Clinical score (NDS, NSS) 7 ± N/A Clinical score (NDS), quantitative sensory testing 17 ± 10 Clinical score, quantitative sensory testing, autonomic function tests mean=5.0 Clinical score (NDS) 16 ± N/A Clinical score N/A Clinical score N/A Clinical score (NSS, NDS, NSP), quantitative sensory testing, electrophysiology, autonomic function test 11.2 (9.5) Quantitative sensory testing (monofilament, VPT) N/A Quantitative sensory testing (monofilament) 8 ± 7 Clinical score, quantitative sensory testing


CHAPTER 1

137

Table 1.54 Data sources: Prevalence of diabetic neuropathy Region Country/territory


SEA Bangladesh India Mauritius Sri Lanka WP Australia China China, Hong Kong Indonesia Japan Korea, Republic of Malaysia Philippines Singapore Taiwan Thailand Viet Nam

Chuang et al, 2002a,221 Ramachandran et al, 1999222 Ramachandran et al, 2000223 Shaw et al, 1998180 Fernando, 1996300 Weerasuriya et al, 1998268 Tapp et al, 2004269 Chuang et al, 2002a,221 Ko et al, 1999271 Chuang et al, 2002a,221 Kawano et al, 2001181 Chuang et al, 2002a,221 Chuang et al, 2002a,221 Chuang et al, 2002a,221 Thai et al, 1990231 Chuang et al, 2002a,221 Wang et al, 2000301 Fuh, 2002d,232 Hsu et al, 2005302 Tandhanand et al, 2001236 Chuang et al, 2002a,221

Clinic (secondary care) Clinic (secondary care) Clinic (secondary care) Population based Clinic (secondary care) Clinic (primary care) Population based Clinic (secondary care) Clinic (secondary care) Clinic (secondary care) Clinic Clinic (secondary care) Clinic (secondary care) Clinic (secondary care) Population based Clinic (secondary care) Population based Clinic (secondary care) Population based Clinic (secondary care) Clinic (secondary care)

1,606 3,010 617 847 500 597 821 2,344 150 2,084 6,472 948 1,045 2,635 117 1,625 219 4,535 587 2,314 1,179

DM DNI N/A NDS NSP NSS VPT

diabetes mellitus diabetic neuropathy index not available neuropathy disability score neuropathy symptom profile neuropathy symptom score vibration perception threshold

a. b. c. d.

138

Extra details supplied by authors Abstract only More than one centre used to derive prevalence figure Unpublished data

CHAPTER 1


Age (yrs)

Duration DM (yrs)

Diagnostic tool

10-91 mean=52 10-50 ≥25 30-60 25-65 ≥25 7-92 18 73 toe • N/A 93 toe 7,079 all 52 toe 9,710 mean=62 122 toe N/A N/A 79 toe N/A N/A 79 above ankle • 70.9 (12.6) 167 toe • 70.9 (12.6) 167 tibia • all 926 toe 2,106 all 84 toe 2,015 N/A 57 toe 1,666 69.1 (11.1) N/A toe N/A N/A 307 toe 3,515 ≥40 N/A toe • N/A N/A N/A 3,010 mean=52 21 N/A 847 mean=54 2 • 500 30-60 24 N/A 447 35-54 3 toe 2,115 18 N/A 65 (12) 4-17 15-60 15-60 35-74 mean=66 15-60 mean=66 15-60 15-60 15-60 31-71+ mean=60 15-60 40+ 69.7 (10.2) 15-60 mean=68 mean=68 15-60 62.9 (7.0) 8-30 mean=66 N/A

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