Africa

The health landscape of sub-Saharan Africa is dominated by poverty and a high burden of infectious diseases, including HIV/AIDS and malaria. The continuing high burden of infectious disease tends to dominate the health policy agenda, despite growing evidence of the increasing impact of diabetes and other chronic non-communicable diseases in Africa. This is particularly the case within urban areas where the age-specific prevalences of diabetes, obesity and hypertension often approach or exceed those in richer parts of the world. As urbanization continues and populations age, diabetes is set to become one of the major health problems of the region. Even now it is estimated that at least 1 in 20 deaths of those aged 20 to 79 years is due to diabetes. The evidence suggests that children with type 1 diabetes often go undiagnosed, or if diagnosed do not have access to insulin, and die as a result. In 2009 the IDF African Region launched its action plan to tackle the escalating threat from diabetes.

Diabetes and IGT prevalence

There will be an estimated 12.1 million people, or 3.2% of the adult population, with diabetes in the African Region. There are marked differences between the rates of diabetes prevalence among different communities in sub-Saharan Africa. The highest prevalences are among the ethnic Indian population of Tanzania 1  and South Africa 2 . There is also a marked urban/rural difference in diabetes prevalence, with consequent likely increases as more people move to urban areas.

The availability of prevalence and incidence data for sub-Saharan Africa is very limited, with the result that data had to be extrapolated from distant and probably dissimilar countries and populations. There is, therefore, a great need for further epidemiological investigation in the region. Such a need can also be linked with the high proportion of diabetes that has not been previously detected, but found only at the time of surveying. Undiagnosed diabetes accounted for 85% of those with diabetes in studies from South Africa 3 , 80% in Cameroon 4 , 70% in Ghana 5  and over 80% in Tanzania 6 .

The impact of type 2 diabetes is bound to continue if nothing is done to curb the rising prevalence of impaired glucose tolerance, which now varies between 0.9% and 14.7% of the adult population. According to estimates today, the number of people with diabetes is expected to double in the next 20 years to 23.9 million in 2030.

Mortality

More than 330,000 people are expected to die from diabetes-related causes in this region, accounting for 6% of all deaths in the 20-79 age group in 2010. It is significant to note that people in the 30-39 age group will account for the highest number at about 78,000 deaths. This age group will also have the highest percentage of deaths due to diabetes compared to other age groups (see Figure 3.1).

National Diabetes Programmes

Less than half of the countries that responded to the IDF member association survey had a national diabetes programme, and of these, only one-third had implemented the programme. Important areas that NDPs focused on included routine clinical care, community awareness, essential medication and supplies, and secondary prevention of complications.

Map 3.1 Prevalence (%) estimates of diabetes (20-79 years), 2010, African Region

Europe

There exists a great diversity of populations and affluence among the 54 countries and territories in the European Region, with gross domestic product (GDP) varying from over USD85,000 per capita for Luxembourg to less than USD2,000 for several countries in eastern Europe 1 .

Diabetes and IGT prevalence

The number of adults with diabetes in this region is expected to reach 55.2 million, accounting for 8.5% of the adult population in 2010. National prevalence rates for diabetes show a wide variation from 2.1% in Iceland to 12.0% in Germany. Abnormal glucose tolerance in this region shows little association with affluence, and there was no evidence that any difference in urban/rural prevalence existed except in a few countries.

There is a paucity of good data for diabetes in the adult population from many of the more affluent countries of the region. Much of the data is based on surveys establishing the prevalence of ‘known diabetes’. Although there is a lack of data from several of the eastern European countries, available data  2   3   4  suggest high levels of diabetes currently, and such high levels of IGT that the diabetes prevalence will almost certainly increase by 2030 to levels above those projected.

This region, however, had by far the most complete and reliable data for type 1 diabetes in children, compared with other regions, with a large proportion of countries having registries that were either nationwide or cover several different parts of the country. About 112,000 children and adolescents are estimated to have type 1 diabetes in the region. The countries making the largest contribution to the overall numbers in type 1 diabetes in the young are the United Kingdom, Russia and Germany.

Mortality

More than 630,000 people are expected to die from diabetes-related causes in 2010. This will account for 11% of all deaths in the 20-79 age group. Although more men than women die of diabetes-related causes below the age of 70, the percentage of diabetes-related deaths in women is markedly higher after 40 years of age (see Figure 3.2)

National Diabetes Programmes

More than 60% of countries that responded to the IDF member association survey indicated that there was a national diabetes programme in their country. Routine clinical care and secondary prevention of diabetes complications were among the important topics addressed by NDPs. Significant aspects of the diabetes burden that were monitored included essential medications and supplies, and prevalence and incidence of the disease.

Map 3.2 Prevalence (%) estimates of diabetes (20-79 years), 2010, European Region

Middle East and North Africa

 
Six countries in the Middle East and North African Region are among the world’s 10 highest for diabetes prevalence and a similar situation applies for the IGT prevalence. These countries are Bahrain, Egypt, Kuwait, Oman, Saudi Arabia and United Arab Emirates. The ageing of populations, together with socio-economic and lifestyle changes, has resulted in the dramatic increase in diabetes prevalence.

Over the past three decades, major social and economic changes have occurred in the majority of these nations. These include progressive urbanization, decreasing infant mortality and increasing life expectancy. Rapid economic development, especially among the more wealthy oil-producing countries, has been associated with tremendous modification in lifestyle towards the westernized pattern reflected by changes in nutrition, less physical activity, tendency to increased obesity and more smoking 1   2 .

Diabetes and IGT prevalence

The explosion of diabetes in the MENA Region is mainly due to type 2 diabetes. As with many other countries with high diabetes prevalence, the onset of type 2 diabetes tends to occur at a relatively young age. An estimated 26.6 million people, or 7.7% of the adult population, will have diabetes in 2010, with the number expected to nearly double in the next 20 years. Similarly, the number of people with IGT is also expected to rise markedly by 2030, raising the likelihood of further increases in the prevalence of diabetes as the century proceeds.

Reliable data for type 1 diabetes in children were also available in a number of countries in this region. By far the largest contribution to the total number of children with type 1 diabetes comes from Egypt whose estimates accounts for almost a quarter of the region’s total of 54,000 cases. The range of reported incidence varies from 22.3 per 100,000 aged 0-14 years per year in Kuwait to less than 1 per 100,000 aged 0-14 years in Pakistan (see Data Tables).

Mortality

Diabetes is the expected cause of some 290,000 deaths in this region, which will account for 11.5% of all deaths in the 20-79 age group in 2010. More women than men are expected to die from diabetes-related causes. In the 50-59 age group, mortality attributable to diabetes in women accounts for more than 20% of all deaths (see Figure 3.3).

Healthcare expenditure

In spite of the high estimates of diabetes prevalence in the MENA Region, the total healthcare expenditure for diabetes is expected to be only USD5.6 billion for the whole region. This is projected to account for only 1.5% of global spending. People with diabetes in the 50-59 age group are expected to incur the highest costs.

National Diabetes Programmes

A high percentage (80%) of countries that responded to the IDF member association survey indicated the existence of a national diabetes programme. In the majority of these countries, the NDP had been implemented. Primary prevention as well as screening and early diagnosis are important areas of focus in many of the NDPs in this region of extremely high diabetes prevalence. At the same time, NDPs monitored community awareness, and the prevalence and incidence of diabetes in their efforts to deal with the diabetes burden.

Map 3.3 Prevalence (%) estimates of diabetes (20-79 years) 2010, Middle East and North African Region

North America and Caribbean

The North America and Caribbean Region has the highest comparative prevalence of diabetes among the IDF regions with 10.2% in the adult population affected by the disease. The majority of the population in this region lives in the United States of America, Mexico and Canada. Although the region comprises 26 countries and territories, 68% of the adult population currently reside in the USA, with a further 21% living in Mexico and 8% in Canada, so that only 3% of the region’s adult population reside in the other 23 smaller nations.

Diabetes and IGT prevalence

An estimated 37.4 million people with diabetes live in this region, and the number is expected to increase by more than 40% to 53.2 million in 2030. The NAC Region is expected to continue to have the highest comparative prevalence in 2030 when 12.1% of adults are anticipated to have diabetes.

The high prevalence of abnormal glucose tolerance in the adult population for Canada and the USA are very much a consequence of their older age distribution, such that in 2010, 32% of their population will be over 50 years of age, and this is expected to rise to 36% by 2030 1 . This is in contrast to 18% of the Mexican population and 16% of the Caribbean population being over 50 years of age, increasing to 24% and 19%, respectively, by 2030.

As all the Caribbean islands other than Barbados, Guadeloupe, Haiti and Martinique had their estimates extrapolated from Jamaican data  2 , the differences in prevalence between these countries are a consequence only of their different age distributions.

There are an estimated 97,000 children with type 1 diabetes in the region. The USA estimate accounts for almost 90% of the region’s total, and to a lesser extent, the estimate for Canada predominates (see Data Tables).

There also has been a marked increase in the estimate of the number of adults with IGT for this region, indicating an urgent need for diabetes prevention programmes.

Mortality

More than 15% of all deaths in the 20-79 age group may be attributed to diabetes in the NAC Region in 2010. This amounts to more than 300,000 deaths. Diabetes-related events are expected to cause significantly more deaths in middle-aged women than men, and account for almost 30% of all deaths in women in the 50-59 age group (see Figure 3.4).

Healthcare expenditure

Healthcare expenditure for diabetes in the NAC Region is predicted to account for 57% of global spending. The USA alone will account for most of the USD214 billion expected to be spent in the region. Healthcare spending in this region is not significantly higher for women than for men, even though more deaths related to diabetes are thought to occur for middle-aged women than men in the same age group.

National Diabetes Programmes

The NAC Region had a relatively low response rate to the IDF member association survey on national diabetes programmes, with only one-third responding. Of these, slightly more than half reported having a NDP. Primary and secondary prevention as well psychological and behavioural issues were some of the important topics addressed by the NDPs. Several critical issues such as cost to the health system and individual, and prevalence and incidence of the disease were monitored by the NDPs in this region.

Map 3.4 Prevalence (%) estimates of diabetes (20-79 years), 2010, North America and Caribbean Region

South and Central America

The South and Central American Region encompasses 20 countries and territories, most of which are still developing economically. South America and Central America have similar age distribution profiles to each other. About 20% of the population will be older than 50 years in 2010, with this figure likely to increase to 28% by 2030. Thus the region has a markedly younger age distribution than most of North America. As urbanization continues and populations age diabetes will become an even greater public priority in this region.

Diabetes and IGT prevalence

An estimated 18 million people, or 6.3% of the adult population, will have diabetes in 2010. In the following 20 years, the number of people with diabetes is expected to rise by more than 60% to almost 30 million. In addition, current estimates indicate a further 21.2 million people, or 7.4 % of the adult population, will have IGT in 2010. There is a need for further epidemiological studies in this region as considerable extrapolation to obtain prevalence estimates was required. Only seven countries have any epidemiological data from which prevalence estimates could be derived.

Although the incidence of type 1 diabetes in children in the SACA Region is generally low, there are some sharp contrasts between the rates in neighbouring countries (see Appendix 1). A strong inverse ecological correlation has been reported in this region between a country’s incidence rate and the proportion of its population that is Amerindian (indigenous). This has influenced the selection of countries to use for extrapolation, but the choice still can make a considerable difference to the resulting estimate. The Brazilian estimate accounts for 70% of the region’s total of some 37,000 children.

Mortality

Although the number of excess deaths due to diabetes is lowest in this region compared to other regions, it nonetheless accounts for 9.5% of all deaths in the 20-79 age group. More than 170,000 men and women are expected to die from diabetes-related causes in 2010. Diabetes-related events are expected to be the cause of death in about 17% of all deaths in women in the 50-59 age group (See Figure 3.5).

Healthcare expenditure

Expenditure on diabetes and its complications is estimated at USD8.1 billion in the SACA Region, accounting for about 2% of the global total. Almost 30% of that spending is expected to be for people with diabetes in the 50-59 age group.

National Diabetes Programmes

More than half of the countries that responded to the IDF member association survey on national diabetes programmes reported that they had a NDP. All of these countries also indicated that it was being implemented. Screening and early diagnosis as well coronary vascular disease complications were among the important topics addressed by the NDPs. The programmes were also concerned with community awareness of diabetes, and essential medicines and supplies.

Map 3.5 Prevalence (%) estimates of diabetes (20-79 years), 2010, South and Central American Region

South-East Asia

Although the South-East Asian Region comprises only seven countries, it is one of the most populous regions in the world. The adult population of India will account for 85% of the region's total population in 2010. There is a wide gap in per capita GDP with Mauritius having the highest at USD12,400, while the other countries all have less than USD5,000, although India which has had an annual growth of 7.3% was experiencing economic development at a faster pace than almost anywhere in the world, except its neighbour, China 1 .

Diabetes and IGT prevalence

Current estimates show that 7.0% of the adult population, or 58.7 million people, will have diabetes in 2010. Studies 2   3  indicate that diabetes prevalence in smaller urban centres (100,000 – 1,000,000 inhabitants) tends to be about half of the larger cities, but still twice that of rural areas (less than 100,000 people).

The anticipated increase in regional diabetes prevalence to 8.4% in 2030 is very much a consequence of the increasing life expectancy in India (the proportion of the population over 50 years is expected to increase from 16% to 23% between 2010 and 2030), and of the urbanization of the population (the proportion living in urban settings will increase from 33% to 46%). Evidence suggests that in more affluent parts of the country, the rural prevalence is higher than in less affluent rural areas 4 , indicating that increasing economic growth will raise diabetes prevalence in India even more than these possibly conservative estimates have indicated. With regard to IGT, the same pattern as for diabetes emerged, with large cities having twice the prevalence of smaller cities, for which the prevalence is twice that of rural areas.

Mauritius, the second smallest country of the region, highlights the extent to which people of Indian origin appear predisposed to diabetes, when exposed to more affluent economic circumstances. This island has one of the world’s highest diabetes prevalence rates with 17% of the adult population affected by diabetes.

India accounts for most of the estimated 114,000 cases of type 1 diabetes in children in the region. The incidence rate for India was frequently used in extrapolation for other countries in the region and therefore plays a pivotal role in the estimates. The large childhood population in India and the widespread use of the Indian data for extrapolation have important consequences not only for the regional total but also for the worldwide estimate. This region contributes more than any other to the worldwide total. Diabetes-associated mortality in children is also likely to play an important role in this region, but unfortunately there is inadequate information to address these issues.

Mortality

The SEA Region is projected to have the highest number of deaths due to diabetes of all the regions in 2010. An estimated 1.1 million adults is expected to die from diabetes-related causes, accounting for 14.3% of all deaths in the 20-79 age group. Mortality due to diabetes may account for almost a quarter of all deaths in women in the 50-59 age group and 15% of deaths in men in the same age group (see Figure 3.6).

Healthcare expenditure

In spite of the large number of people with diabetes in the SEA Region, spending on healthcare for diabetes is expected to be only USD3.1 billion for the region, accounting for less than 1% of the global total. Most of the estimated spending is predicted to occur in India.

National Diabetes Programme

Only one-third of countries in this region responded to the IDF member association survey. According to survey responses, national diabetes programmes have yet to be implemented in this region.

Map 3.6 Prevalence (%) estimates of diabetes (20-79 years), 2010, South-East Asian Region

Western Pacific

The world’s most populous region, the Western Pacific, contains 39 disparate countries and territories with predicted populations for 2010 ranging from 1.4 billion for China to less than 5,000 in the smallest Pacific island nations of Niue and Tokelau. Similarly the economic profile varies from per capita GDPs of over USD35,000 for Australia, Hong Kong, Japan and Singapore to less than USD3,000 in one-third of the other countries 1 .

Countries with limited resources struggle with the double burden of managing infectious diseases and the diabetes epidemic. Many also face a lack of government awareness of the seriousness of the diabetes threat to their populations.

Diabetes and IGT prevalence

Some 76.7 million people, or 5% of the adult population, are projected to have diabetes in 2010. In the next 20 years, the number of people with diabetes is expected to increase by almost 50% to 112.8 million. There is a great range in the prevalence of diabetes in the region from the world’s highest found in the Micronesian population of Nauru with 31% of the adult population affected by diabetes to Mongolia with 1.6%.

The diabetes epidemic has the greatest potential to explode in China, simply because of its population size. Although the current prevalence there of 4.2% is among the region’s lowest, the high prevalence among Chinese populations in the more urbanized and affluent cities of Hong Kong and Singapore indicate what may develop as China rapidly urbanizes and expands economically (see Appendix 1). The data indicated for 2030 are likely to represent an underestimate of China’s diabetes problem if it continues to develop economically faster than almost any other country in the world.

Only some 6% of children with type 1 diabetes worldwide come from the WP Region, despite it having the largest childhood population. About 31,000 children are expected to have type 1 diabetes in 2010. With the exception of Australia and New Zealand, the incidence rates for type 1 diabetes in children in this region appear uniformly low. Despite its very low incidence, China accounts for almost 30% of the region’s total.

Mortality

Current estimates suggest that more than one million adults in the WP Region will die of diabetes-related causes in 2010, which will account for almost 10% of all deaths in the 20-79 age group. More men than women in the younger age groups are expected to die from causes attributable to diabetes. However, as in the other regions, diabetes will account for a higher percentage of deaths in middle-aged women than it will for middle-aged men (see Figure 3.7).

Healthcare expenditure

Expenditure on healthcare for diabetes in this populous region accounts for about 10% of the global total. At least USD38 billion is expected to be spent on healthcare for diabetes. The amount spent on healthcare per person is thought to vary greatly between countries, ranging from more than USD3,000 in Australia and Japan to less than USD10 in the Democratic Republic of Korea and Myanmar (see Data Tables).

National Diabetes Programmes

More than half the countries which responded to the IDF member association survey reported that they had a national diabetes programme, most of which had been implemented. Screening and early diagnosis, and routine clinical care were among those topics most frequently addressed by NDPs. Critical aspects of the diabetes burden such as essential medications and supplies, and total cases of treatment were also monitored by NDPs.

Map 3.7 Prevalence (%) estimates of diabetes (20-79 years), 2010, Western Pacific Region