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EpidemiologyofDiabetes
Dr.ShabanaTharkar

WHOhasdefinedHealthas"astateofcompletephysicalmentalandsocialwell
being and not merely an absence of disease or infirmity". Any form of functional
abnormality or deviation from the above definition refers to ill health, which may
resultinaneventordeath.

Diabetes, a chronic disorder, affects multiple organs and destroys the normal
functional capacity. Diabetes is associated with modifiable and unmodifiable risk
factorswhichmaydirectlyorindirectlyinfluencestheincidenceandtheprevalenceof
diabetes.

ICEBERGPHENOMENON

Thediagnosedcasesofdiabetesmellitus,representsonlythetipoftheiceberg.
The huge hidden mass is the submerged portion which is represented by the
undiagnosed cases which can represent diabetes and prediabetes conditions. The
issues and challenges regarding the prevention of diabetes are targeted towards this
proportionoftheunidentifiedcasesinthecommunity.

EPIDEMIOLOGYOFTYPE1DIABETES

Globalincidence:Thereisawidevariationintheincidenceoftype1diabetes
betweenthepopulationsacrosstheglobe.HighincidenceisseeninFinland(49cases
per100000/year),Sardinia(37cases)andSweden5(32cases),whilelowincidenceis
seen in certain provinces of china and Venezuela (0.1 cases per 100000 / year) and
Ukraine. The incidence varies between 10 and 20 per 100000 / year in regions of
northernAfrica6

AgeandSexdistribution:Thereareseveralstudiesreportingthepatternofage
Distribution711. In most population there are two peaks of steep increase in the
incidenceoftype1ofdiabetes.Oneisamongthechildrenbelow5yearagegroupand
theotherpeakisbetween1014yearsagegroup6.(ReferTable1)
Table1:AgespecificincidenceofTypeIdiabetesinchildrenagedupto14years(per
100,000population)

Region Incidence
Country&Area Males Females
04y 59y 1014y 05y 59y 1014y
Canada
PrinceEdwardIsl. 28.6 31.3 32.2 8.5 25.1 38.5
CentralAmericaandthe
Westindies 1.5 3.4 2.5 1.9 3.0 3.5
Cuba
SouthAmerica
Brazil 2.4 5.3 10.1 7.6 2.7 8.5
Asia
China 0.3 0.3 0.6 0.3 1.5 0.6
Israel 2.2 4.5 6.5 2.7 9.1 8.2
Japan 0.5 0.8 2.2 1.5 2.6 4.2
RepublicofKorea 0.4 0.2 1.0 0.4 0.5 0.9
Kuwait 14.9 16.7 18.7 10.7 14.8 17.9
Russia 2.3 2.8 8.7 1.9 4.9 7.8

Oceania
Australia 7.1 14.0 21.0 8.5 17.6 22.1
NewZealand 4.2 5.2 20.9 10.8 7.2 20.1
Europe
Australia 5.1 8.2 10.3 4.5 8.3 9.9
Belgium 3.7 12.5 11.6 5.8 11.2 14.1
Croatia 2.2 9.1 12.3 3.4 4.8 12.6
Denmark 16.5 12.4 35.6 8.5 26.2 29.6
Estonia 3.1 11.O 18.1 3.2 13.5 13.3
Finland 28.0 39.6 45.3 27.1 38.1 35.5
France 5.4 8.6 9.5 3.8 9.9 12.7
Greece 2.8 4.7 10.5 2.2 5.9 10.1
Hungary 4.5 8.2 10.4 4.3 7.6 10.8
Norway 13.4 26.3 27.3 7.9 26.2 23.8
Romania
Bucharest 0.7 2.5 10.5 5.1 6.0 5.9
Spain
Catalonia 4.7 9.8 17.0 3.4 10.9 17.7
Sweden 16.8 25.4 31.6 14.5 26.3 29.4
UnitedKingdom 10.0 12.9 18.8 9.7 13.6 16.7
Reproduced from, Epidemiology of Diabetes Mellitus an international perspective.
JohnWileypublicationsEditionbyJeanMarie,PaulZimmetandRhysWilliams.

AfewstudiesinEuropeanpopulationhavereportedmalepreponderancewhileAfrican
andAsianstudiesreportedFemalepreponderance12

THEINDIANSCENARIO

Type1diabetesislessprevalentinIndianpopulationandaccountsfor5%ofthe
total diabetic population. The overall incidence calculated during the period from
January1991toDecember1994evens10.5per100000personyears.Thereispaucity
intheavailabilityofdataonincidenceofdiabetesinIndianchildren.Toovercomethis,
an TDDM registry group was formed in 1995 in Chennai comprising doctors from
varioushospitalsthattreattype1diabetesmellituspatients.Theincidenceamongthe
boyswassignificantlyhigher12.611per100000personyearsthanthegirls9.6
4.7per100000personyears.Therewasasteepriseseeninthe1015yearsagegroup
inbothboysandgirls.However,studiesdoneinAsiarevealmuchlowerIncidence13.

RISKFACTORSFORTYPE1DIABETESMELLITUS:

Theetiologyoftype1diabetesisstillunclearthoughthereissomeamountof
genetic and environmental influence.1415 The evidences are weak and a lot of
researchhastobedonetoestablishtheassociationofriskfactorswithtype1diabetes
mellitus(ReferTable2).

Table2
Possibleassociationwithviralinfections
Cowsmilkprotein
Nnitrosocompounds
Lowlevelofzinc
DeficiencyofvitaminD
Increasedbirthweightandmoreweightgain
Increasedmaternalageatbirth
Familialclustering

TABLE3:GLOBALPREVALENCESOFDIABETESANDIGT

2007 2025
Totalworldpopulation(billions) 6.6 7.9
Adultpopulation(2079years) 4.1 5.2
No.ofpeoplewithDiabetes(millions) 233 358
WorldDiabetesprevalence(%) 5.7 6.8
No.,ofpeoplewithIGT(millions) 308 418
WorldIGTprevalence(%) 7.5 8.0

Source:IDFDiabetesAtlas
EPIDEMIOLOGYOFTYPE2DIABETES:
Globalprevalence:
Currently the trend of modification and urbanization is taking its toll in the form of
risingprevalencesofnoncommunicablediseases.
TheInternationalDiabetesFederationDirectory,in1994showedthattheglobal
burdenofthediseasewasestimatedat110millionandthisfigureislikelytoincrease
furtherto239millionby2010andto358millionby2025.WorldhealthOrganization
alsohasproducedareportusingepidemiologicalinformationandestimatedtheglobal
burdenat135millionin1995withthenumberreaching299millionby2025.
These predictions of prevalence estimates of Diabetes though vary, due to
differences in country specific estimates; they are remarkably similar at the global
level.Type2diabetesisreportedtohavethehighestprevalenceinNauruIslands,Pima
Indians, south Asians and certain particular ethnic groups of population. The
prevalence of impaired glucose tolerance is also rising concomitantly in many
populations
Details of prevalences of Diabetes and IGT among the world population are
shownintables4&5fortheyears2007and2025.

Table4: Regional estimates for diabetes (2079 age group), 2007 and 2025;
prevalencesadjustedtoworldpopulation

Regions 2007 2025

Population No.of Diabetes Population No.of Diabetes
inmillions people prevalence inmillions people prevalence
with (%) with (%)
diabetes diabetes
Africa 336 10.4 3.6 537 18.7 4.5
East 318 24.5 9.2 492 44.5 10.4
Mediterranean
Europe 634 53.2 6.6 653 64.1 7.8
NorthAmerica 306 26.8 8.0 376 38.4 9.3
SouthAmerica 272 16.2 6.3 364 32.7 9.3
Southeast 770 34.5 4.8 1,083 59.5 5.9
Asia
WestPolynesia 1,468 67.1 4.4 1,731 99.6 5.2
Total 4,106 232.6 5.7 5,236 357.5 6.8

Source:IDFDiabetesAtlas

Table5:Regionalestimatesforimpairedglucosetolerance(IGT)(2079agegroup),
2007and2025;prevalencesadjustedtoworldpopulationRegions20072025

Regions 2007 2025

Population No. of IGT Population No.of IGT
inmillions people prevalence inmillions people prevalence
with (%) with (%)
IGT IGT
Africa 336 24.2 8.2 537 40.3 9.2
East 318 22.4 8.0 492 38.6 8.6
Mediterranean
Europe 634 53.3 9.1 653 71.2 9.6
NorthAmerica 306 19.9 5.8 376 28.0 6.7
SouthAmerica 272 19.8 7.5 364 27.6 7.9
SoutheastAsia 770 45.2 6.0 1,083 70.5 6.7
WestPolynesia 1,468 111.9 7.5 1,731 142.7 7.8
Total 4,106 308.5 7.5 5,236 418.8 8.0

DIABETESININDIA

Forcenturiesithasbeenknownthatdiabetesmellitusisadiseaseofthehigh
class,buttherecentstudieshavedemonstratedthatthisisalsopreventinlowersocial
economicgroupofwraps.Nationalurbandiabetes(NUDS)surveywasdonein2001by
DESI.Theagestandardizedprevalenceoftype2diabeteswas12.1%usingtheWHO
criteria for diagnosis of diabetes. The study showed the following age adjusted
prevalencesin6majorcitiesinIndia.

1. Hyderabad 16.6%
2. Chennai 13.5%
3. Bangalore 12.4%
4. Calcutta 11.7%
5. NewDelhi 11.6%
6. Bombay 9.3%

URBANRURALDIFFERENCES

TheprevalenceofdiabetesvarieswithinIndiaitself.Beinglifestylerelated,itis
3timesmoreprevalentinurbanareaswhencomparedtoruralareas2Interregional
differenceswithinthestateofKeralashowstheprevalenceof12.4inurbanareas,8.1
% in semi urban and 2.5 in coastal areas1. Ahuja MMS conducted several surveys
among the rural populations of North India and showed prevalences of diabetes
rangingfrom0.4%inruralareasofHimachalPradeshto3.9%inruralGujarat.

The contributing factors to the differences in prevalence between urban and

ruralpopulationsarechanginglifestylesduetomodernization:increasedconsumption
of fat rich diet and decreased physical activity among people in urban areas lead to
raisedprevalenceofdiabetesandalsometabolicsyndrome,

INCREASINGTREND

Population studies done by Diabetes Research Centre at Chennai, at regular

intervals showed that the prevalence of diabetes, is increasing at an alarming rate.
Shown below is the 'stepladder fashion' increase in the prevalence of diabetes over
theyears.
RISKFACTORSASSOCIATEDWITHDIABETES:

The combination of the genetic factors epidemiological transition influencing

changes in dietary patterns, physical inactivity and increased stress in today's world,
contributetothehighprevalence.

TheIndiansareespeciallypredisposedtothedevelopmentofdiabetes.Thereis
increase in incidence of type 2 diabetes mellitus even among young age groups in
Indian population. Literature suggests that certain features are unique for Indians
resulting in lower threshold for development of diabetes when compared to the
western population. The unique features which predispose to diabetes mellitus for
Indian are increased insulin resistance, increased waist circumstance and greater
abdominaladiposityinspiteofhavingevenlowerbodymassindex.

MORTALITYANDMORBIDITYRELATEDTODIABETES:

The mortality in diabetes is seriously underestimatedas a minority of persons

dies from unique diabetes trelated conditions like diabetic ketoacidosis or
hypoglycemia.Mortalityattributabletodiabetesgloballyinadults(2070yearsold)is
estimatedtobe3.5milliondeathswhichisroughly6%oftotalworldmortality.About
50% of people with diabetes die due to cardiovascular disease and 1020% die from
renalfailure.

Table 6: Number of deaths attributable to diabetes in 2007 in South East

Asianregion*

Country Male Female

No.ofpersons (%) No.ofpersons (%)
Bangladesh 23,573 6.2 49,729 13.6
Bhutan 306 4.7 533 9.7
Indian 249,054 6.1 390,905 11.8
Maldives 65 7.7 133 16.9
Mauritius 510 11.8 633 23.5
Nepal 3,869 5.1 11,082 13.6
Srilanka 7,154 8.8 10,287 22.1
Total 284,531 463,302
*SourceIDFdiabetesAtlas

 Theprevalenceofcomorbidconditionsassociatedwithlongstandingdiabetes
especiallythemicrovascularandmacrovascularcomplicationsisalsoontherise(Refer
Table 7.). Prevalence of hypertension varies between 3038% among the diabetic
patient

Table7:PrevalenceofComplicationsinType2diabetes.
Typeofcomplications*17 Prevalence%

1. Retinopathy 37.2

2. Peripheralvasculardisease 4.3
3. Neuropathy 25.3
4. Nephropathy 15

5. Coronaryarterydisease 11.9


The prevalence of foot infection is higher among the diabet patients from the
ruralareas(34%)thantheurbancounterpart(26%).Footamputationduetodiabetes
is also more prevalent in the rural areas (13%), while it is 8% among the diabetic
patientsfromurbanareas4.
PRIMARYPREVENTIONOFDIABETES
Duetothenaturalhistoryofthediseaseandstagesinevolution,thegoodnewsisthat
DiabetesisPREVENTABLEatanearlystage.
Differentstagesinthedevelopmentofdiabetesmellitus

 Prediabetesstages'
EGI EarlyGlucoseIntolerance
IFG ImpairedFastingGlucose
IGT ImpairedGlucoseTolerance

Primary prevention of diabetes is possible by lifestyle modifications, healthy diet,

exercise and by weight reduction.16 Diabetes drugs like metformin, acarbose and
glitazoneshavealsobeenstudiedforprimarypreventionofdiabetes.

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