Articles

Worldwide incidence and prevalence of inflammatory bowel

disease in the 21st century: a systematic review of
population-based studies
Siew C Ng*, Hai Yun Shi, Nima Hamidi, Fox E Underwood, Whitney Tang, Eric I Benchimol, Remo Panaccione, Subrata Ghosh, Justin C Y Wu,
Francis K L Chan, Joseph J Y Sung, Gilaad G Kaplan*

Summary
Background Inflammatory bowel disease is a global disease in the 21st century. We aimed to assess the changing Published Online
incidence and prevalence of inflammatory bowel disease around the world. October 16, 2017
http://dx.doi.org/10.1016/
S0140-6736(17)32448-0
Methods We searched MEDLINE and Embase up to and including Dec 31, 2016, to identify observational, population-
See Online/Comment
based studies reporting the incidence or prevalence of Crohn’s disease or ulcerative colitis from 1990 or later. A study http://dx.doi.org/10.1016/
was regarded as population-based if it involved all residents within a specific area and the patients were representative S0140-6736(17)32669-7
of that area. To be included in the systematic review, ulcerative colitis and Crohn’s disease needed to be reported *Contributed equally
separately. Studies that did not report original data and studies that reported only the incidence or prevalence of Department of Medicine and
paediatric-onset inflammatory bowel disease (diagnosis at age <16 years) were excluded. We created choropleth maps Therapeutics, Institute of
for the incidence (119 studies) and prevalence (69 studies) of Crohn’s disease and ulcerative colitis. We used temporal Digestive Disease, State Key
Laboratory of Digestive
trend analyses to report changes as an annual percentage change (APC) with 95% CI. Diseases, Li Ka Shing Institute
of Health Science, The Chinese
Findings We identified 147 studies that were eligible for final inclusion in the systematic review, including 119 studies of University of Hong Kong, Hong
incidence and 69 studies of prevalence. The highest reported prevalence values were in Europe (ulcerative colitis 505 per Kong Special Administrative
Region, China (Prof S C Ng PhD,
100 000 in Norway; Crohn’s disease 322 per 100 000 in Germany) and North America (ulcerative colitis 286 per 100 000 in H Y Shi PhD, W Tang MPhil,
the USA; Crohn’s disease 319 per 100 000 in Canada). The prevalence of inflammatory bowel disease exceeded 0·3% in Prof J C Y Wu MD,
North America, Oceania, and many countries in Europe. Overall, 16 (72·7%) of 22 studies on Crohn’s disease and Prof F K L Chan MD,
Prof J J Y Sung PhD);
15 (83·3%) of 18 studies on ulcerative colitis reported stable or decreasing incidence of inflammatory bowel disease in
Departments of Medicine and
North America and Europe. Since 1990, incidence has been rising in newly industrialised countries in Africa, Asia, and Community Health Sciences,
South America, including Brazil (APC for Crohn’s disease +11·1% [95% CI 4·8–17·8] and APC for ulcerative colitis University of Calgary, Calgary,
+14·9% [10·4–19·6]) and Taiwan (APC for Crohn’s disease +4·0% [1·0–7·1] and APC for ulcerative colitis +4·8% AB, Canada (N Hamidi MD,
F E Underwood MSc,
[1·8–8·0]).
Prof R Panaccione MD,
G G Kaplan MD); Children’s
Interpretation At the turn of the 21st century, inflammatory bowel disease has become a global disease with accelerating Hospital of Eastern Ontario
incidence in newly industrialised countries whose societies have become more westernised. Although incidence is Inflammatory Bowel Disease
Centre, Division of
stabilising in western countries, burden remains high as prevalence surpasses 0·3%. These data highlight the need for
Gastroenterology, Hepatology
research into prevention of inflammatory bowel disease and innovations in health-care systems to manage this complex and Nutrition, Children’s
and costly disease. Hospital of Eastern Ontario,
Ottawa, ON, Canada
(E I Benchimol MD);
Funding None.
Department of Pediatrics and
School of Epidemiology, Public
Introduction 21st century.4 Although the incidence of ulcerative colitis Health and Preventive
The inflammatory bowel diseases, Crohn’s disease and and Crohn’s disease increased in the western world in the Medicine, University of
Ottawa, Ottawa, ON, Canada
ulcerative colitis, are chronic idiopathic disorders causing latter half of the 20th century,4,5 little was known about the (E I Benchimol); Institute for
inflammation of the gastro-intestinal tract.1 In the past changing incidence in other parts of the world. Now, Clinical Evaluative Sciences,
decade, inflammatory bowel disease has emerged as a newer epidemiological studies suggest that incidence Toronto, ON, Canada
public health challenge worldwide.2 In North America might be rising rapidly in South America, eastern Europe, (E I Benchimol); NIHR
Biomedical Research Centre,
and Europe, over 1·5 million and 2 million people suffer Asia, and Africa. Additionally, an increase in disease Institute of Translational
from the disease, respectively.3 Outside the western world incidence among ethnicities and nationalities in whom Medicine, University of
(ie, countries influenced by a western European cultural inflammatory bowel diseases were previously uncommon Birmingham, Birmingham, UK
heritage, including the USA, Canada, Australia, New has substantial implications for the understanding of (Prof S Ghosh MD); and
Department of
Zealand, and all countries in western Europe), the pathogenesis and environmental triggers in differing Gastroenterology, Beijing
number of individuals affected by inflammatory bowel populations.6 This epidemiological shift, which is being Friendship Hospital, Capital
disease remains unclear.4 seen in newly industrialised countries and in Asian Medical University, National
Traditionally regarded as a disease of westernised immigrants to the west, mirrors the experience reported Clinical Research Center for
Digestive Disease, Beijing,
nations, the epidemiology of inflammatory bowel disease in the west more than 50 years ago, occurring with rapid China (H Y Shi)
is changing throughout the world at the turn of the socioeconomic development.7

www.thelancet.com Published online October 16, 2017 http://dx.doi.org/10.1016/S0140-6736(17)32448-0 1

 Articles

Correspondence to:
Dr Gilaad Kaplan, Departments
of Medicine and Community
Health Sciences, University of
Calgary, Calgary, AB T2N 4Z6,
Canada
ggkaplan@ucalgary.ca
or
Prof Siew C Ng, Department of
Medicine and Therapeutics,
Institute of Digestive Disease,
State Key Laboratory of Digestive
Diseases, Li Ka Shing Institute of
Health Science, The Chinese
University of Hong Kong, Hong
Kong Special Administrative
Region, China
siewchienng@cuhk.edu.hk
Research in context
Evidence before this study
In a previous systematic review, we searched MEDLINE from
1950 to 2010 (8103 citations) and Embase from 1980 to 2010
(4975 citations) for population-based studies that reported the
incidence or prevalence of Crohn’s disease or ulcerative colitis.
The search identified 260 population-based studies on the
incidence or prevalence of Crohn’s disease or ulcerative colitis.
Collectively, these studies defined the epidemiological patterns
of the inflammatory bowel diseases during the 20th century.
Since the 1950s, the incidence and prevalence of inflammatory
bowel disease steadily increased in the countries of
North America, Europe, and Australia. During this time, more
than two-thirds of studies reported that incidence rates were
increasing significantly in the western world. We define the
western world as consisting of countries influenced by a
western European cultural heritage, including the USA, Canada,
Australia, New Zealand, and all countries in western Europe. By
contrast, few population-based studies on the epidemiology of
inflammatory bowel disease were published from countries in
Africa, Asia, and South America. At the turn of the 21st century,
additional epidemiological studies have been reported from
across the world. For example, the Asia-Pacific Crohn’s and
Colitis Epidemiologic Study Group (ACCESS) defined the
incidence of inflammatory bowel disease in 12 countries in Asia
and Australia. These newer studies, which were not included in
the original systematic review, have shed light on the changing
global epidemiological patterns of inflammatory bowel disease.
Added value of this study
We did a systematic review of population-based studies on the
incidence (119 studies) or prevalence (69 studies) of
inflammatory bowel disease from 1990 to 2016. Since 1990,
incidence rates have shifted in western countries, with 73% of
studies on Crohn’s disease and 83% of studies on ulcerative
colitis showing stable or falling incidence. However, disease
burden remains high, with prevalence surpassing 0·3% in
North America, Oceania, and most countries in Europe. By
contrast, newly industrialised countries in Africa, Asia, and
South America whose societies become increasingly
westernised and urbanised, are mirroring the progression of
inflammatory bowel disease in the western world during
the 1900s.
Implications of all the available evidence
Since the recognition of ulcerative colitis in 1875 and Crohn’s
disease in 1932, the incidence of inflammatory bowel disease
has increased substantially in the western world. Our findings
show a paradigm shift whereby the incidence of inflammatory
bowel disease in most western countries has begun to stabilise
and in some regions decrease. However, after several decades
of sharply rising incidence, the prevalence of inflammatory
bowel disease has risen to more than 0·3% of the population in
North America, Australia, and many countries in Europe. The
high prevalence of inflammatory bowel disease in the western
world will challenge clinicians and health policy makers to
provide quality and cost-efficient care to patients with
inflammatory bowel disease. More striking is the observation
that as newly industrialised countries have transitioned
towards a westernised society, inflammatory bowel disease
emerges and its incidence rises rapidly. The peak in the
incidence of inflammatory bowel disease has probably not yet
transpired in these newly industrialised countries.
Consequently, these countries will need to prepare their clinical
infrastructure and personnel to manage this complex and
costly disease. During the past 100 years, the incidence of
inflammatory bowel disease has risen, then plateaued in the
western world, whereas countries outside the western world
seem to be in the first stage of this sequence. Thus, future
research should focus on identification of the environmental
risk factors seen during the early stages of industrialisation of
society to highlight avenues to prevent the development of
inflammatory bowel disease.

In the western world, inflammatory bowel disease is
associated with morbidity, mortality, and substantial costs
to the health-care system.3,8 The rising incidence of
inflammatory bowel disease in newly industrialised
countries could indicate an emerging epidemic of the
disease outside the western world. This observation
suggests that the impact of inflammatory bowel disease
on health-care systems will need to be reassessed in the
context of shifting epidemiological patterns throughout
the world. Furthermore, insight into geographical
patterns and disease time trends will help researchers
and policy makers to prepare the clinical infrastructure
and health-care resources needed to mitigate the burden
of inflammatory bowel disease.
We did a systematic review of population-based studies
reporting the incidence of inflammatory bowel disease
across the world since 1990 based on different
geographical regions and did temporal trend analyses of
incidence. We aimed to update the information provided
by our previous report,5 and provide insight into the
epidemiology of inflammatory bowel disease from a
global perspective.
Methods
Search strategy and selection criteria
For this systematic review, we first identified studies
reporting the incidence and prevalence of inflammatory
bowel disease from 1990 onwards from our previous
systematic review.5 We updated the previous database
search by searching MEDLINE and Embase from
Dec 1, 2010, to Dec 31, 2016, to identify population-based
studies reporting the incidence and prevalence of
inflammatory bowel disease. We did the search using a
pre-determined search strategy and in accordance with

2 www.thelancet.com Published online October 16, 2017 http://dx.doi.org/10.1016/S0140-6736(17)32448-0


the quality of reporting of the meta-analyses of
observational studies in epidemiology (MOOSE)
guidelines.9 The search was not limited by language. The
detailed search strategy is provided in the appendix.
Two teams independently did the different stages of the
systematic review. The first team was based in Calgary
(AB, Canada), led by GGK, with NH and FEU as
reviewers. The second team was from Hong Kong
(China), with HYS and WT as reviewers, led by SCN.
During all stages of screening and data extraction, the
teams from Calgary and Hong Kong were blinded to each
other. Disagreements were resolved through consensus
and discussion.
We screened search results first by title and abstract
and then by full text. We eliminated abstracts in the
initial screen if they were not observational and did not
investigate the epidemiology of inflammatory bowel
disease. We excluded studies that did not report original
data (eg, review articles). Abstracts meeting these criteria
were eligible for full-text review, and population-based
articles were independently considered for inclusion in
the review if the studies reported incidence or prevalence
of ulcerative colitis or Crohn’s disease or contained
adequate information to calculate incidence or
prevalence. A study was regarded as population-based if
it involved all residents within a specific area and the
study population was representative of that area. We
excluded studies consisting of hospital surveys.
To be included in the systematic review, ulcerative
colitis and Crohn’s disease had to be reported separately.
We excluded population-based studies restricted to the
incidence or prevalence of only paediatric-onset
inflammatory bowel disease (ie, age of diagnosis
<16 years). Non-English language papers were translated
using Google Translate (Google, Mountain View, CA,
USA) or by colleagues proficient in the language in
question. Lastly, we identified papers outside of the
search strategy using expert knowledge of active studies
(eg, the latest data from the Asia-Pacific Crohn’s and
Colitis Epidemiologic Study Group [ACCESS]). When
possible, we contacted authors to provide data not
presented in their reports.
The data extracted included the main author,
geographical location (area and country), study period,
overall and yearly incidence of inflammatory bowel
disease, ulcerative colitis, and Crohn’s disease per 100 000,
and the ratio of ulcerative colitis to Crohn’s disease. We
collected data on prevalence per 100 000 with 95% CIs.
We recorded incidence per 100 000 person-years with
95% CIs for the overall study time period. To assess the
quality of studies, we used a modified version of the
Cochrane Collaboration-endorsed Newcastle-Ottawa
Quality Assessment Scale (NOS)7 that addressed aspects
of quality relevant to population-based studies of
incidence or prevalence. We combined studies in the
analyses when the same cohort was observed over the
same time period.
www.thelancet.com Published online October 16, 2017 http://dx.doi.org/10.1016/S0140-6736(17)32448-0 3
Articles
Data analysis
We grouped the incidence and prevalence data by
geographical region using the United Nations classi­
fication of economic regions,10 which is based on See Online for appendix
geographical proximity and economic similarities. The
regions are North America, Europe (northern, southern,
western, eastern), Africa, Asia (eastern, southern, south-
eastern, western), South America, and Oceania.
We created choropleth maps for the incidence and
prevalence of Crohn’s disease and ulcerative colitis for
the time period 1990–2016. Each map was divided into
five colours corresponding to quintiles defined in our
prior systematic review.5 We preserved the incidence or
prevalence ranges per quintile and the colour scheme to
allow temporal comparison with the previously
published global inflammatory bowel disease maps. If
an author reported multiple time periods for a region,
we used the most recent period for that area. When data
were reported for only a region within a country, the
entire country was shaded on the map. Additionally, we
created scatter plots for population-based studies
reporting the annual incidence of Crohn’s disease or
ulcerative colitis from 1990 to 2016 stratified by the
following regions: North America, Europe, Oceania,
Asia, South America, and Africa. We used QGIS 2.18.8
to create the maps and the HTML Image Map Creator
1.0 plugin to create interactive maps. The country
boundary data were created by the Natural Earth
Community.11
We calculated temporal trends in incidence for each
study using Joinpoint Regression Program 4.4.0.0
regression modelling, which is calculated by fitting a
linear regression to the natural logarithm of the annual
rates with the year as the predictor variable. We
estimated the non-constant vari­ance by assuming that
the dependent variable counts followed a Poisson
distribution. For this temporal trend analysis, we
included only studies that had 5 or more years of data
and reported at least three timepoints. We used the For more on the Asia-Pacific
median year if the timepoints reported were longer than Crohn’s and Colitis
Epidemiologic Study Group see
one year. The β coefficients from these regressions were http://www.access-apibd.com/
exponentiated to an annual percentage change (APC) in
incidence with a 95% CI.
Role of the funding source
There was no funding source for this study. SCN and
GGK had full access to all of the data in the study and
take responsibility for the integrity of the data and the
accuracy of the data analysis. SCN and GGK had
responsibility for the submission of the manuscript.
Results
We identified 95 records that fulfilled our criteria from
our previously published systematic review.5 For the
period from Dec 1, 2010, to Dec 31, 2016, our search
identified an additional 11  170 records; 3514 from
MEDLINE and 7656 from Embase. After removal of
 Articles
95 studies from published systematic reviews 11 170 citations identified from literature search
9713 citations after duplicates removed
9487 citations excluded in screening of titles or
abstracts with general criteria
226 full-text articles assessed for eligibility
79 studies excluded
58 not population-based studies
9 no incidence or prevalence or enough
information to calculate the values
4 only reported inflammatory bowel disease
(did not separate into Crohn’s disease and
ulcerative colitis)
5 studies on paediatric participants only
3 duplicates
147 studies included in systematic review
119 incidence studies (103 of Crohn’s disease and 101 of
ulcerative colitis)
69 prevalence studies (61 of Crohn’s disease and 60 of
ulcerative colitis)
95 studies derived from Molodecky et al (2012)⁵ 52 new studies found in the review
Figure 1: Study selection
For the interactive maps see duplications and initial screening, 226 articles were
https://people.ucalgary. eligible for full-text review (figure 1). The observed
ca/~ggkaplan/IBDG2016.html
agreement between reviewers for eligibility of articles
on the initial screening was 99·5%. On full-text review
of 226 articles, 79 were excluded (figure 1), with inter-
reviewer agreement of 86·7%. Overall, 147 studies were
eligible for final inclusion in the systematic review,
including 119 studies of incidence (103 on Crohn’s
disease and 101 on ulcerative colitis) and 69 studies of
prevalence (61 on Crohn’s disease and 60 on ulcerative
colitis; figure 1).
Characteristics of the 119 incidence studies and
69 prevalence studies, including references, are
available in the appendix. The patient definition was
adequate in 143 studies (three studies had no description
of the patient definition, whereas one study was not
available as full text), and 114 studies had populations of
patients that were representative of the general
populations (32 studies had potential for selection
biases or did not discuss representativeness, whereas
one study was not available as full text). The quality
assessment of each manuscript is also shown in
the appendix. Incidence was reported for North America
(nine studies), South America (seven studies),
Oceania (seven studies), eastern Asia (22 studies),
4 www.thelancet.com Published online October 16, 2017 http://dx.doi.org/10.1016/S0140-6736(17)32448-0
south-eastern Asia (11 studies), southern Asia
(seven studies), western Asia (nine studies), eastern
Europe (13 studies), northern Europe (44 studies),
southern Europe (33 studies), western Europe
(18 studies), and Africa (one study). Of the 69 prevalence
studies, 30 studies were done in Europe, 17 in Asia, 14 in
North America, five in South America, two in Oceania,
and one in Africa.
The worldwide incidence (figure 2) and prevalence of
Crohn’s disease and ulcerative colitis (figure 3) are
presented in maps. Our interactive global maps
that show and describe the incidence and pre­
valence of Crohn’s disease and ulcerative colitis are
avail­able online.4
Incidence and prevalence of IBD varied greatly by
geographic region. The table shows the ranges in
incidence and prevalence estimates for Crohn’s disease
and ulcerative colitis, stratified into North America,
eastern Europe, northern Europe, southern Europe,
western Europe, eastern Asia, south-eastern Asia,
southern Asia, western Asia, South America, and
Oceania. The exact incidence and prevalence values for
each region are shown in the appendix.
Scatter plots representing the annual incidence of
Crohn’s disease and ulcerative colitis from 1990 to 2016
stratified by geographic region are represented in
figure 4. We assessed time trends in 28 studies of
ulcerative colitis and 30 studies of Crohn’s disease that
reported incidence during a period of 5 or more years
(appendix). Since 1990, 16 (72·7%) of 22 studies on
Crohn’s disease and 15 (83·3%) of 18 studies on
ulcerative colitis from North America and Europe have
reported APCs showing stable or decreasing incidence
(appendix). Studies of temporal trends from newly
industrialised countries in Asia and South America
were sparse, but all showed stable or increasing APCs.
For example, Brazil, which had an APC for Crohn’s
disease of +11·1% (95% CI 4·8 to 17·8) and an APC for
ulcerative colitis of +14·9% (10·4 to 19·6) from
1988 to 2012, and Taiwan, which had an APC for Crohn’s
disease of +4·0% (1·0 to 7·1) and an APC for ulcerative
colitis of +4·8% (1·8 to 8·0) from 1998 to 2008. By
contrast, a nationwide study in South Korea showed
stable incidence from 2006 to 2012, with an APC for
Crohn’s disease of –2·4% (–4·7 to 0·0) and an APC for
ulcerative colitis of –2·2% (–4·6 to 0·2), whereas a study
of a district in the capital Seoul reported steadily
increasing incidence from 1991 to 2005, with an APC for
Crohn’s disease of +13·8% (8·7 to 19·0) and an APC for
ulcerative colitis of +9·5% (2·7 to 16·7).
Figure 2: Worldwide incidence of Crohn’s disease and ulcerative colitis.
Map of worldwide incidence in quintiles for (A) Crohn’s disease and (B) ulcerative
colitis. An interactive global map of the incidence of Crohn’s disease and
ulcerative colitis is available online
 Articles

Crohn’s disease incidence per

100 000 person-years, 1990–2016
Unknown
0·00–0·80
0·81–1·94
1·95–3·76
3·77–6·38
>6·38

Western Europe Southern Asia

Ulcerative colitis incidence per

100 000 person-years, 1990–2016
Unknown
0·00–1·85
1·86–3·09
3·10–4·97
4·98–7·71
>7·71

Western Europe Southern Asia

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( hn's disease prevale~ce

ro 100 000, 1990-201
per
D Unknown
. 0·60- 6'75
D 6 '76-25·00
D 25·10-48·00
D 48 ·10-135 ·60
D >135·60

Western Europe

.. revalence
Ulcerative cOhtl~~_2016
per 100 000, 19
D Unknown
• 2-42-21 ·00
D 21·10-44·30
D 44-40-100'90
D 101 ·00 -198·00
D >198·00

Western Europe

6 www.thelancet.com Published online October 16, 2017 http://dx.doi.org/10.1016/S0140-6736(17)32448-0

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Incidence per 100 000 person-years Prevalence per 100 000

Crohn’s disease Ulcerative colitis Crohn’s disease Ulcerative colitis
Lowest estimate Highest Lowest Highest Lowest Highest Lowest Highest
estimate estimate estimate estimate estimate estimate estimate
North America 6·30 23·82 8·8 23·14 96·3 318·5 139·8 286·3
(California, USA) (Nova Scotia, (Olmsted (Nova Scotia, (California, (Nova Scotia, (Quebec, (Olmsted
Canada) County, USA) Canada) USA) Canada) Canada) County, USA)
Eastern Europe 0·40 14·6 0·97 11·9 1·51 200·0 2·42 340·0
(Chisinau, (Veszprém, (Romania, (Veszprém, (Romania, (Hungary, (Romania, (Hungary,
Moldova) Hungary) Nationwide) Hungary) Nationwide) Nationwide) Nationwide) Nationwide)

Northern 0·0 11·4 1·7 57·9 24·0 262·0 90·8 505·0

Europe (Greenland, (Funen, (Tartu, (Faroe Islands, (Kuopio, (Southeast, (Leicestershire, (Southeast,
Nationwide) Denmark) Estonia) Nationwide) Finland) Norway) UK) Norway)
Southern 0·95 15·4 3·3 11·47 4·5 137·17 14·5 133·9
Europe (Vukovarsko- (Casteltermini, (Zagreb, (Caceres, (Vukovarsko- (Ciudad Real, (Vukovarsko- (Zadar,
Srijemska, Italy) Croatia) Spain) Srijemska, Spain) Srijemska, Croatia)
Croatia) Croatia) Croatia)
Western Europe 1·85 10·5 1·9 17·2 28·2 322·0 43·1 412·0
(Guadeloupe and (Central, (Puy-de- (Central, (Tuzla, Bosnia (Hesse, (Tuzla, Bosnia (Hesse,
Martinique Netherlands) Dome, Netherlands) and Germany) and Germany)
islands, France) France) Herzegovina) Herzegovina)
Eastern Asia 0·06 3·2 0·42 4·6 1·05 18·6 4·59 57·3
(Kunming, (South Korea, (Xian, China) (Seoul, South (Taiwan, (Japan, (Taiwan, (Japan,
China) Nationwide) Korea) Nationwide) Nationwide) Nationwide) Nationwide)
South-eastern 0·14 0·41 0·15 0·68 2·17 2·17 6·67 6·67
Asia (Kinta Valley, (Brunei, (Manila, (Kinta Valley, (Kinta Valley, (Kinta Valley, (Kinta Valley, (Kinta Valley,
Malaysia) Nationwide) Philippines) Malaysia) Malaysia) Malaysia) Malaysia) Malaysia)
Southern Asia 0·09 3·91 0·69 6·02 1·2 1·2 5·3 44·3
(Colombo and (Hyderabad, (Colombo (Punjab, India) (Colombo and (Colombo (Colombo and (Punjab, India)
Gampaha, Sri India) and Gampaha, Sri and Gampaha, Sri
Lanka) Gampaha, Sri Lanka) Gampaha, Sri Lanka)
Lanka) Lanka)
Western Asia 0·94 8·4 0·77 6·5 50·6 53·1 4·9 106·2
(Riyadh, Saudi (Southern (Trakya, (Southern (Southern (Beirut, (Trakya, Turkey) (Beirut,
Arabia) Israel, Israel) Turkey) Israel, Israel) Israel, Israel) Lebanon) Lebanon)
South America 0·0 3·50 0·19 6·76 0·9 41·4 4·7 44·3
(District of (São Paulo, (Piauí, Brazil) (São Paulo, (São Paulo, (Southwest, (São Paulo, (Barbados,
Colón, Panama) Brazil) Brazil) Brazil) Puerto Rico) Brazil) Nationwide)
Oceania 12·96 29·3 7·33 17·4 155·2 197·3 145·0 196·0
(Geelong, (Geelong, (Geelong, (Geelong, (Canterbury, (Barwon, (Canterbury, (Barwon,
Australia)* Australia)* Australia)* Australia)* New Zealand) Australia) New Zealand) Australia)
Africa 5·87 5·87 3·29 3·29 19·02 19·02 10·57 10·57
(Constantine, (Constantine, (Constantine, (Constantine, (Constantine, (Constantine, (Constantine, (Constantine,
Algeria) Algeria) Algeria) Algeria) Algeria) Algeria) Algeria) Algeria)

*Geelong has the lowest and highest estimates because of reporting in time periods ranging from 2007 to 2013.

Table: Range in incidence and prevalence of inflammatory bowel disease since 1990 stratified by geographic regions

Discussion continues to rise in North America, in many countries in

During the 20th century, inflammatory bowel disease was
mainly a disease of westernised countries of North America,
Europe, and Oceania.5 At the turn of the 21st century,
inflammatory bowel disease became a global disease with
accelerating incidence in the newly industrialised countries
of Asia, South America, and Africa, where societies
have become more westernised.2,4 Estimated prevalence
Figure 3: Worldwide prevalence of Crohn’s disease and ulcerative colitis
Map of worldwide prevalence in quintiles for (A) Crohn’s disease and (B)
ulcerative colitis. An interactive global map of the prevalence of Crohn’s disease
and ulcerative colitis is available online
Europe, and in Australia and New Zealand, which
translates to a high burden of inflammatory bowel
disease in these countries.2 Prevalence of inflammatory
bowel disease in newly industrialised countries is low,
but given the rising incidence identified in many of
these countries, is expected to climb. This increasing
global burden of inflammatory bowel disease will bring
important challenges to health-care systems around
the world as they work to care for this complex and
costly disease.2
In our previous systematic review of population-based
studies,5 75% of studies on Crohn’s disease and 60% of

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in society have translated to the stabilisation, and in

A
30
some regions decrease, in the inci­dence of inflammatory
North America South America
Oceania Asia bowel disease in the western world at the turn of the
Europe Africa 21st century.
Incidence of Crohn’s disease per 100 000 person-years

25 Our systematic review did not include population-

based studies restricted to paediatric-onset inflammatory
bowel disease. Results from some studies15,16 suggest that
20
the incidence of paediatric-onset inflammatory bowel
disease might be increasing in certain regions of the
15 western world. Additionally, evidence has suggested that
although immigrants to the western world have lower
incidence of inflammatory bowel disease than non-
10
immigrants, the offspring of individuals immigrating
from some low-prevalence regions in Asia have similarly
5 high incidence of inflammatory bowel disease compared
to the children of non-immigrants.17,18 Further studies are
needed to explore differential trends in the incidence of
0
inflammatory bowel disease by age at the diagnosis of
inflammatory bowel disease and the effect of immigration
B
30 on inflammatory bowel disease incidence in a population.
Although incidence seems to be stabilising in the
western world, the prevalence of inflammatory bowel
Incidence of ulcerative colitis per 100 000 person-years

25 disease continues to rise. In the 21st century, the pre­

20
15
10
5 of the population in 2015 and could rise to 0·9% by 2025.27
0
1990 1995 2000 2005 2010 2015
Year
Figure 4: Annual incidence of (A) Crohn’s disease and (B) ulcerative colitis from 1990 to 2016
studies on ulcerative colitis reported significant increases
in incidence in North America and Europe during the
latter half of the 20th century. Since 1990, incidence has
shifted substantially in the western world such that 72·7%
of studies of Crohn’s disease and 83·3% of studies of
ulcerative colitis show stable or decreasing incidence.
Excluding studies from Croatia and Bosnia and
Herzegovina,12,13 which underwent a war that devastated
the health-care infrastructure in the 1990s, only one
(6·7%) of 15 studies on ulcerative colitis showed rising
incidence in North America or Europe. The plateauing
incidence of inflammatory bowel disease in the western
world might represent a transition in environmental
exposures. For example, public health efforts in the 1970s
and 1980s reduced rates of smoking initiation among
adolescents.14 Future research should investigate whether
public health efforts altering environmental exposures
valence of inflammatory bowel disease exceeded 0·3% of
the total population in Canada, Denmark, Germany,
Hungary, Australia, New Zealand, Sweden, the UK, and
the USA.15,19−26 Westernised countries are experiencing
compounding prevalence, which is the exponential rise in
prevalence of chronic diseases, like inflammatory bowel
disease, that has increased rates of diagnosis with lower
mortality.2 For Canada, a predictive model estimated that
the prevalence of inflammatory bowel disease was 0·6%
The rising prevalence of inflammatory bowel disease in
westernised countries is likely to become a substantial
challenge that clinicians and health policy makers will face
over the next generation as they struggle to provide quality
and cost-efficient care to patients with inflammatory
bowel disease.
Cohort studies from Asia, Africa, and South America
have consistently described the rising incidence of
inflammatory bowel disease in countries outside the
western world. The variation in the incidence of
inflammatory bowel disease between regions could partly
be explained by varying risk factors, different database
capture systems, and differing access to health care.2,4
Furthermore, during the past generation, newly
industrialised countries have experienced greater
urbanisation, with populations moving from rural areas to
densely populated cities. In China, variation in incidence
across regions was correlated with population density.28
This correlation might explain why a nationwide study of
South Korea showed stable incidence of inflammatory
bowel disease,29 whereas a study focused on a highly
populated district of Seoul showed significant increases in
incidence.30 Although our study did not specifically study
disease incidence gradients, the results of several studies

8 www.thelancet.com Published online October 16, 2017 http://dx.doi.org/10.1016/S0140-6736(17)32448-0


from Europe have shown a north–south gradient of disease
incidence,31,32 whereas in Canada, a nationwide comparison
showed an east–west disease gradient.33 The ACCESS
cohort found a north–south gradient across all regions in
Asia for inflammatory bowel disease and ulcerative colitis,
but not for Crohn’s disease (unpublished).28 Additionally, a
south–north gradient and west–east gradient for the
incidence of Crohn’s disease was seen in China, with
higher incidences in southern and western parts of China.
Collectively, historical and epidemiological data from
the past century and a half suggest that the emergence of
inflammatory bowel disease has followed the industrial­
isation and westernisation of society.4 Sir Walter Wilks
originally coined the term ulcerative colitis in 1875,34 and
the landmark paper on Crohn’s disease by Burrill
Bernard Crohn, Leon Ginzburg, and Gordon
Oppenheimer was published in 1932.7,35 During the
20th century, the incidence of both ulcerative colitis and
Crohn’s disease increased substantially in the western
world with earlier studies showing that the incidence of
ulcerative colitis was higher than that of Crohn’s disease.5
Later, epidemiological studies showed that the incidence
of Crohn’s disease was catching up, and in many regions
in the western world, surpassing that of ulcerative colitis.5
Analogous epi­ demiological patterns have also been
reported in newly industrialised countries outside the
western world—just shifted forward in time. For
example, the earliest case reports in China of ulcerative
colitis were in the 1950s, with the early epidemiological
studies mostly describing ulcerative colitis.7 Although
ulcerative colitis is still more common in Asia than
Crohn’s disease, data from more recent epidemiological
studies have shown that the incidence of Crohn’s disease
is catching up.7 Future studies are needed to establish
whether the rising incidence rates in newly industrialised
countries approxi­mate those of the western world during
the 20th century. If so, the prevalence of inflammatory
bowel disease is likely to steadily increase in newly
industrialised countries.
Our study has some limitations. We did a compre­
hensive systematic review of the published literature on
the incidence and prevalence of inflammatory bowel
disease, but we chose not to do a meta-analysis because of
variability between studies.5 We stratified regions by
geography on the basis of proximity of countries within a
continent, recognising that many differences exist
between countries within a geographical zone that could
lead to variability in reporting of the incidence and
prevalence of inflammatory bowel disease. Heterogeneity
between countries could be explained by differences in
genetic predisposition, environ­mental exposures, socio­
economic factors, and immi­ gration.4 Heterogeneity
between studies could also be explained by methodological
limitations, some of which include differences in pop­
ulation characteristics, study designs, access to health
care, and the advancement of diagnostic approaches
between countries.36 Furthermore, differences in data
www.thelancet.com Published online October 16, 2017 http://dx.doi.org/10.1016/S0140-6736(17)32448-0 9
Articles
quality, reporting, and completeness between databases
could have contributed to the differences seen between
countries. Additionally, study quality was not an exclusion
criterion and therefore probably contributed to differences
in incidence and prevalence estimates. Some studies
reported crude incidence rates, whereas others reported
age-adjusted or sex-adjusted incidence rates. Because of
the different study periods and reporting of annual
incidence, temporal trends were not homogeneous
between studies.
This systematic review provides a comprehensive global
overview of the incidence and prevalence of inflammatory
bowel disease over the past generation. We have identified
a substantial shift in the epidemiology of inflammatory
bowel disease. Since 1990, the incidence of inflammatory
bowel disease has stabilised in the western world, but
prevalence remains high. By contrast, newly industrialised
countries are facing rising incidence, analogous to trends
seen in the western world during the latter part of the
20th century. Unfortunately, the peak in the incidence of
inflammatory bowel disease has probably not yet
transpired in these countries. The changing global
burden of inflammatory bowel disease during the next
decade will require a two-pronged solution that involves
research into interventions to prevent inflammatory
bowel disease and innovations in the delivery of care to
patients with inflammatory bowel disease.
Contributors
SCN, HYS, NH, FEU, WT, EIB, RP, SG, JCYW, FKLC, JJYS, and GGK
contributed to the study design. SCN, HYS, NH, FEU, WT, and GGK did
the data collection and the literature search. FEU created the figures.
Data were analysed by SCN and GGK and interpreted by SCN, HYS,
NH, FEU, WT, EIB, RP, SG, JCYW, FKLC, JJYS, and GGK. The
manuscript was written by SCN, HYS, NH, FEU, WT, EIB, RP, SG,
JCYW, FKLC, JJYS, and GGK. All authors saw and approved the
manuscript. SCN and GGK had full access to all of the data in the study
and take responsibility for the integrity of the data and the accuracy of
the data analysis.
Declaration of interests
We declare no competing interests.
Acknowledgments
EIB was supported by a New Investigator Award from the Canadian
Institutes for Health Research, Canadian Association of Gastroenterology,
and Crohn’s and Colitis Canada. EIB was also supported by the Career
Enhancement Program of the Canadian Child Health Clinician Scientist
Program. GGK is a Canadian Institutes for Health Research-Embedded
Clinician Research Chair.
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