IDF DIABETES ATLASSixth edition

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Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Chapter 6

Table of contents

Acknowledgements 05Foreword 07Introduction 09executive summary 11

What is diabetes? 19Type1 diabetes 22Type2 diabetes 23Gestational diabetes 23Impaired glucose tolerance and impaired fasting glucose 24Diabetes complications 24other complications 26

The global burden 29Diabetes and impaired glucose tolerance 322.1 Diabetes 342.2 Undiagnosed diabetes 382.3 Impaired glucose tolerance 402.4 Diabetes in young people 422.5 Hyperglycaemia in pregnancy 442.6 Mortality 462.7 Health expenditure 48

Regional overviews 51A global perspective 543.1 Africa 563.2 europe 583.3 Middle east and north Africa 603.4 north America and caribbean 623.5 South and centralAmerica 643.6 South-east Asia 663.7 Western Pacific 68

Global issues in diabetes 714.1 A global review of diabetic retino pathy 764.2 Rates of diabetic ketoacidosis at diagnosis in children with type1 diabetes 784.3 Diabetes in Indigenous peoples 804.4 Diabetes in rural communities 82

Linking local to global 855.1 Driving the global agenda on diabetes 885.2 Including diabetes in development 905.3 The IDF Diabetes Scorecard 925.4 Training health professionals in diabetes 94

Resources and Solutions 996.1 Diabetes in older people 1026.2 IDF programmes and campaigns 1046.3 clinical guidelines and Position Statements 1066.4 About the International Diabetes Federation 110

Appendices and references 113country summary table: estimates for 2013 114country details table: estimates for 2013 128Abbreviations and acronyms 142Glossary 143References 146List of tables, maps and figures 153

04 I IDF Diabetes Atlas I Sixth edition

International Diabetes Federation, 2013no part of this publication may be reproduced, translated, 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 Fourth edition, 2009 Fifth edition, 2011 Sixth edition, 2013

online version of IDF Diabetes Atlas: www.idf.org/diabetesatlas

ISbn: 2-930229-85-3

Design and layout: De Visu Digital Document Design cover photos: istockphoto.com Tim nolan

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Acknowledgements

Corporate sponsors IDFwould like to express its thanks to the following sponsors for their generous support of the sixth edition:

Diabetes Atlas, sixth edition committeenam Han cho (chair), David Whiting (deputy chair), Leonor Guariguata, Pablo Aschner Montoya, nita Forouhi, Ian Hambleton, Rui Li, Azeem Majeed, Jean claude Mbanya, Ayesha Motala, k.M. Venkat narayan, Ambady Ramachandran, Wolfgang Rathmann, Gojka Roglic, Jonathan Shaw, Martin Silink, D.R.R. Williams, Ping Zhang.

Editorial teamLeonor Guariguata, Tim nolan, Jessica beagley, Ute Linnenkamp, olivier Jacqmain.

ContributorsThe International Diabetes Federation (IDF) would like to thank the following core contributors:

Florencia Aguirre, Alex brown, nam Han cho, Gisela Dahlquist, the Diabetes education consultative Section (DecS), Sheree Dodd, Trisha Dunning, Sir Michael Hirst, christopher Hwang, Dianna Magliano, chris Patterson, courtney Scott, Jonathan Shaw, Gyula Soltsz, Juliet Usher-Smith, David Whiting.

Other Contributorscarlos Aguilar Salinas, Riyadh Alshamsan, Tabassum Ambia, carmen Gloria Aylwin, caroline baan, Juliana chan, Adel A. el-Sayed, Laercio Franco, Juan Jos Gagliardino, Jody Grundman, Lucy Hadley, christian Herder, Hak c. Jang, Pili kamenju, Andre Pascal kengne, Tawfik khoja, Mandana kooijmans, Silvia Lapertosa, kerry Lydon, Ronald ching Wan Ma, Lydia Makaroff, chris Millett, Graham ogle, Martijn Parker, nasheeta Peer, Lorenzo Piemonte, Salman Rawaf, Joachim Rosenbauer, Segundo Secln, chamukuttan Snehalatha, Anne Mieke Spijkerman, Teresa Tamayo, Sean Taylor, Sara Webber, Sarah H. Wild, Mary Vinocour, bernardZinman.

Lilly Diabetes

Merck and co, Inc.

novo nordisk A/S Supported through an unrestricted grant by the novo nordisk changing Diabetes initiative

Pfizer, Inc.

Sanofi Diabetes

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Despite the grim picture painted by the new figures, we already have the knowledge and expertise to begin creating a brighter future for generations to come. We must increase awareness of the importance of a healthful diet and physical activity, especially for children and adolescents. crucially though, environments have to be created that lay the foundations for healthy living. These measures are most pressing in low- and middle-income countries, precisely those which are least prepared to confront this huge-scale pandemic, and whose very development will be thwarted in its aftermath. It is essential that health professionals particularly the primary care practitioners receive adequate and appropriate training to be able to perform effectively on the front line against diabetes.

In the last two years, progress has been made toward driving political change for diabetes. building on the momentum of the 2011 Un Political Declaration on non-communicable diseases (ncDs), the 66th World Health Assembly in May 2013 saw the unanimous adoption by Member States of a voluntary Global Action Plan for the prevention and control of ncDs. Diabetes is now prominent on the global health agenda, with specific targets for access to essential medicines and for halting the growth of obesity and diabetes. Still, we must not miss this opportunity. Governments and policy-makers, health professionals and those affected by the disease must remain engaged in the fight so that IDF may achieve its vision of living in a world without diabetes.

Sir Michael HirstPresident,

International Diabetes Federation

It is a bittersweet pleasure to be presiding over the International Diabetes Federation upon the launch of this sixth edition of the IDF Diabetes Atlas. The evidence published herein on the millions of people swept up by the diabetes pandemic vindicates the Federations relentless efforts to promote solutions to this worldwide health crisis. Previous editions of the Atlas were a crucial tool in the successful campaign for a Un Resolution on diabetes and our figures informed the subsequent political declaration on non-communicable diseases. We have achieved much: diabetes is now firmly on the highest of decision-making agendas. but the figures in this edition are a harsh reminder of how far we still have to go.

Today, there are 382 million people living with diabetes. A further 316 million with impaired glucose tolerance are at high risk from the disease an alarming number that is set to reach 471million by 2035. Diabetes is on the rise all over the world and countries are struggling to keep pace. The misconception that diabetes is a disease of the wealthy is still held by some to the detri-ment of desperately needed funding to combat the pandemic. but the evidence published in the IDF Diabetes Atlas disproves that delusion: a stag-gering 80% of people with diabetes live in low- and middle-income countries, and the socially disad-vantaged in any country are the most vulnerable to the disease. Todays emerging diabetes hotspots include countries in the Middle east, Western Pacific, sub-Saharan Africa and South-east Asia where economic development has transformed lifestyles. These rapid transitions are bringing previously unheard of rates of obesity and diabetes; developing countries are facing a firestorm of ill health with inadequate resources to protect their population.

by the end of 2013, diabetes will have caused 5.1 million deaths and cost USD 548 billion in healthcare spending. Without concerted action to prevent diabetes, in less than 25years time there will be 592million people living with the disease. Most of those cases would be preventable. However, without a multi-sectoral, all-of-society approach, the disturbing projections in this edition of the IDF Diabetes Atlas will be realised.

Foreword

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For the first time, the IDF Diabetes Atlas has produced estimates of high blood glucose in preg-nancy. This serious and underreported condition is affecting many women and infants an esti-mated 21.4million live births in 2013. not only does diabetes pose a grave threat to the health of a mother and her child but evidence shows high blood glucose levels during pregnancy can lead to an increased risk of type2 diabetes later in life for the child, further contributing to the already devastating epidemic.

More high-quality studies than ever before have contributed to the estimates in this edition of the IDF Diabetes Atlas. nevertheless, more studies are needed to describe the burden of diabetes in order to improve the precision of the estimates, and contribute to an evidence base that is funda-mental in driving powerful advocacy for people with diabetes.

Professor Nam Han Chochair,

IDF Diabetes Atlas committee, 6th edition

This 6th edition of the IDF Diabetes Atlas once again sets the standard for evidence on the global epidemiology of diabetes. The new estimates build on the groundwork laid by previous editions, and confirm the precipitous rise in diabetes over the last few years. An astounding 382 million people are estimated to have diabetes, with dramatic increases seen in countries all over the world. The overwhelming burden of the disease continues to be shouldered by low- and middle-income countries, where four out of five people with diabetes are living. Socially and economically disadvantaged people in every country carry the greatest burden of diabetes and are often the most affectedfinancially.

The new estimates show an increasing trend towards younger and younger people developing diabetes, a trend that is very worrisome for future generations. If current demographic patterns continue, more than 592million people will be affected with diabetes within a generation. This figure takes into account changes only in the popu-lation and patterns of urbanisation, and is almost certainly an underestimate. estimates of type1 diabetes in young people also show unexplained and rapid increases in several regions along with the rise in type2 diabetes in younger populations.

The burden of diabetes is reflected not only in the increasing numbers of people with diabetes, but also in the growing number of premature deaths due to diabetes. In 2013, roughly half of all deaths due to diabetes in adults were in people under the age of 60, and in less-developed regions like sub-Saharan Africa, that proportion climbs to 75%. As life expectancy increases, while the infectious disease burden decreases, and development drives rapid changes in lifestyles, it is the developing regions that will see the greatest increases in the burden of diabetes.

Introduction

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IDFs most recent estimates indicate that 8.3% of adults 382million people have diabetes, and the number of people with the disease is set to rise beyond 592million in less than 25years. Yet, with 175million of cases currently undiagnosed, a vast amount of people with diabetes are progressing towards complications unawares. Moreover, with 80% of the total number affected living in low- and middle-income countries, where the epidemic is gathering pace at alarming rates, the IDF Diabetes Atlas latest figures provide a worrying indication of the future impact of diabetes as a major threat to global development.

Diabetes in all its forms imposes unacceptably high human, social and economic costs on countries at all income levels. Since the publication of the first International Diabetes Federation Diabetes Atlas in 2000 successive editions have provided consistent evidence of the continuing growth in rates of diabetes incidence and prevalence world-wide. This 6th edition brings new evidence of the same kind, and carries a bitter but unavoidable message: despite the array of tools at our disposal to tackle the disease effective drug therapies, advanced technology, ever-improving education and preventive strategies the battle to protect people from diabetes and its disabling, life-threat-ening complications is being lost.

Executive summary

56 M37 M

138 M24 M

72 M35 M

20 M

Number of people with diabetes by IDF Region, 2013

Middle east and north africa MenA

south and central aMerica SAcA

Western Pacific WP

north aMerica and caribbean nAc

euroPe eUR

africa AFR

south-east asia SeA

WorlD

382 Mpeople living with diabetes

46%undiagnosed

12 I IDF Diabetes Atlas I Sixth edition

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Type1 diabetes

Normal situation

gestational diabetes

Type2 diabetes

of the long-term damage being caused by their disease. Gestational diabetes, which appears during pregnancy, can lead to serious health risks to the mother and her infant and increase the risk for developing type2 diabetes later in life.

All types of diabetes require close collabora-tion between those affected and their healthcare providers in order to prevent a range of costly, dangerous complications, which can provoke damage to the eyes, kidneys, feet and heart, and, left untreated, result in early death.

What is diabetes? The three main types of diabetes type1 diabetes, type2 diabetes and gestational diabetes occur when the body cannot produce enough of the hormone insulin or cannot use insulin effectively. Insulin acts as a key that lets the bodys cells take in glucose and use it as energy.

People with type1 diabetes, the result of an auto-immune process with very sudden onset, need insulin therapy to survive. Type2 diabetes, on the other hand, can go unnoticed and undiagnosed for years. In such cases, those affected are unaware

Diabetes is a huge and growing problem, and the costs to society are high and escalating.

AFR 109.1%

WP 46%

SAcA 59.8%

SeA 70.6%

MenA 96.2%

eUR 22.4%

2013 2035

nAc 37.3%

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592 Mpeople living with diabetes

in 2035

increase:

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Top 10countries / territories of number of people with diabetes (20-79years), 2013

china

India

USA

brazil

Russian Federation

Mexico

Indonesia

Germany

egypt

Japan

Millions0 10 20 30 40 50 60 10070 80 90

98.4

65.1

24.4

11.9

10.9

8.7

8.5

7.6

7.5

7.2

The Global Burden The majority of the 382million people with diabetes are aged between 40 and 59, and 80% of them live in low- and middle-income countries. All types of diabetes are on the increase, type2 diabetes in particular: the number of people with diabetes will increase by 55% by 2035.

An additional 21million cases of high blood glucose in pregnancy are estimated to contribute to the global burden of diabetes. That is equivalent to 17% of live births to women in 2013 that had some form of high blood glucose in pregnancy.

In human as well as financial terms, the burden of diabetes is enormous, provoking 5.1million deaths and taking up some USD548 billion dollars in health spending (11% of the total spent world-wide) in 2013.

Top 10 countries/territories for prevalence* (%) of diabetes (20-79 years), 2013

MIDDLe eAST AnD noRTH AFRIcA

WeSTeRn PAcIFIc

23%

23%

23%

24%

24%26%

29%

35%35%

37%

* comparative prevalence

vanuatu

cook islands

Marshall islands

federated states ofMicronesia

nauru

saudi arabia qatar

kuWait

kiribati

tokelau

More than 21million live births were affected by diabetes during pregnancy in 2013.

14 I IDF Diabetes Atlas I Sixth edition

Diabetes caused 5.1million deaths in2013. Every six seconds a person dies from diabetes.

Regional overviews Different regions are being affected to widely differing degrees. With more than 138 million people affected, the Western Pacific has more people with diabetes than any other region. At the other end of the regional diabetes ranking, Africas diabetes population is currently the smallest among the regions. However, this is set to double by 2035, and, ominously for Africas capacity to develop, more than three-quarters of deaths from diabetes in 2013 occurred in people under 60 that is to say, in their prime productive years.

The outlook is similarly worrying in South and central America, where the diabetes population is projected to increase by 60% by 2035. Rapid development has driven a fast-growing epidemic of diabetes in South-east Asia, accounting for close to

one-fifth of all cases worldwide. Similarly, wealth and development in the Middle east and north Africa has led to high proportions of diabetes where one in ten adults in the region have the disease.

A look at health spending on diabetes by region reveals huge disparities in responses to the epidemic. Two regions spent more on diabetes than the rest of the regions put together: north America and caribbean, with an estimated USD263 billion equal to nearly half the worlds health expenditure on diabetes; and europe with USD147 billion. Despite their growing diabetes populations, spending in South-east Asia and Africa accounted for less than 1% of all global health expenditure on the disease.

56 M37 M

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72 M35 M

20 M54%

62%

36%

48%27%

24%

49%

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number of people with diabetes (20-79 years), 2013 Proportion of cases of diabetes (20-79 years) that are undiagnosed, 2013

Global health expenditure due to diabetes (20-79 years)

$$$

20132035

548 billion uSD

627 billion uSD

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IDFREGION

2013 MILLIONS

2035 MILLIONS

INCREASE %

Africa 19.8 41.4 109%

Middle East and North Africa 34.6 67.9 96%

South-East Asia 72.1 123 71%

South and Central America 24.1 38.5 60%

Western Pacifi c 138.2 201.8 46%

North America and Caribbean 36.7 50.4 37%

Europe 56.3 68.9 22%World 381.8 591.9 55%

147 B14 B

263 B

26 B

88 B76%

28%2

50%38%

44%

55%44%

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