IDF Diabetes Atlas 2nded

DIABETES
ATLAS
Second edition
Second edition
The mission of the International Diabetes Federation is to

work with our member associations to enhance the lives
of people with diabetes.
Diabetes Atlas committee
Bjørnar Allgot (co-chair)
Delice Gan (co-chair)
Hilary King
Pierre Lefèbvre
Jean-Claude Mbanya
Martin Silink
Linda Siminerio
Rhys Williams
Paul Zimmet
Editor and project manager: Delice Gan

Project coordinator: Catherine Regniers
Diabetes Atlas, second edition,

and other IDF publications are available from:
International Diabetes Federation
Executive Office
19 Avenue Emile de Mot
B-1000 Brussels
Belgium
Tel +32-2-5385511
Fax +32-2-5385114
idf@idf.org
www.idf.org
Electronic version of Diabetes Atlas:

www.idf.org/e-atlas
© International Diabetes Federation, 2003
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
Permission has been obtained to use material

from the following organizations:
(1) United Nations
(2) World Bank
(3) World Health Organization
Copyright permission has been obtained

from Martin Dunitz to adapt ‘The St Vincent
Declaration: experience gained for better
outcome of cardiovascular, eye and kidney
complications in the future’ in Chapter 8.
ISBN 2-930229-27-6
Design and layout: perplex | Aalst, Belgium

Cover: De Blauwe Peer, Gent, Belgium
Printer: Imprimerie L Vanmelle SA, Gent/Mariakerke, Belgium
Diabetes Atlas Second Edition

Acknowledgements
The International Diabetes Federation (IDF) Chapter 1
would like to express its thanks to the World 1.1 R Sicree, J Shaw, P Zimmet
Diabetes Foundation for its generous support 1.2 R Tapp, J Shaw, P Zimmet
in making the Diabetes Atlas, second edition,
Chapter 2
possible.
2.1 G Soltèsz, C Patterson, G Dahlquist
2.2 R Singh, J Shaw, P Zimmet
IDF would also like to thank Novo Nordisk A/S
for its generous support. Chapter 3
Introduction P Zimmet
IDF would like to thank Novartis Pharma AG 3.1 N Rigby, RJ Leach, WPT James
for its generous support in making possible 3.2 CS Cockram, K Hynes
the report on impaired glucose tolerance in
Chapter 4
Chapter 1.
R Williams
IDF would also like to thank Johnson and Chapter 5

Johnson for its generous support in making J-C Mbanya, L Fezeu
possible the report on type 2 diabetes in the
Chapter 6
young in Chapter 2.
6.1 J Piette
6.2 L Siminerio
A publication such as this would not have
6.3 T Songer
been possible without the commitment and
contribution of many people around the Chapter 7
world. IDF would like to thank and gratefully 7.1 K Ramaiya, R Sicree, C Patterson
acknowledges the contributions of the 7.2 M Arab, AS Shera, R Sicree, C Patterson
following authors: 7.3 M Massi-Benedetti, L Etu-Seppälä,
R Sicree, C Patterson
7.4 Y Vovides, B Wentzell, R Sicree,
C Patterson
7.5 A Pérez-Comas, R Sicree, C Patterson
7.6 H Mahtab, MA Sayeed, R Sicree,
C Patterson
7.7 G Bunyan, R Sicree, C Patterson
Chapter 8
8.1 M Massi-Benedetti, J Akwe Akwi,
P Ferolla, MO Federici
8.2 Y Vovides, B Wentzell
8.3 CS Cockram
Chapter 9
C Regniers, D Gan, B Allgot
Chapter 10
P Lefèbvre
Profiles
J Colquhoun, D Lukoseviciene, N Ojha,
G Rafique, M Silink
Appendix 2
A Hornsby
Special thanks to S Murray for coordinating the

work at the International Diabetes Institute.

IDF also gratefully acknowledges the help of
the following people in making this publication
possible:
N Abdella, K Ajlouni, C Alexander, AS Alkuwari,

MC Almaraz, A Al-Nuaim, FI Al-Zurba, T Aspray,
V Augustiniene, B Balkau, TK Banerjee,
A Barceló, T Beljic, P Bennett, O Bernard,
C Berne, PR Betts, G Booth, E Briganti,
C Castell, A Chan, S-Y Chen, B Choi, P Chou,
LM Chuang, SS Chung, R Colagiuri, S Colagiuri,
M Comaschi, D Dabelea, M Dagmar, R Dankner,
H Dean, D De Bacquer, B Detournay,
CL de Visser, M Dragan, R Duarte, T Dwyer,
R Dyck, M Elbagir, M Eliasson, M Engelau,
J Eriksson, E Eskelinen, J Feinglass, E Ford,
MC Foss, M M-T Fuh, MM Garcia de Belaunde,
C Giorda, RT Go, A Goday, R Gupta, CH Han,
N Hancu, M Harris, J Harvey, L de Hassine,
GE Holder-Nelson, G Hu, C Invitti, ED Janus,
J Jervell, F Johansen, AJ Karter, S Kiauka,
T Kitagawa, D Koev, M Korecova, CF Kwok,
L Lavery, A Lerario, N Levitt, S Likitmaskul,
B McBride, M McGill, SM Makled, K Midthjell,
J Mohith, Z Naeemullah, P Nilsson,
W Nitiyanant, F Nobels, H-H Parving,
J Perusicova, G Piatt, E Placzkiewicz,
D Ragoobirsingh, A Ramachandran,
U Ramdanee, H Rashidi, W Rathmann,
I Raz, G Rennert, G Roglic, A Rotchford,
E Rudinskiene, M Sadikot, I Satman,
MA Sayeed, A Schranz, D Simon, A Sinha,
J Skrha, E Spichler, E Stern, S Tandhanand,
W Thefeld, R Toomath, J Tuomilehto, G Uwaifo,
K Van Acker, D Webb, S Wild, P Wilson, JP Yeo
IDF gratefully acknowledges the support and

help given by its member associations, task
forces and consultative sections.
Special thanks to L Al Obaidi, S Ash,

V Campanella de Lemes, L Cann, E Ng, N Ohja,
P Onraed, L Rabemananjara and Y Vovides for
their invaluable contribution in the regions.

Contents
Contents
Foreword 7
Introduction 9
Executive Summary 11
1. The Global Burden of Diabetes 15

1.1 Diabetes and Impaired Glucose Tolerance: Prevalence and Projections 17
1.2 Complications of Diabetes 72
2. Diabetes in the Young: a Global Perspective 113

2.1 Global Trends in Childhood Type 1 Diabetes 114
2.2 Type 2 Diabetes in the Young 135
3. The Widening Circle 157

3.1 Obesity 159
3.2 Cardiovascular Disease and Diabetes: Double Jeopardy 167
4. The Economic Impact of Diabetes 175
5. Access to Insulin and Diabetes Supplies 193
6. Diabetes Education 207

6.1 Effectiveness of Self-management Education 208
6.2 Educational Practices: a Global View 216
6.3 Cost-Effectiveness of Diabetes Education 221
7. Meeting the Challenges 225

7.1 Africa 226
7.2 Eastern Mediterranean and Middle East 231
7.3 Europe 237
7.4 North America 244
7.5 South and Central America 250
7.6 South-East Asia 255
7.7 Western Pacific 260
8. Reducing the Burden 267

8.1 The St Vincent Declaration 268
8.2 Declaration of the Americas on Diabetes 276
8.3 Western Pacific Declaration on Diabetes 278
8.4 Declaration of the Eastern Mediterranean and Middle East Region 280

Contents
9. Diabetes Associations: from Patients to Partners 283
10. Prevention and Strategic Action 301
Appendices
Appendix 1 Methodology 305
Appendix 2 Socio-economic Indicators 316
Appendix 3 IDF Member Associations Address List 329
Glossary 345
Acronyms 349
World Diabetes Foundation 352
Index 354
Index of Countries 357

Foreword
Foreword
S
everal years ago it was proposed by my predecessors that it would be helpful
to bring together relevant data about diabetes and diabetes associations around
the world. This culminated in the publication of the first edition of the Diabetes
Atlas at the 17th IDF Congress in Mexico. It was beautifully produced and instantly
popular. It went to Ministers of Health in IDF member countries, WHO offices, diabetes
associations and many others.
The Diabetes Atlas has proved to be an invaluable resource. It was decided that it
should go on the IDF website to be updated regularly – but should reappear in hard
copy for the 18th IDF Congress in Paris.
Many new sections have been included since the first edition. The epidemiology
section has been updated, stressing again the rapid rise in prevalence, as has that
on economics. A new section on impaired glucose tolerance (IGT) is included, giving
an indication of the further rise in diabetes that is to come. This is the first time
worldwide data on IGT have been collected together.
The prevalence of complications is now included – important for planners, health

professionals and people with diabetes alike. It is also the first time that such
information has been compiled in one publication. It is useful in showing not only the
prevalence data but also the gaps in our knowledge in this area.
Another new chapter discusses the relationship between obesity and diabetes as well
as the effect of diabetes on cardiovascular disease. The vital topic of access to insulin
is also covered – an area of critical importance in many IDF member countries.
Diabetes education has an expanded section, emphasizing its role in the successful
management of the disease. There are then very useful chapters on IDF regional
activities and diabetes associations. Primary prevention and socio-economic indicators
complete the text.
The evidence that we have shows beyond doubt that diabetes is on an epidemic
increase and that the toll from this disease will be huge in economic, social and
individual terms if action is not taken now.
There is also evidence that prevention of type 2 diabetes is possible. What remains
now is for all of us – governments, health organizations, diabetes associations – to
take the next step to use the knowledge that we have to curb the rise of diabetes and
its complications.

Foreword
I personally feel that the second edition is a major step forward and will prove
invaluable to governments and diabetes associations as well as individuals.
Production of the Diabetes Atlas is a costly undertaking. We should acknowledge the
time given by many colleagues in IDF and also our various sponsors, particularly the
new charity the World Diabetes Foundation, without whom the second edition of the
Diabetes Atlas would not have been possible.
Sir George Alberti

IDF President, 2000 - 2003

Introduction
Introduction
S
ince the publication of the first edition of the Diabetes Atlas in 2000, a number
of things have changed. Our appreciation of the extent of the burden of diabetes
in the world has been refined, our knowledge of the risks to health as a whole
and to diabetes in particular has increased and our conviction that type 2 diabetes is
potentially preventable has been confirmed with solid evidence about the steps we
need to make that potential a reality.
WHO and IDF continue their partnership in the fight to improve the wellbeing of people
with diabetes and to include in this partnership other organizations with an important
part to play in this endeavour.
In terms of the worldwide burden, the WHO Global Burden of Disease estimated that
around 177 million people in the world had diabetes in the year 2000. This second
edition of the Diabetes Atlas estimates 194 million in the year 2003, and around
two-thirds of these people live in developing countries. The projections for the future
provide no comfort at all. If current trends prevail, the above figure may well more
than double by the year 2025. We also know that already as much as a quarter or even
a third of acute sector health expenditures in some communities has to be devoted to
diabetes and its long-term complications.
The World Health Report 2002 quantifies the impact of several major risk factors on
current mortality and overall burden of disease. It brings into focus the importance
of overweight and low levels of physical activity in increasing the risks of developing
type 2 diabetes as well as a number of other conditions of enormous public health
importance. In that Report it is estimated that 58% of the global burden of diabetes,
21% of ischaemic heart disease and 8-42% of certain cancers are attributable to BMI
(body mass index) above 21 kg/m2.
Physical inactivity is related to diabetes risk both directly as a result of its effect on
insulin sensitivity but also indirectly via obesity and the World Health Report estimates
that 11-24% of people, depending on the region in which they live, are currently
physically inactive.
The Report also quantifies the potential for future reduction of the burden of disease.
A relatively modest 25% reduction of current and future obesity and physical inactivity
could avoid at least one-half and one-third of the burden attributed to these respective
risk factors in the year 2020. Several risk factors can be addressed in synergy with
policies that promote a healthy diet and encourage physical activity.

Introduction
As long as diabetes exists, the need to manage it effectively will always be here.
However, by slowing the incidence of new cases, through reducing levels of risk in the
population as a whole and in those at high risk, the management of existing diabetes
can surely only be improved.
Recently published randomized controlled trials provide clear proof that behavioural
changes which lead to weight reduction and/or increased physical activity or the use
of some widely available drugs can delay, or at least postpone, the transition from
impaired glucose tolerance to type 2 diabetes. Such evidence provides hope that
the current inexorable rise in the numbers of people with diabetes may, one day, be
slowed or even reversed.
While we work towards this promising future, IDF’s Diabetes Atlas provides one way of
tracking this epidemic and, more importantly, galvanizing IDF member associations,
governments, industry and other committed organizations to take action. Action is
needed now to ensure that people who already have diabetes can lead fuller and more
productive lives and that there is some hope of reducing the number of people at risk
of developing diabetes and its life-threatening complications.
Derek Yach
Executive Director
Noncommunicable Diseases and Mental Health Cluster
World Health Organization
Geneva
10

Executive Summary
Executive Summary
M any new topics have been included

in the second edition of the Diabetes
Atlas to reflect the growing need to tackle
dominate the health economies of many
countries by the end of the first quarter
of the current century.
It is estimated that
currently some
194 million people
the diabetes pandemic on all fronts. worldwide, or 5.1% in
These topics emphasize the importance The decision to include data on IGT was the adult population,
of looking not just at the epidemiology based on two major factors associated have diabetes and
of diabetes but also at its risk factors, with its presence: a high sensitivity that this will jump to
the management of the disease to for future diabetes incidence and its 333 million, or 6.3%,
prevent or delay complications and association with future cardiovascular by 2025.
primary prevention of diabetes in high disease occurrence. IGT is now
risk groups. This edition of the Atlas also recognized as being a stage in the
shows the immense costs of diabetes, in transition from normality to diabetes.
financial and human terms, to both the Thus, individuals with IGT are at high
individual and society as a whole. risk of progressing to type 2 diabetes,
although such progression is not
The Diabetes Atlas therefore aims to inevitable. Some 70% of these individuals,
communicate the global impact of however, are expected to develop the
diabetes and to underline the need for disease.
intervention now. In spite of the number
of studies describing the epidemiology The reports in this edition of the Diabetes
of diabetes, many governments and Atlas reconfirm that diabetes is now one
public health planners still remain largely of the most common non-communicable
unaware of the current magnitude, or, diseases globally. It is the fourth or fifth
more importantly, the future potential leading cause of death in most developed
for increases in diabetes and its serious countries and there is substantial
complications in their own countries. evidence that it is epidemic in many
developing and newly industrialized
The second edition of the Diabetes Atlas nations.
extends coverage to 212 countries and
territories around the world. It provides It is estimated that currently some
current estimates of the prevalence of 194 million people worldwide, or 5.1%
diabetes and impaired glucose tolerance in the adult population, have diabetes
(IGT) as well as forecasts the estimates and that this will jump to 333 million, or
for 2025, forewarning of the enormous 6.3%, by 2025.
burden to come. The future predictions
of cost are as alarming as the future This situation is exacerbated by the
predictions of prevalence. They suggest estimated number of people with IGT
that unless effective prevention measures – currently at 314 million, or 8.2% in
are introduced, expenditure devoted the adult population, and expected to
to diabetes and its complications will increase to 472 million, or 9.0%, by 2025.
11

Executive Summary
Type 2 diabetes constitutes about 85% The studies on type 2 diabetes in children
to 95% of all diabetes in developed have important implications in that
countries, and accounts for an even they highlight the risk of complications
higher percentage in developing occurring at a relatively young age,
countries. It is now a serious global which will place a significant burden on
health problem, which, for most health budgets as well as society as a
countries, has evolved in association whole. Early detection and intervention is
with rapid cultural and social changes, therefore essential to reduce the risk of
ageing populations, increasing future complications.
urbanization, dietary changes, reduced
physical activity, and other unhealthy Governments will be forced to deal with
lifestyle and behavioural patterns. the problem of type 2 diabetes in children
The change in lifestyle is a worldwide in time to come. As such, it would be
phenomenon, occurring in both better to address the problem as a public
developed and emerging nations, where health issue under the heading of primary
it is most prevalent in urban areas. care and prevention, rather than dealing
with the consequences of an entrenched
The risk of developing type 2 diabetes is condition and its complications in a
clearly linked to an increasing prevalence young population.
of obesity. Reports from the World Health
Organization (WHO) and the International Although type 1 diabetes usually
Obesity Task Force (IOTF) indicate that accounts for only a minority of the total
approximately 58% of diabetes mellitus burden of diabetes in a population it is
globally can be attributed to body mass the predominant form of the disease in
index above 21 kg/m2. However, there younger age groups in most developed
are indications that in western countries, countries. The incidence of childhood
around 90% of type 2 diabetes cases are onset diabetes is increasing in many
attributable to weight gain. countries in the world with an estimated
overall annual increase of around 3%.
Whereas previously type 2 diabetes
affected only individuals in the older age It is estimated that on an annual basis
groups, there are now ever increasing some 65,000 children worldwide under
reports of type 2 diabetes in children the age of 15 years develop type 1
worldwide, with some as young as eight diabetes. Of the estimated total of
years of age being affected. There is now about 400,000 prevalent cases of type
growing recognition that type 2 diabetes 1 diabetes in childhood, more than a
in children is becoming a global public quarter come from the South-East Asian
health issue with potentially serious Region, and more than a fifth from the
health outcomes. European Region where reliable, up-
to-date estimates of incidence were
The purpose of the report on type 2 available for the majority of countries.
diabetes in the young is to call attention
to this emergent problem by bringing The continued mapping of global trends
together for the first time, the available in incidence of type 1 diabetes in all age
epidemiological data on type 2 diabetes groups is important, and in conjunction
incidence and prevalence in the young with other scientific research may provide
from around the world. By the inclusion a logical basis for intervention studies
of such data it is hoped to highlight and future primary prevention strategies
deficiencies in the knowledge of the which must be the ultimate goal.
disease and also to promote strategies
to deal with it.
12

Executive Summary
The new section on diabetic healthcare costs of diabetes worldwide,

complications, which brings together for people in the 20-79 age group,
available studies on the prevalence of is currently estimated to be at least
the major complications, is a reminder 153 billion international dollars and may
of the urgent need for effective diabetes be as much as 286 billion.
care. The main relevance of diabetes
complications in a public health If predictions of diabetes prevalence for
perspective is the relationship to human 2025 are fulfilled, total direct healthcare
suffering and disability, and the huge expenditure on diabetes worldwide for
socio-economic costs through premature that year will be between 213 billion and
morbidity and mortality. Indeed, diabetic 396 billion international dollars. In some
complications are those aspects of the countries this will be as much as 40% of
disease that are most feared such as their total healthcare budget. If predictions of
blindness and amputation, and account diabetes prevalence
for much of the social and financial Even while sophisticated medical for 2025 are fulfilled,
burden of diabetes. technology and new medications are total direct healthcare
being developed in one part of the expenditure on diabetes
In virtually every developed society, world, one cannot ignore the fact that worldwide for that year
diabetes is ranked among the leading there are people dying from the simple will be between 213
causes of blindness, renal failure and lack of access to insulin in another part. billion and 396 billion
lower limb amputation. Through its Continuous accessibility to insulin is still international dollars.
effects on cardiovascular disease a major problem in many developing In some countries this
(50-80% of people with diabetes die of countries especially those in sub-Saharan will be as much as 40%
cardiovascular disease), it is also now Africa such that there are reports of of their total healthcare
one of the leading causes of death. premature deaths due to the chronic budget.
lack of access to insulin in some of these
Cardiovascular death rates on the whole countries.
are either high or appear to be climbing
in countries where diabetes is prevalent. At the same time, although the medical
The outlook for cardiovascular disease aspects of diabetes care such as eye
(CVD) is alarming when one considers exams and blood glucose monitoring
the number of people with diabetes have improved in recent years, outcomes
worldwide and that this is set to more for many people with diabetes remain
than double by 2025. poor. While many factors contribute
to poor outcome, this apparent
The recent decline in cardiovascular contradiction also reflects the central
disease in the USA, Australasia and role that people with diabetes themselves
western Europe may be compromised play in determining their health status,
significantly by this upsurge in and the challenges associated with
diabetes. In other parts of the world supporting their efforts to manage their
where CVD have been proliferating in self-care.
recent years, the additional impact of
diabetes threatens to have devastating The expanded section on diabetes
consequences. education clearly shows that diabetes
education is now considered an integral
The heavy financial burden is shown part of diabetes care. Diabetes self-
clearly in the chapter on the economic management education assists people
impact of diabetes in which estimates in coping with the mental and physical
are made on the direct healthcare demands of their illness, given their
expenditure in countries covered by unique economic, cultural and social
the Diabetes Atlas. The annual direct circumstances.
13

Executive Summary
Diabetes self-management education The ultimate goal of a publication

is therefore a multi-faceted process such as the Diabetes Atlas would be to
involving much more than helping stimulate research and concrete action
people with diabetes monitor their blood by governments and all those concerned
glucose, or take their medication as with health and wellbeing to stem the
prescribed. Diabetes education must be rising tide of diabetes in order to bring
an ongoing process rather than a one- about better lives for all.
time event because a person’s health
status and need for support changes over
time. More importantly, self-management
education is most likely to be successful
when it is part of a comprehensive and
coordinated approach to diabetes care.
Education for people with diabetes has

therefore become one of the key activities
of diabetes associations and regional
organizations, as evidenced in the Atlas.
In facing the challenges brought about
by the diabetes epidemic, diabetes
associations and regional organizations
have galvanized into action. Declarations
on diabetes, spelling out strategic
actions, have been signed in five regions
– Eastern Mediterranean and Middle East,
Europe, North America together with
South and Central America, and Western
Pacific.
These declarations also reflect the

significance of strategic alliances at all
levels with organizations such as the
World Health Organization (WHO). At the
global level, IDF is collaborating with
WHO to embark on a major course of
action, the ‘Global awareness, advocacy
and action in diabetes’ programme. This
programme aims to raise awareness
about diabetes and its complications
amongst the public, health professionals
and decision makers, with major
emphasis on prevention particularly in
low income countries.
By promoting diabetes prevention, IDF

will also ensure that those millions who
already have diabetes will not face the
nightmare of a regression in the quality
of care they deserve while, on the
contrary, there is a great need in many
parts of the world to improve it.
14

The Global Burden of Diabetes
Chapter 1
The Global Burden of Diabetes Chapter 1
D iabetes is now one of the most

common non-communicable 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.
1.1 Diabetes and Impaired
Glucose Tolerance:
The number of studies describing the
Prevalence and Projections
epidemiology of diabetes over the last
1.2 Complications of Diabetes 20 years has been extraordinary, but
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
problem, both because of its association
with diabetes incidence and its own
association with an increased risk of the
development of cardiovascular disease.
This chapter provides estimates of the

prevalence of diabetes mellitus and IGT
for 212 countries and territories for
the years 2003 and 2025, so that some
15
Chapter 1
concept of the likely future burden should

be apparent. In adding to the scope of
the first edition of the Diabetes Atlas,
data are also provided on the prevalence
of many of the complications of
diabetes. The data on diabetes, IGT and
diabetes complications were compiled
at the International Diabetes Institute,
Melbourne, Australia.
The data presented here 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 should be used
when interpreting this report, and the
data limitations will be discussed further
throughout the text.
Comparisons 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 always to be considered,
and the reader must realize that the key
purpose of a report such as this is to
stimulate action in the form of preventive
and management programmes, as well as
further research.
16
Chapter 1
1.1 Diabetes and Impaired Glucose Tolerance:

Prevalence and Projections
Introduction At a glance
Diabetes mellitus and lesser forms of

glucose intolerance, particularly impaired All diabetes and IGT 2003 2025
glucose tolerance, can now be found in
almost every population in the world and Total world population (billions) 6.3 8.0
epidemiological evidence suggests that, Adult population (billions)
without effective prevention and control (20-79 years) 3.8 5.3
programmes, diabetes will likely continue Number of people with diabetes (millions)
to increase globally (1). (20-79 years) 194 333
World diabetes prevalence (%)
Major categories of glucose (20-79 years) 5.1 6.3
intolerance Number of people with IGT (millions)
Diabetes is recognized as a group (20-79 years) 314 472
of heterogeneous disorders with the IGT prevalence (%)
common elements of hyperglycaemia (20-79 years) 8.2 9.0
and glucose intolerance due to insulin
deficiency, impaired effectiveness of
insulin action, or both (2).
Diabetes mellitus is classified on

the basis of aetiology and clinical
presentation of the disorder into four
types: The diagnosis of type 2 diabetes usually
• type 1 diabetes occurs after the age of 40 years although
• type 2 diabetes the age of onset is often a decade earlier
• gestational diabetes in populations with a high diabetes
• other specific types prevalence (10). Type 2 diabetes can
remain asymptomatic for many years
Type 1 diabetes and the diagnosis is often made from
Type 1 diabetes results from cellular- associated complications or incidentally
mediated autoimmune destruction of through an abnormal blood or urine
pancreatic islet beta cells causing the loss glucose test.
of insulin production (3). It ranks as the
most common chronic childhood disease Type 2 diabetes is often, but not always,
in developed nations (4), but occurs at all associated with obesity, which itself
ages (5) and the clinical presentation can can cause insulin resistance and lead
vary with age (6, 7). to elevated blood sugar levels. It is
strongly familial, but major susceptibility
Type 2 diabetes genes have not yet been identified. In
Type 2 diabetes is characterized by contrast to type 1 diabetes, persons with
insulin resistance and relative insulin type 2 diabetes are not dependent on
deficiency, either of which may be exogenous insulin and are not ketosis-
present at the time that diabetes becomes prone, but may require insulin for
clinically manifest (8, 9). The specific control of hyperglycaemia if this is not
reasons for the development of these achieved with diet alone or with oral
abnormalities are not yet known. hypoglycaemic agents.
17
Chapter 1
Figure 1.1
Differences in the prevalence of type 2 diabetes among selected ethnic groups, 2003
(adapted from King et al (11))
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a. Rates are age-standardized to Segi’s World Population for ages 30 to 64 years
Type 2 diabetes constitutes about 85 or urbanized populations that may have

to 95% of all diabetes in developed experienced a greater degree of lifestyle
countries (1), and accounts for an change. The lowest rates are generally
even higher percentage in developing found in rural communities where people
countries. Type 2 diabetes is now a are living lifestyles incorporating high
common and serious global health levels of physical activity.
problem, which, for most countries, has
evolved in association with rapid cultural The incidence and prevalence of type 2
and social changes, ageing populations, diabetes is also reported to be increasing
increasing urbanization, dietary changes, in children. Studies from America and
reduced physical activity and other Japan have demonstrated an increasing
unhealthy lifestyle and behavioural incidence (12, 13). Other ethnic groups
patterns (1). with high adult diabetes prevalence such
as the Pima Indians (14) are also reporting
Figure 1.1 highlights the large range of increasing adolescent prevalences. The
type 2 diabetes prevalence even within importance of this problem and the need
the same or similar ethnic groups, when for further research are emphasized by
living under different conditions. Clearly, the authors of this chapter. A section
many of the differences between these collating studies on type 2 diabetes
rates reflect underlying behavioural, in children and adolescents has been
environmental and social risk factors, included in Chapter 2.
such as diet, level of obesity and physical
activity. Impaired glucose tolerance (IGT) is an
asymptomatic condition defined by
Within ethnic groups, high rates of type elevated (though not diabetic) levels of
2 diabetes are usually found in migrant blood glucose two hours after a 75g oral
18
Chapter 1
glucose challenge. Along with impaired appropriate strategies for the detection of
fasting glucose (IFG), it is now recognized GDM can be developed.
as being a stage in the transition from
normality to diabetes. Classification criteria and
reporting standards
Thus, individuals with IGT are at high Standardization of methods and
risk of progressing to type 2 diabetes, reporting in diabetes epidemiology
although such progression is not promotes comparison between studies
inevitable, and probably over 30% of and may permit the pooling of results
individuals with IGT will return to normal from different investigations (22, 23).
glucose tolerance over a period of Standardized criteria for detecting and
several years (15). Not surprisingly, IGT reporting glucose intolerance have
shares many characteristics with type 2 evolved greatly since the 1960s (24).
diabetes, being associated with obesity,
advancing age, insulin resistance and an In the late 1970s both the US National
insulin secretory defect (16). Diabetes Data Group (NDDG) and the World
Health Organization (WHO) produced new
In addition to estimating the prevalence criteria on which to diagnose diabetes
of diabetes for the years 2003 and 2025, mellitus. In 1985, WHO modified their
data on case numbers and national criteria to be more consistent with NDDG
prevalence of IGT are presented for values. More recently, the American
both years in this section. The decision Diabetes Association (ADA) (25) and WHO
to include data on IGT was based on (26) have produced new recommendations
two major factors associated with for the diagnosis of diabetes. The major
its presence: a higher sensitivity for change recommended is the lowering of
future diabetes incidence (17), and its the diagnostic value of the fasting plasma
association with future occurrence of glucose concentration to 7.0 mmol/l. For
cardiovascular disease (18, 19). glucose tested in whole blood, the new
recommended threshold is 6.1 mmol/l (26).
Gestational diabetes
The most widely accepted definition of In many population studies, individuals
gestational diabetes mellitus (GDM) is have been categorized as having diabetes
“carbohydrate intolerance of varying mellitus based on blood glucose values
degrees of severity with onset or first measured after an overnight fast and/or
recognition during pregnancy” (20, 21). two hours after a 75g oral glucose load.
This definition applies regardless of Whilst WHO still recommends the oral
whether insulin is used for treatment or glucose tolerance test (OGTT) as being
the condition persists after pregnancy. the single best choice, they also state
It does not exclude the possibility that that “if it is not possible to perform the
unrecognized glucose intolerance may OGTT (eg for logistical or economic
have antedated the pregnancy. reasons), the fasting plasma glucose
alone may be used for epidemiological
It is widely believed that differences in purposes” (26).
reported prevalence of GDM parallel the
differences that have been found in the It is important to realize that different
frequency of type 2 diabetes among screening and diagnostic criteria may
different populations. Nonetheless GDM have been used for different studies in
is increasing in prevalence in concert with this report. The impact that the recent
the worldwide rise in type 2 diabetes. diagnostic cut-off level changes have on
Studies currently in progress hold much prevalence estimates seems to vary from
hope of providing the data from which country to country (27). In this section,
‘outcome based’ diagnostic criteria and
19
Chapter 1
the criteria used will be reported when curves for prevalence (with respect
they are known. to age).
3 Applying the prevalence rates to
Global estimates of diabetes the population distribution of that
The global burden of diabetes has been country, and where no data for
estimated several times (28-31). In 1994, countries were available, to those
the International Diabetes Federation other countries of similar ethnicity
Directory (28) contained type 1 and and economic circumstances.
type 2 diabetes estimates supplied 4 Assuming an urban:rural prevalence
by member nations. Using these data ratio of 2:1 for diabetes (but not IGT),
the International Diabetes Federation except in those countries classified
(IDF) estimated that over 100 million by WHO (30) as market economies,
people worldwide had diabetes. Also in or former socialist economies. The
1994, McCarty et al (29) used data from urban proportion of the population
population-based epidemiological studies was derived from UN estimates (32).
and estimated that the global burden of The only other exception to this
diabetes was 110 million in 1994 and 2:1 urban:rural prevalence ratio was
that it would likely more than double to for India (and Nepal, for which data
239 million by 2010. were derived from India), for which
the cited data indicated that the
WHO (30) also produced a report using urban:rural ratio was nearer to 4:1 for
epidemiological information and diabetes prevalence (33, 34).
estimated the global burden at 5 The data for diabetes rates include
135 million in 1995, with the number both type 1 and type 2 diabetes,
reaching 299 million by the year 2025. with a separate chapter providing
In 1997, Amos et al (31) estimated the estimates on type 1 diabetes in
global burden of diabetes to be 124 children and adolescents (see
million people, and projected that this Chapter 2).
would increase to 221 million people by 6 The prevalence of diabetes
the year 2010. Despite using different throughout the Diabetes Atlas
methodologies, and at times showing includes both undiagnosed and
large differences in country-specific previously diagnosed diabetes.
estimates, these reports have arrived
at remarkably similar global figures of This section contains prevalence
diabetes. estimates of diabetes and IGT for the
years 2003 and 2025, and although the
Methodology Tables contain data listed to one decimal
point, it should not be inferred that this
The principal details of the methodology indicates the degree of precision, but
are provided in Appendix 1.1, where details rather to facilitate calculations and the
of the rationale and process of obtaining appearance of the tables. In general, no
age-specific prevalences for those countries predictions of diabetes or IGT numbers
with adequate data are given. should be taken as having reliability of
more than one significant figure.
The principal aspects of the
determination of prevalence were: The consequence of applying current age
and gender specific prevalence rates to
1 Identification of studies through a estimate 2025 prevalences and number
detailed literature search, and contact of cases is that only changes in the
with IDF member organizations. age and urban/rural distribution of the
2 Employing the methodology indicated population will affect the estimates. Since
in Appendix 1.1 to create smoothed it is likely that the age specific prevalence
20
Chapter 1
rates (the prevalence at any given age) Figure 1.2

will rise due to increasing obesity, the World population (20-79 age group) by region
figures are probably underestimates.
��
Results
��
The main aim of this section is to
estimate the prevalence of diabetes
mellitus and IGT for each country for the
��
years 2003 and 2025. Data are provided
��
for 212 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 Western Pacific (WP). �
��
Rates for each country have not been ��

age-standardized, but are presented as ��
the crude rates for the specific country
and region according to the number
of persons aged 20-79 years for that Figure 1.3
national and geographical entity. Prevalence of diabetes (20-79 age group) by region
��
The data presented are for all diabetes
and IGT for adults from 20 to 79 years,
and relate only to individuals 20 years
of age or older because the majority of ��
people who have type 2 diabetes and IGT
are adults. Type 2 diabetes in children
��
and adolescents is acknowledged as a

very important and growing problem �
(see Chapter 2).
Furthermore as the emphasis is on

��
numbers of persons with diabetes and
IGT for each country, prevalence rates are
markedly affected by the population age
distribution so that those countries with �
��
older age distributions will inevitably
have higher crude prevalences for the ��
20-79 year age group. It should be noted ��
that column numbers in the Tables may
not always exactly be the sum of the
components because of rounding effects.
Demography Pacific Region, which has China as

The total populations and the population a member, and the South-East Asian
aged from 20-79 years are shown in Region, which has India as a member,
Figure 1.2. It is clear that the Western have the greatest numbers in people.
21
Chapter 1
Figure 1.4 Diabetes

Number of people with diabetes (20-79 age group) by region Prevalence
In 2003, it is estimated that
��
approximately 194 million people
worldwide, or 5.1% in the age group
20-79, have diabetes. This estimate is
��
expected to increase to some 333 million,
or 6.3% in the adult population, by 2025.
��
The European Region with 48 million and
��
Western Pacific Region with 43 million

currently have the highest number of
��
people with diabetes. However the
prevalence rate of 3.1% for the Western
Pacific Region is significantly lower than
��
7.9% in the North American Region and
7.8% in the European Region as seen in
Figure 1.3.
�
��
By 2025, the region with the greatest
�� number of persons with diabetes is
�� expected to change to the South-East
Asian Region with about 82 million
as shown in Figure 1.4. The region’s
Figure 1.5 prevalence of 7.5% will however continue
Prevalence of impaired glucose tolerance (20-79 age group) to be lower than that of North America,
by region estimated at 9.7%, and Europe at 9.1%.
�� Age distribution
The 40-59 age group currently has
the greatest number of persons with
diabetes. By 2025, because of the ageing
of the world’s population, there will be
��
146 million aged 40-59 and 147 million
��
aged 60 or older.
Gender distribution
The estimates for both 2003 and 2025
�
showed a female predominance in the
number of persons with diabetes. The
female numbers were about 10% higher
than for males.
�
�� Urban/rural distribution
In 2003, the number of people with
��
diabetes in urban areas was 78 million,
��
compared to 44 million persons with
diabetes in rural areas in countries
not considered to be established
market economies, or former socialist
economies. By 2025, it is expected
that this discrepancy will increase to
22
Chapter 1
182 million urban and 61 million rural Figure 1.6

persons with diabetes. Number of people with impaired glucose tolerance
(20-79 age group) by region
Impaired Glucose Tolerance
��
Prevalence
In 2003, it is estimated that
approximately 314 million people
worldwide, or 8.2% in the age group ��
20 – 79, have IGT. By 2025, the number
of people with IGT is projected to
increase to 472 million, or 9.0% in the
��
adult population. ��
The South-East Asian Region currently

has the highest number of people with
��
IGT with some 93 million and the highest
prevalence rate with 13.2%. While the
Western Pacific Region is the next highest
in terms of number with about 78 million, �
��
its prevalence rate of 5.7% is the lowest
compared with the other regions as seen ��
in Figure 1.5. ��
By 2025, the trend is expected to

continue with the South-East Asian Figure 1.7
Region leading in prevalence with Estimated prevalence of diabetes and impaired glucose
13.5% and in number with some 146 tolerance (20-79 age group) by region
million people as seen in Figure 1.6. The
��
prevalence of IGT in the European Region
will remain the next highest with 10.9%.
��
As can be seen in Figure 1.7, the
prevalence of IGT is more than twice that
of diabetes in the African and South-East
��
Asian Regions, whereas in the Eastern
��
Mediterranean and Middle East, and North

American Regions the prevalence of IGT ��
is slightly lower than that of diabetes.
Age distribution �
As with diabetes, the 40-59 age group
currently has the greatest number of
persons with IGT and this will remain true �
��
by 2025.
��
Gender distribution ��

There was also a female predominance ��
in the number of persons with IGT in the
estimates for both 2003 and 2025. The
female numbers were about 20% higher
than for males.
23
Chapter 1
Figure 1.8 a random blood glucose (RBG), and

Estimated number of people with diabetes and impaired some based their data on self-report
glucose tolerance (20-79 age group) by region (SR). It is difficult to control for this
unless, for example, only those studies
��
that used an OGTT were included. This
would also have the effect of excluding
studies lacking OGTT data, which
��
would have increased the number
of countries for which data were
extrapolated from another country.
��
��
• There were some inconsistencies in the

��
technique used for a particular test (eg
for the Argentinian data, diabetes was
measured according to a 50g two-hour
�� post-glucose load test, and not a 75g
load as recommended by WHO), and
persons with previously diagnosed
� diabetes were excluded from the
��
analysis.
��
�� • There were inconsistencies in the

��
diagnostic criteria adopted, resulting
from the updating of the diagnostic
criteria in 1997 (25). The use of a
lower fasting diagnostic criterion for
diabetes will tend to result in a higher
Regional estimates for diabetes and IGT prevalence of diabetes and lower
for 2003 and 2025 are shown in Table prevalence of IGT. The diagnostic
1.1, and highlight the large increases criteria used for each country are
in absolute numbers of both conditions indicated in the data source tables.
over the 22-year period as also shown in
Figure 1.8. • Three of the datasets reported only
previously diagnosed diabetes – New
Discussion Zealand (35), Canada (36) and Germany
(37). In order to account for those with
In order to make national, regional and undiagnosed diabetes, the figures
global predictions for the prevalence from New Zealand were doubled based
of diabetes, a number of assumptions on Australian data showing that the
needed to be made, and therefore ratio of known:unknown persons with
the results are subject to a number diabetes is 1:1 (38, 39), as was data
of limitations. In addition to those from Germany (40) while data from
highlighted in the Methodology section in the USA (41) indicated that Canadian
Appendix 1.1, some of these are that: figures should be increased by 50%.
• The studies included in this section • If a country lacked data, it was

often used differing screening assumed that their age and sex-
techniques. The majority of studies specific prevalence rates of diabetes
used an OGTT to screen for diabetes, mellitus were the same as those
however, some studies used a fasting rates in another socio-economically,
blood glucose test (FBG), some a ethnically and geographically similar
two-hour blood glucose (2BG), some country.
24
Chapter 1
Table 1.1
Regional estimates for diabetes and impaired glucose tolerance (20-79 age group), 2003 and 2025
2003 2025
No. of No. of No. of No. of
Population people with Diabetes people IGT Population people with Diabetes people IGT
(20-79) diabetes prevalence with IGT prevalence (20-79) diabetes prevalence with IGT prevalence
Region (millions) (millions) (%) (millions) (%) (millions) (millions) (%) (millions) (%)
AFR 295 7.1 2.4 21.4 7.3 541 15.0 2.8 39.4 7.3
EMME 276 19.2 7.0 18.7 6.8 494 39.4 8.0 36.5 7.4
EUR 621 48.4 7.8 63.2 10.2 646 58.6 9.1 70.6 10.9
NA 290 23.0 7.9 20.3 7.0 374 36.2 9.7 29.6 7.9
SACA 252 14.2 5.6 18.5 7.3 364 26.2 7.2 29.5 8.1
SEA 705 39.3 5.6 93.4 13.2 1,081 81.6 7.5 146.3 13.5
WP 1,384 43.0 3.1 78.5 5.7 1,751 75.8 4.3 120.2 6.9
Total 3,823 194 5.1 314 8.2 5,251 333 6.3 472 9.0
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.
It is hoped that this report will assist

in monitoring the trends of diabetes
prevalence over time, by adopting the
same methodology for future reports.
A report such as this should also be
an indicator of a country’s and region’s
‘database’ of research. It should stimulate
research in those countries lacking
data, as well as encourage further and
improved research in those countries
where available data may not be
representative of national rates.
Finally, 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.
25
Chapter 1
Map 1.1
Prevalence estimates of diabetes, 2003
� ��
��
��
��
��
��
��
� ��
Map 1.2
Prevalence estimates of diabetes, 2025
� ��
��
��
��
��
��
��
� ��
26
Chapter 1
Map 1.3
Prevalence estimates of impaired glucose tolerance, 2003
� ��
��
��
��
��
��
��
� ��
Map 1.4
Prevalence estimates of impaired glucose tolerance, 2025
� ��
��
��
��
��
��
��
� ��
27
Chapter 1
Top ten
Figure 1.9
Estimated top 10 prevalences of diabetes (20-79 age group), 2003
��
��
��
��
��
��
��
��
��
��
� � ��
��
��
��
Table 1.2
Estimated top 10: Prevalence of diabetes (20-79 age group), 2003 and 2025
2003 2025
Country Prevalence (%) Country Prevalence (%)
1 Nauru 30.2 1 Nauru 33.0
2 United Arab Emirates 20.1 2 United Arab Emirates 24.5
3 Bahrain 14.9 3 Singapore, Republic of 19.5
4 Kuwait 12.8 4 Bahrain 18.3
5 Tonga 12.4 5 Kuwait 16.4
6 Singapore, Republic of 12.3 6 Tonga 15.9
7 Oman 11.4 7 Mauritius 14.7
8 Mauritius 10.7 8 Barbados 12.8
9 Germany 10.2 9 Hong Kong 12.8
10 Spain 9.9 10 Suriname 12.3
Only countries have been included for which surveys including glucose testing were undertaken for that country
Table 1.3
Estimated top 10: Number of people with diabetes (20-79 age group),
2003 and 2025
2003 2025
Country Persons (millions) Country Persons (millions)
1 India 35.5 1 India 73.5
2 China, People’s Republic of 23.8 2 China, People’s Republic of 46.1
3 USA 16.0 3 USA 23.1
4 Russia 9.7 4 Pakistan 11.6
5 Japan 6.7 5 Russia 10.7
6 Germany 6.3 6 Brazil 10.7
7 Pakistan 6.2 7 Mexico 9.0
8 Brazil 5.7 8 Egypt 7.8
9 Mexico 4.4 9 Japan 7.1
10 Egypt 3.9 10 Germany 7.1
28
Chapter 1
Top ten
Figure 1.10
Estimated top 10 prevalences of impaired glucose tolerance (20-79 age group), 2003
��
��
��
��
��
��
��
��
��
��
� � ��
��
��
��
Table 1.4
Estimated top 10: Prevalence of impaired glucose tolerance
(20-79 age group), 2003 and 2025
2003 2025
Country Prevalence (%) Country Prevalence (%)
1 Nauru 20.4 1 Nauru 21.2
2 Bahrain 17.2 2 United Arab Emirates 20.8
3 United Arab Emirates 17.2 3 Bahrain 20.7
4 Kiribati 17.2 4 Kuwait 19.6
5 Kuwait 16.8 5 Poland 18.5
6 Singapore, Republic of 16.6 6 Kiribati 18.1
7 Poland 16.6 7 Mauritius 17.7
8 Mauritius 16.2 8 Singapore, Republic of 17.5
9 India 14.2 9 Hong Kong 14.6
10 Japan 13.0 10 India 14.5
Only countries have been included for which surveys including glucose testing were undertaken for that country
Table 1.5
Estimated top 10: Number of people with impaired glucose tolerance
(20-79 age group), 2003 and 2025
2003 2025
Country Persons (millions) Country Persons (millions)
1 India 85.6 1 India 132.0
2 China, People’s Republic of 33.2 2 China, People’s Republic of 54.3
3 Russia 17.8 3 Indonesia 20.9
4 USA 13.9 4 USA 19.3
5 Indonesia 12.9 5 Russia 18.3
6 Japan 12.6 6 Japan 12.7
7 Brazil 7.5 7 Brazil 11.7
8 Ukraine 6.2 8 Pakistan 10.9
9 Pakistan 5.7 9 Bangladesh 10.1
10 Bangladesh 5.3 10 Nigeria 7.4
29
Chapter 1
Table 1.6
Data sources: prevalence estimates of diabetes mellitus (DM) and
impaired glucose tolerance (IGT) – African Region
Country Data used

Angolaa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43
Beninb Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45
Botswanac South Africa (Omar et al, 1993 and Levitt et al, 1993)46,47
Burkina Faso b
Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45
Burundi a
Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43
Cameroon Cameroon (Mbanya et al, 1997)44
Cape Verdeb Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45
Central African Republic b
Chad Sudan (Elbagir et al, 1996)48
Comorosa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43
Congo, Democratic Republic of a Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43
Congo, Republic of b
Côte d’Ivoire b
Djibouti Sudan (Elbagir et al, 1996)48
Equatorial Guineab Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45
Eritrea a
Ethiopia a
Gabonb Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45
Gambiab Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45
Ghana Ghana (Amoah et al, 2002)45
Guinea b
Guinea-Bissaub Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45
Kenyaa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43
Lesotho c
South Africa (Omar et al, 1993 and Levitt et al, 1993)46,47
Liberia b
Madagascara Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43
Malawia Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43
Malib
Mauritania Sudan (Elbagir et al, 1996)48
Mozambiquea Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43
Namibiac South Africa (Omar et al, 1993 and Levitt et al, 1993)46,47
Niger b
Nigeria b
Reunion Mauritius (Dowse et al, 1990)49
Rwandaa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43
Sao Tome and Principe b
Senegal b
Seychelles Mauritius (Dowse et al, 1990)49
Sierra Leoneb Cameroon (Mbanya et al, 1997)44 and Ghana (Amoah et al, 2002)45
Somalia a
South Africa c
Swazilandc South Africa (Omar et al, 1993 and Levitt et al, 1993)46,47
Tanzaniaa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43
Togo b
Uganda a
Western Sahara Sudan (Elbagir et al, 1996)48
Zambiaa Tanzania (McLarty et al, 1989 and Aspray et al, 2002)42,43
Zimbabwe a
a. The prevalence was calculated after the combination of the data of the two studies, notwithstanding the
different criteria. IGT figures were calculated from the McLarty data, as the Aspray study only used FBG
criteria.
b. The prevalence was calculated as the average of the two studies as their sample sizes differed considerably.
c. The prevalence was calculated after the combination of the data of the two studies. IGT figures were based
only on the study of Omar et al.
30
Chapter 1
Screening method Diagnostic criteria Sample size Age (yrs)

OGTT/FBG WHO – 1985, 1999 7,781 15+
OGTT WHO – 1985, 1999 6,500 24+
OGTT WHO – 1985 1,208 15+
OGTT WHO – 1985, 1999 6,500 24+
OGTT/FBG WHO – 1985, 1999 7,781 15+
OGTT WHO – 1985 1,767 24-74
OGTT WHO – 1985, 1999 6,500 24+
OGTT WHO – 1985, 1999 6,500 24+
2BG WHO – 1985 1,284 25-84
OGTT/FBG WHO – 1985, 1999 7,781 15+
OGTT/FBG WHO – 1985, 1999 7,781 15+
OGTT WHO – 1985, 1999 6,500 24+
OGTT WHO – 1985, 1999 6,500 24+
2BG WHO – 1985 1,284 25-84
OGTT WHO – 1985, 1999 6,500 24+
OGTT/FBG WHO – 1985, 1999 7,781 15+
OGTT/FBG WHO – 1985, 1999 7,781 15+
OGTT WHO – 1985, 1999 6,500 24+
OGTT WHO – 1985, 1999 6,500 24+
OGTT WHO – 1999 4,733 25+
OGTT WHO – 1985, 1999 6,500 24+
OGTT WHO – 1985, 1999 6,500 24+
OGTT/FBG WHO – 1985, 1999 7,781 15+
OGTT WHO – 1985 1,208 15+
OGTT WHO – 1985, 1999 6,500 24+
OGTT/FBG WHO – 1985, 1999 7,781 15+
OGTT/FBG WHO – 1985, 1999 7,781 15+
OGTT WHO – 1985, 1999 6,500 24+
2BG WHO – 1985 1,284 25-84
OGTT/FBG WHO – 1985, 1999 7,781 15+
OGTT WHO – 1985 1,208 15+
OGTT WHO – 1985, 1999 6,500 24+
OGTT WHO – 1985, 1999 6,500 24+
OGTT WHO – 1985 4,929 25-74
OGTT/FBG WHO – 1985, 1999 7,781 15+
OGTT WHO – 1985, 1999 6,500 24+
OGTT WHO – 1985, 1999 6,500 24+
OGTT WHO – 1985 5,080 25-74
OGTT WHO – 1985, 1999 6,500 24+
OGTT/FBG WHO – 1985, 1999 7,781 15+
OGTT WHO – 1985 1,208 15+
OGTT WHO – 1985 1,208 15+
OGTT/FBG WHO – 1985, 1999 7,781 15+
OGTT WHO – 1985, 1999 6,500 24+
OGTT/FBG WHO – 1985, 1999 7,781 15+
2BG WHO – 1985 1,284 25-84
OGTT/FBG WHO – 1985, 1999 7,781 15+
OGTT WHO – 1985 1,208 15+
31
Chapter 1
Table 1.7
Prevalence estimates of diabetes mellitus (DM), 2003 – African Region
Population DM Number of people with DM (000’s)

(20-79) prevalence in the 20-79 age group
Country (000’s) % Rural Urban Male Female 20-39 40-59 60-79 Total
Angola 5,846 2.7 33.1 123.7 84.0 72.8 51.6 69.5 35.8 156.8
Benin 2,911 2.1 23.6 38.9 32.7 29.8 19.0 28.1 15.5 62.5
Botswana 716 3.6 3.2 22.3 8.8 16.7 4.1 13.9 7.5 25.5
Burkina Faso 4,969 2.7 90.4 44.8 67.8 67.4 40.1 55.2 40.0 135.3
Burundi 2,860 1.3 22.0 16.0 19.4 18.6 12.6 15.6 9.8 38.0
Cameroon 7,278 0.8 19.5 38.9 23.9 34.5 9.4 42.3 6.7 58.4
Cape Verde 228 2.3 1.1 4.2 2.2 3.1 2.0 1.7 1.7 5.3
Central African Republic 1,780 2.3 16.3 25.0 21.1 20.2 10.7 17.6 13.0 41.3
Chad 3,674 2.7 60.7 39.9 39.1 61.5 12.2 54.5 33.9 100.6
Comoros 355 2.5 1.9 7.0 4.8 4.1 3.2 3.9 1.8 8.9
Congo, Democratic Republic of 22,436 2.5 136.6 415.4 294.7 257.3 182.3 237.4 132.3 552.0
Congo, Republic of 1,403 2.6 7.6 28.3 18.4 17.6 10.5 15.2 10.3 35.9
Côte d’Ivoire 7,959 2.3 63.9 121.9 107.3 78.6 51.4 83.0 51.5 185.8
Djibouti 300 4.9 1.3 13.5 4.8 9.9 1.3 8.3 5.2 14.8
Equatorial Guinea 226 2.5 1.8 3.8 2.9 2.7 1.5 2.5 1.7 5.6
Eritrea 1,906 1.9 13.6 22.7 19.7 16.6 11.8 15.6 8.8 36.2
Ethiopia 29,562 1.9 214.6 335.8 299.4 250.9 176.6 234.9 138.8 550.4
Gabon 647 2.9 5.0 13.9 9.9 9.0 4.0 8.1 6.8 18.9
Gambia 703 2.2 7.4 8.0 8.3 7.0 4.1 7.2 4.0 15.4
Ghana 9,986 3.3 143.8 190.2 185.0 149.0 93.4 152.8 87.8 334.0
Guinea 3,855 2.0 37.6 41.2 42.8 36.0 23.3 35.5 20.1 78.9
Guinea-Bissau 588 2.0 7.0 4.8 6.3 5.5 3.1 5.2 3.5 11.8
Kenya 14,604 2.5 78.1 281.5 193.6 166.0 133.7 152.3 73.5 359.6
Lesotho 1,040 3.1 17.3 14.8 12.3 19.8 4.2 17.6 10.4 32.1
Liberia 1,573 2.0 10.5 21.3 17.0 14.8 11.6 11.6 8.6 31.8
Madagascar 7,782 2.5 47.3 144.6 104.3 87.5 63.2 85.5 43.2 191.9
Malawi 5,131 1.7 38.0 49.3 46.6 40.6 28.8 35.5 23.0 87.2
Mali 5,231 2.0 54.4 52.5 55.8 51.1 30.7 42.6 33.6 106.9
Mauritania 1,309 3.5 11.4 34.6 18.0 28.0 5.6 26.1 14.3 46.0
Mozambique 8,681 3.1 44.9 221.6 142.4 124.1 86.0 118.8 61.6 266.5
Namibia 831 3.1 10.1 15.4 9.5 16.0 3.9 13.6 8.0 25.5
Niger 4,728 3.1 36.4 110.3 57.7 89.0 20.8 83.9 41.9 146.7
Nigeria 54,248 2.2 439.3 779.4 655.4 563.3 354.5 528.9 335.3 1,218.7
Reuniona 474 13.1 10.0 51.9 29.1 32.8 11.2 29.7 21.0 61.9
Rwanda 3,645 1.1 28.3 13.1 22.7 18.7 15.2 14.7 11.4 41.4
Sao Tome and Principeb 107 2.8 1.0 1.9 1.6 1.4 0.6 1.3 1.0 2.9
Senegal 4,607 2.3 34.9 68.9 54.7 49.0 31.3 46.8 25.6 103.7
Seychellesa,b 49 12.3 1.5 4.5 2.9 3.0 1.0 2.9 2.0 6.0
Sierra Leone 2,268 2.2 21.3 27.6 25.7 23.2 14.0 21.8 13.1 48.9
Somalia 4,086 2.3 24.5 67.5 49.6 42.4 32.2 40.5 19.3 92.0
South Africa 24,741 3.4 272.1 569.1 322.7 518.5 127.1 489.6 224.5 841.2
Swaziland 450 3.0 6.0 7.4 5.2 8.2 2.0 7.4 3.9 13.4
Tanzania 16,616 2.3 98.1 281.0 203.4 175.7 134.9 163.9 80.3 379.1
Togo 2,196 2.1 21.4 23.7 23.9 21.2 13.2 19.4 12.5 45.1
Uganda 10,018 1.5 71.0 83.9 84.9 70.0 56.7 60.7 37.5 154.9
Western Sahara 149 4.9 0.1 7.1 2.9 4.4 0.7 3.6 2.9 7.3
Zambia 4,625 3.0 21.8 118.2 76.1 64.0 49.2 59.1 31.8 140.1
Zimbabwe 5,686 2.6 68.2 80.5 59.0 89.7 24.7 79.7 44.3 148.7
AFR Total * 295,065 2.4 2,380 4,692 3,580 3,491 1,985 3,265 1,821 7,072
* The totals may not be the exact sum of the column due to rounding.
a. Reunion and the Seychelles were deemed as having the same ethnicity distribution as Mauritius.
b. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that of world population 2003.
32
Chapter 1
Table 1.8
Prevalence estimates of diabetes mellitus (DM), 2025 – African Region

Angola 11,873 3.2 48.5 334.5 206.0 176.9 142.3 167.3 73.4 382.9
Benin 5,851 2.4 36.1 107.0 74.4 68.7 43.4 60.8 39.0 143.1
Botswana 1,011 3.5 1.8 33.6 14.6 20.9 7.3 17.6 10.7 35.5
Burkina Faso 10,920 1.9 99.2 105.7 106.3 98.6 69.6 89.4 46.0 204.9
Burundi 5,534 1.8 37.6 60.6 53.1 45.1 36.2 39.0 23.0 98.2
Cameroon 12,625 1.2 28.3 119.5 64.5 83.3 49.9 52.7 45.2 147.8
Cape Verde 412 3.2 1.6 11.4 6.4 6.6 3.0 6.5 3.6 13.0
Central African Republic 2,988 2.4 19.7 51.8 36.5 35.0 22.0 29.0 20.6 71.6
Chad 7,349 2.8 94.7 113.5 82.2 126.1 27.7 116.6 63.9 208.2
Comoros 715 3.5 3.3 21.9 13.9 11.4 7.7 12.6 5.0 25.2
Congo, Democratic Republic of 49,259 3.0 220.5 1,251.8 799.2 673.2 556.3 625.2 290.9 1,472.4
Congo, Republic of 2,823 2.6 10.6 62.9 37.7 35.8 23.3 30.9 19.4 73.5
Côte d’Ivoire 13,673 2.3 76.0 244.3 182.3 138.0 90.5 140.4 89.4 320.3
Djibouti 378 3.5 0.8 12.3 3.6 9.5 2.0 5.2 5.9 13.1
Equatorial Guinea 430 2.7 2.2 9.2 6.0 5.5 3.2 5.0 3.3 11.4
Eritrea 3,628 2.6 22.3 71.5 51.2 42.6 30.4 41.1 22.3 93.8
Ethiopia 52,442 2.4 307.4 952.9 692.5 567.8 457.0 510.8 292.5 1,260.3
Gabon 1,095 2.8 5.2 25.7 16.2 14.7 8.4 12.3 10.2 30.9
Gambia 1,167 2.6 10.0 19.9 15.9 14.1 7.3 13.2 9.4 29.9
Ghana 17,839 4.1 216.6 507.7 408.3 315.9 178.0 345.2 201.0 724.2
Guinea 7,131 2.4 56.5 114.1 93.0 77.5 47.2 77.6 45.8 170.6
Guinea-Bissau 1,036 2.2 9.8 12.6 11.9 10.5 6.4 9.6 6.3 22.3
Kenya 25,033 3.4 107.3 753.5 472.7 388.2 300.0 386.7 174.1 860.8
Lesotho 1,195 2.9 13.0 21.7 14.2 20.5 5.9 15.8 13.0 34.6
Liberia 3,300 2.4 18.0 61.6 43.5 36.0 22.4 42.5 14.7 79.5
Madagascar 15,397 3.3 75.4 431.5 276.5 230.4 161.4 233.2 112.4 507.0
Malawi 8,961 2.2 53.7 142.7 109.3 87.1 74.6 78.3 43.5 196.4
Mali 10,339 2.2 82.2 149.0 124.0 107.2 69.2 99.4 62.6 231.2
Mauritania 2,590 3.9 16.1 85.3 40.5 60.9 11.8 56.6 33.0 101.4
Mozambique 13,773 3.6 49.8 447.1 270.3 226.6 183.7 212.7 100.4 496.9
Namibia 1,463 3.2 12.2 35.1 19.4 28.0 8.4 25.5 13.4 47.4
Niger 10,662 2.6 133.9 148.2 115.4 166.8 39.3 162.8 80.0 282.2
Nigeria 103,872 2.5 615.3 1,987.4 1,411.5 1,191.2 777.5 1,118.4 706.9 2,602.7
Reuniona 640 16.4 11.5 93.1 49.3 55.3 12.8 49.8 42.1 104.7
Rwanda 6,305 1.4 46.3 44.9 50.4 40.8 32.1 38.7 20.4 91.2
Sao Tome and Principeb 146 3.4 1.2 3.8 2.7 2.3 0.8 2.1 2.0 5.0
Senegal 8,798 2.6 52.0 176.1 120.0 108.1 64.6 104.3 59.2 228.1
Seychellesa,b 67 14.9 1.7 8.3 4.9 5.1 1.4 4.7 3.9 10.0
Sierra Leone 4,181 2.3 29.3 68.7 51.5 46.5 29.1 43.2 25.7 98.0
Somalia 9,053 2.9 43.7 220.5 142.5 121.7 92.7 119.3 52.3 264.2
South Africa 26,816 3.9 249.3 805.7 416.8 638.2 130.2 536.3 388.5 1,055.0
Swaziland 589 2.9 5.1 11.8 6.8 10.1 3.3 8.1 5.5 16.9
Tanzania 31,855 3.1 152.2 849.6 544.6 457.2 343.5 460.8 197.6 1,001.8
Togo 4,178 2.3 32.6 65.0 52.3 45.3 28.5 42.7 26.4 97.6
Uganda 22,514 2.0 132.4 327.4 252.9 206.9 175.6 197.7 86.5 459.8
Western Sahara 269 5.2 0.1 13.9 5.8 8.3 1.3 8.6 4.2 14.0
Zambia 8,922 3.6 31.1 286.1 177.0 140.1 121.1 141.3 54.7 317.1
Zimbabwe 10,041 2.8 89.3 194.7 119.5 164.5 56.6 152.6 74.8 284.0
AFR Total * 541,140 2.8 3,364 11,677 7,870 7,171 4,566 6,750 3,724 15,041
b. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that of world population growth
from 2003 to 2025.
33
Chapter 1
Table 1.9
Prevalence estimates of impaired glucose tolerance (IGT), 2003 – African Region
Population IGT Number of people with IGT (000’s)

Country (000’s) % Male Female 20-39 40-59 60-79 Total
Angola 5,846 7.5 190.2 251.0 193.9 152.4 95.0 441.2
Benin 2,911 6.9 99.3 102.7 82.9 77.5 41.5 202.0
Botswana 716 7.0 31.4 18.9 15.3 12.3 22.7 50.3
Burkina Faso 4,969 7.0 156.8 189.3 144.6 113.2 88.3 346.1
Burundi 2,860 7.5 86.2 127.0 94.4 76.5 42.4 213.2
Cameroon 7,278 2.2 104.5 56.4 23.9 86.4 50.6 161.0
Cape Verde 228 6.8 6.2 9.2 7.2 4.2 4.0 15.4
Central African Republic 1,780 7.4 63.0 69.2 47.3 49.2 35.7 132.3
Chad 3,674 2.3 29.9 53.5 21.0 38.5 23.9 83.4
Comoros 355 7.3 11.3 14.7 12.4 8.7 4.9 26.0
Congo, Democratic Republic of 22,436 7.6 729.1 966.7 746.0 572.8 377.0 1,695.8
Congo, Republic of 1,403 7.2 48.7 51.7 39.5 36.5 24.4 100.4
Côte d’Ivoire 7,959 7.2 308.9 262.6 219.2 219.5 132.8 571.5
Djibouti 300 2.6 2.3 5.6 1.5 3.9 2.5 7.9
Equatorial Guinea 226 7.5 8.3 8.6 6.0 6.4 4.4 16.8
Eritrea 1,906 7.6 62.6 82.0 62.7 51.5 30.3 144.6
Ethiopia 29,562 7.6 978.6 1,270.7 966.5 796.1 486.7 2,249.3
Gabon 647 8.1 25.7 26.7 15.5 20.1 16.8 52.5
Gambia 703 7.4 26.0 25.8 18.9 21.5 11.5 51.9
Ghana 9,986 12.0 564.8 636.3 529.4 409.1 262.6 1,201.1
Guinea 3,855 7.0 137.9 133.9 109.0 104.9 57.8 271.7
Guinea-Bissau 588 7.4 21.4 22.0 15.9 16.7 10.8 43.4
Kenya 14,604 7.2 461.0 592.7 514.6 338.9 200.2 1,053.7
Lesotho 1,040 8.5 58.7 30.1 19.7 22.5 46.5 88.8
Liberia 1,573 6.5 52.0 50.6 49.8 30.4 22.4 102.7
Madagascar 7,782 7.5 256.3 331.0 257.2 207.1 122.9 587.3
Malawi 5,131 7.5 166.1 221.0 170.5 131.6 85.0 387.2
Mali 5,231 7.2 183.2 193.8 148.2 129.0 99.9 377.1
Mauritania 1,309 2.3 10.8 18.9 7.5 14.3 7.9 29.7
Mozambique 8,681 7.6 286.0 376.5 284.6 228.3 149.6 662.5
Namibia 831 8.0 43.3 22.9 17.0 15.4 33.7 66.1
Niger 4,728 6.7 160.8 157.1 140.8 117.7 59.4 318.0
Nigeria 54,248 7.1 1,947.9 1,900.5 1,527.5 1,432.8 888.1 3,848.4
Reuniona 474 16.2 29.2 47.6 29.2 31.0 16.6 76.8
Rwanda 3,645 7.2 114.7 149.5 128.5 83.3 52.4 264.2
Sao Tome and Principeb 107 8.1 4.3 4.3 2.6 3.5 2.6 8.7
Senegal 4,607 7.0 160.5 162.2 131.1 124.7 66.9 322.7
Seychellesa,b 49 16.1 3.2 4.7 2.9 3.2 1.7 7.9
Sierra Leone 2,268 7.2 79.8 82.8 63.2 62.5 36.9 162.6
Somalia 4,086 7.4 129.9 171.1 139.6 104.5 56.9 301.0
South Africa 24,741 7.2 1,201.8 573.4 498.6 553.8 722.8 1,775.2
Swaziland 450 7.8 23.4 11.7 9.1 8.9 17.0 35.1
Tanzania 16,616 7.3 525.5 694.8 574.2 413.1 233.1 1,220.3
Togo 2,196 7.1 77.1 78.5 62.1 57.4 36.1 155.6
Uganda 10,018 7.3 319.3 407.9 351.2 233.9 142.1 727.2
Western Sahara 149 2.5 1.3 2.4 0.8 1.6 1.3 3.7
Zambia 4,625 7.4 151.4 189.5 158.8 107.2 74.9 340.9
Zimbabwe 5,686 7.2 285.0 124.2 126.9 99.6 182.6 409.2
AFR Total * 295,065 7.3 10,426 10,984 8,789 7,434 5,186 21,410
b. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that of world population 2003.
34
Chapter 1
Table 1.10
Prevalence estimates of impaired glucose tolerance (IGT), 2025 – African Region

Angola 11,873 7.2 374.9 484.9 418.6 279.6 161.6 859.8
Benin 5,851 7.1 204.9 210.0 167.6 151.6 95.7 414.9
Botswana 1,011 7.2 47.0 26.0 22.8 16.7 33.6 73.0
Burkina Faso 10,920 6.7 357.3 373.7 327.9 268.4 134.8 731.0
Burundi 5,534 7.3 175.3 230.5 193.6 131.2 80.9 405.7
Cameroon 12,625 2.2 188.1 93.6 45.2 156.8 79.7 281.7
Cape Verde 412 7.8 15.1 17.1 10.0 14.4 7.9 32.2
Central African Republic 2,988 7.1 102.7 109.6 86.7 73.7 51.8 212.3
Chad 7,349 2.2 58.5 100.6 43.3 75.1 40.7 159.1
Comoros 715 7.7 24.2 30.7 22.5 21.4 11.0 54.9
Congo, Democratic Republic of 49,259 7.2 1,568.1 1,991.9 1,753.6 1,125.6 680.7 3,559.9
Congo, Republic of 2,823 6.9 96.2 99.7 82.6 69.9 43.4 195.9
Côte d’Ivoire 13,673 7.3 522.6 471.2 382.0 371.8 240.0 993.8
Djibouti 378 2.1 2.3 5.7 2.4 2.5 3.0 7.9
Equatorial Guinea 430 7.3 15.5 15.7 11.9 11.7 7.6 31.2
Eritrea 3,628 7.7 122.2 155.8 119.2 96.2 62.5 277.9
Ethiopia 52,442 7.4 1,718.8 2,144.7 1,834.1 1,200.7 828.8 3,863.5
Gabon 1,095 7.5 40.7 41.1 30.0 28.4 23.3 81.7
Gambia 1,167 7.7 44.5 45.2 30.2 34.9 24.5 89.6
Ghana 17,839 12.7 1,070.9 1,188.0 874.2 837.3 547.5 2,258.9
Guinea 7,131 7.3 265.8 252.5 194.7 205.4 118.1 518.3
Guinea-Bissau 1,036 7.2 36.9 37.5 29.1 27.6 17.7 74.4
Kenya 25,033 7.5 827.7 1,041.4 847.0 636.2 385.9 1,869.1
Lesotho 1,195 8.6 66.5 36.7 26.2 19.8 57.1 103.1
Liberia 3,300 6.9 117.5 109.0 88.2 103.3 35.0 226.5
Madagascar 15,397 7.7 518.3 661.4 500.5 419.9 259.3 1,179.6
Malawi 8,961 7.2 292.2 355.9 319.2 198.2 130.6 648.0
Mali 10,339 7.1 368.5 361.3 295.8 268.0 166.0 729.8
Mauritania 2,590 2.3 22.2 38.0 14.6 28.9 16.7 60.2
Mozambique 13,773 7.3 444.6 563.9 484.7 316.8 207.0 1,008.5
Namibia 1,463 7.5 73.3 36.5 30.9 28.2 50.7 109.9
Niger 10,662 6.8 370.9 348.9 315.6 270.0 134.2 719.7
Nigeria 103,872 7.1 3,807.8 3,593.1 2,962.3 2,738.5 1,700.1 7,400.9
Reuniona 640 17.4 44.3 67.2 31.6 47.9 31.9 111.4
Rwanda 6,305 7.3 202.2 260.6 214.1 167.1 81.7 462.9
Sao Tome and Principeb 146 8.9 6.5 6.5 3.1 5.2 4.8 13.0
Senegal 8,798 7.3 318.4 319.9 242.3 254.1 141.8 638.3
Seychellesa,b 67 17.0 4.7 6.7 3.5 4.8 3.1 11.4
Sierra Leone 4,181 7.1 146.5 148.8 118.5 111.6 65.3 295.4
Somalia 9,053 7.3 289.0 375.6 309.6 229.0 126.0 664.6
South Africa 26,816 8.8 1,585.0 766.0 523.5 597.6 1,229.9 2,350.9
Swaziland 589 7.6 29.2 15.6 13.3 9.4 22.1 44.8
Tanzania 31,855 7.5 1,041.2 1,341.5 1,072.5 844.0 466.2 2,382.7
Togo 4,178 7.2 151.1 148.8 117.7 113.3 68.9 299.9
Uganda 22,514 7.1 706.8 896.0 801.7 535.8 265.3 1,602.8
Western Sahara 269 2.6 2.6 4.4 1.4 3.8 1.9 7.0
Zambia 8,922 7.2 289.5 349.5 317.7 208.8 112.6 639.1
Zimbabwe 10,041 6.8 478.0 202.2 228.6 181.4 270.3 680.3
AFR Total * 541,140 7.3 19,257 20,181 16,566 13,543 9,329 39,438
b. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that of world population growth
from 2003 to 2025.
35
Chapter 1
Table 1.11
impaired glucose tolerance (IGT) – Eastern Mediterranean and
Middle East Region
Country Data used

Afghanistana Pakistan (Shera et al, 1995, 1999a, 1999b)50,51,52
Algeriab,c Tunisia (Papoz et al, 1988 and Ghannem et al, 1997)53,54
Armenia Turkey (Satman et al, 2002)55
Bahraind Bahrain (Al-Mahroos et al, 1998)56
Egypt b
Egypt (Herman et al, 1995 and Arab, 1997)57,58
Irane Iran (Amini et al, 1997)59
Iraq Jordan (Ajlouni et al, 1998)60
Jordan Jordan (Ajlouni et al, 1998)60
Kuwait d
Kuwait (Abdella et al, 1998)61
Lebanon Lebanon (Salti et al, 1997)62
Libyac Libya (Kadiki et al, 1999)63
Moroccob,c Tunisia (Papoz et al, 1988 and Ghannem et al, 1997)53,54
Occupied Palestinian Territories Jordan (Ajlouni et al, 1998)60
Omanf Oman (Al-Lawati et al, 2002)64
Pakistana Pakistan (Shera et al, 1995, 1999a, 1999b)50,51,52
Qatard Bahrain (Al-Mahroos et al, 1998)56
Saudi Arabia Saudi Arabia (El-Hazmi et al, 1998)66
Sudan Sudan (Elbagir et al, 1996)48
Syria Jordan (Ajlouni et al, 1998)60
Tunisiab,c Tunisia (Papoz et al, 1988 and Ghannem et al, 1997)53,54
United Arab Emirates UAE (Malik et al, 2002 )67
Yemenf Oman (Al-Lawati et al, 2002)64
a. The prevalence was obtained by combining the data from the three studies.
b. The prevalences were calculated as the average of the two cited studies as their sample sizes
differed considerably.
c. Because of the absence of data for IGT in the studies used for diabetes,
IGT figures were calculated from Jordanian data.
d. Because of the absence of data for IGT in the study used for diabetes,
IGT figures were calculated from UAE data.
e. Because of the absence of data for IGT in the studies used for diabetes,
IGT figures were calculated from Pakistani data.
f. Because of the absence of data for IGT in the studies used for diabetes,
IGT figures were calculated from other Oman data (Asfour et al, 1995)65.
N/A not available
36
Chapter 1

OGTT WHO – 1985 3,409 25+
FBG/SR WHO – 1980 6,570 20+
2BG WHO – 1999 24,788 20+
OGTT WHO – 1985 2,128 40-69
OGTT/Post-prandial GT WHO – 1985 5,251 20+
OGTT WHO – 1985 3,910 40+
OGTT WHO – 1985 2,776 25-79
OGTT WHO – 1985 2,776 25-79
OGTT WHO – 1985 3,003 20+
OGTT WHO – 1985 2,518 30+
Registration N/A 15,912 20+
FBG/SR WHO – 1980 6,570 20+
OGTT WHO – 1985 2,776 25-79
OGTT WHO – 1999 5,731 20-79
OGTT WHO – 1985 3,409 25+
OGTT WHO – 1985 2,128 40-69
OGTT WHO – 1985 15,420 14+
2BG WHO – 1985 1,284 25-84
OGTT WHO – 1985 2,776 25-79
FBG/SR WHO – 1980 6,570 20+
OGTT WHO – 1999 6,612 19+
OGTT WHO – 1999 5,731 20-79
37
Chapter 1
Table 1.12
Prevalence estimates of diabetes mellitus (DM), 2003 – Eastern Mediterranean and Middle East Region

Afghanistan 11,130 8.2 718.0 199.4 501.5 415.8 231.5 487.1 198.7 917.3
Algeria 17,737 4.1 176.0 551.8 321.0 406.8 205.8 344.9 177.1 727.8
Armenia 2,607 8.1 48.6 162.4 81.6 129.3 20.1 96.9 94.0 211.0
Bahrain 439 14.9 2.4 63.1 42.1 23.4 11.4 44.8 9.3 65.5
Egypt 39,299 9.8 1,326.8 2,542.5 1,729.5 2,139.8 1,007.7 1,931.5 930.1 3,869.3
Iran 38,506 3.6 317.0 1,073.7 705.5 685.1 441.4 652.0 297.2 1,390.6
Iraq 11,962 7.7 114.4 801.2 456.0 459.7 147.3 514.3 254.1 915.6
Jordan 2,648 7.0 26.0 159.0 96.0 89.0 35.2 95.6 54.2 185.0
Kuwait 1,240 12.8 1.8 156.4 107.2 51.0 23.6 94.7 39.9 158.2
Lebanon 2,202 6.4 7.0 133.2 67.0 73.3 8.4 59.6 72.2 140.2
Libya 3,128 3.7 7.1 107.4 47.8 66.7 27.5 71.6 15.5 114.5
Morocco 17,598 4.2 197.7 533.9 312.2 419.3 195.2 351.3 185.0 731.5
Occupied Palestinian Territoriesa 1,525 7.4 15.8 96.7 54.7 57.9 18.7 60.9 32.9 112.5
Oman 1,274 11.4 10.6 134.4 84.9 60.1 42.2 74.6 28.2 145.0
Pakistan 72,760 8.5 3,909.2 2,271.2 3,310.5 2,869.8 1,426.3 3,332.6 1,421.5 6,180.4
Qatar 393 16.0 2.3 60.6 46.8 16.1 10.8 45.5 6.6 62.9
Saudi Arabia 10,544 9.4 70.5 921.7 597.1 395.1 145.3 583.4 263.5 992.2
Sudan 16,584 3.1 232.4 290.0 210.4 311.9 61.7 289.8 170.8 522.3
Syria 8,516 6.2 150.4 377.9 260.2 268.0 94.8 281.9 151.5 528.2
Tunisia 5,966 4.6 52.8 220.8 117.9 155.8 66.7 130.1 76.9 273.6
United Arab Emirates 1,829 20.1 26.4 340.9 272.7 94.6 54.7 247.7 64.9 367.3
Yemen 8,137 7.7 267.4 358.2 290.1 335.4 235.7 265.4 124.5 625.6
EMME Total * 276,025 7.0 7,680 11,556 9,713 9,524 4,512 10,056 4,669 19,237
a. Occupied Palestinian Territories assigned urban/rural distribution of Jordan.
38
Chapter 1
Table 1.13
Prevalence estimates of diabetes mellitus (DM), 2025 – Eastern Mediterranean and Middle East Region

Afghanistan 21,973 8.3 1,185.2 634.0 973.3 845.9 449.4 976.6 393.2 1,819.2
Algeria 28,950 5.5 247.5 1,343.5 693.1 897.9 288.5 829.4 473.1 1,591.0
Armenia 2,968 10.7 52.9 263.2 124.9 191.2 21.8 131.6 162.8 316.2
Bahrain 645 18.3 2.7 115.6 67.3 51.1 13.2 56.7 48.4 118.3
Egypt 63,676 12.3 1,879.1 5,923.7 3,440.7 4,362.1 1,669.6 3,709.3 2,423.9 7,802.8
Iran 65,757 4.4 455.6 2,440.3 1,438.5 1,457.5 764.3 1,322.5 809.0 2,895.9
Iraq 23,293 9.1 185.8 1,940.5 1,061.2 1,065.1 284.2 1,197.8 644.2 2,126.3
Jordan 5,054 9.3 45.7 426.0 244.9 226.8 57.1 284.7 129.8 471.7
Kuwait 2,178 16.4 3.0 354.8 219.8 137.9 47.6 139.7 170.4 357.7
Lebanon 3,214 9.1 9.9 282.8 139.5 153.2 10.1 138.2 144.4 292.7
Libya 5,215 4.7 10.8 231.8 94.7 147.9 41.7 166.8 34.0 242.6
Morocco 28,128 5.4 264.7 1,250.4 645.5 869.6 277.1 770.7 467.3 1,515.1
Occupied Palestinian Territoriesa 3,543 8.2 28.2 263.2 147.6 143.7 43.8 159.7 87.9 291.4
Oman 2,710 11.9 10.7 312.7 173.3 150.0 97.1 146.8 79.5 323.4
Pakistan 136,909 8.5 5,700.0 5,906.8 5,890.5 5,716.2 2,754.9 6,078.1 2,773.7 11,606.8
Qatar 537 18.2 2.6 95.0 63.1 34.5 10.3 43.5 43.8 97.6
Saudi Arabia 21,851 9.6 99.8 2,001.5 1,146.4 954.9 355.9 1,017.0 728.5 2,101.3
Sudan 29,070 3.9 334.4 810.7 472.8 672.3 114.3 645.0 385.8 1,145.1
Syria 16,711 8.6 285.6 1,155.9 721.4 720.0 189.2 828.9 423.3 1,441.4
Tunisia 8,442 6.0 69.5 436.2 214.2 291.6 80.1 259.5 166.2 505.8
United Arab Emirates 2,482 24.5 31.4 575.7 409.7 197.3 76.0 230.9 300.2 607.0
Yemen 20,253 8.6 501.7 1,239.3 874.9 866.0 604.4 804.2 332.3 1,740.9
EMME Total * 493,560 8.0 11,407 28,004 19,257 20,153 8,251 19,938 11,222 39,410
a. Occupied Palestinian Territories assigned urban/rural distribution of Jordan.
39
Chapter 1
Table 1.14
Prevalence estimates of impaired glucose tolerance (IGT), 2003 – Eastern Mediterranean and
Middle East Region

Afghanistan 11,130 7.6 286.3 554.7 321.6 337.3 182.1 841.1
Algeria 17,737 7.3 649.5 650.3 417.5 625.5 256.8 1,299.8
Armenia 2,607 7.0 58.7 124.4 42.5 78.4 62.3 183.2
Bahrain 439 17.2 40.0 35.7 26.8 38.7 10.1 75.6
Egypt 39,299 4.6 886.3 934.7 676.2 699.8 445.0 1,821.0
Iran 38,506 7.7 999.3 1,956.7 1,086.5 1,238.0 631.4 2,956.0
Iraq 11,962 7.3 435.3 433.0 282.0 422.7 163.7 868.3
Jordan 2,648 6.9 95.8 87.3 67.8 79.9 35.4 183.1
Kuwait 1,240 16.8 118.2 89.9 71.7 103.2 33.1 208.0
Lebanon 2,202 3.5 32.0 45.6 13.2 32.7 31.7 77.6
Libya 3,128 7.3 122.1 106.3 71.0 111.6 45.9 228.5
Morocco 17,598 7.6 644.9 685.4 402.0 655.2 273.1 1,330.3
Occupied Palestinian Territories 1,525 7.2 54.0 55.1 36.3 51.3 21.5 109.1
Oman 1,274 9.7 56.8 66.8 48.8 57.4 17.3 123.5
Pakistan 72,760 7.8 1,980.7 3,727.3 2,035.3 2,303.7 1,369.0 5,708.0
Qatar 393 16.9 42.4 24.0 21.6 38.0 6.8 66.4
Saudi Arabia 10,544 1.0 48.5 57.1 24.1 56.0 25.6 105.7
Sudan 16,584 2.3 143.4 242.8 94.9 183.9 107.5 386.2
Syria 8,516 6.9 292.4 295.0 207.8 268.3 111.4 587.4
Tunisia 5,966 7.8 230.4 234.9 132.3 224.5 108.5 465.3
United Arab Emirates 1,829 17.2 210.2 104.7 90.4 176.7 47.8 314.9
Yemen 8,137 9.5 270.6 501.1 364.5 307.4 99.8 771.7
EMME Total * 276,025 6.8 7,698 11,013 6,535 8,090 4,086 18,711
40
Chapter 1
Table 1.15
Prevalence estimates of impaired glucose tolerance (IGT), 2025 – Eastern Mediterranean and
Middle East Region

Afghanistan 21,973 7.6 573.2 1,106.2 628.2 679.4 371.8 1,679.5
Algeria 28,950 9.0 1,307.8 1,287.6 564.3 1,376.5 654.7 2,595.5
Armenia 2,968 8.2 83.6 159.7 39.8 98.9 104.6 243.3
Bahrain 645 20.7 68.4 65.2 32.1 48.7 52.7 133.5
Egypt 63,676 5.1 1,599.0 1,668.6 970.5 1,233.5 1,063.7 3,267.7
Iran 65,757 8.7 2,025.7 3,674.7 1,690.5 2,384.9 1,625.0 5,700.4
Iraq 23,293 8.0 932.2 925.0 511.5 944.5 401.2 1,857.3
Jordan 5,054 8.1 213.0 198.3 105.1 224.5 81.6 411.3
Kuwait 2,178 19.6 219.4 208.1 121.9 164.4 141.2 427.5
Lebanon 3,214 4.6 65.4 83.3 15.1 71.2 62.5 148.8
Libya 5,215 8.7 229.4 225.2 99.6 251.5 103.5 454.6
Morocco 28,128 8.9 1,237.8 1,262.6 547.2 1,302.8 650.5 2,500.5
Occupied Palestinian Territories 3,543 7.4 134.0 129.7 81.5 127.1 55.2 263.8
Oman 2,710 10.1 114.1 158.4 108.4 116.3 47.9 272.5
Pakistan 136,909 8.0 3,714.0 7,218.6 3,847.6 4,316.0 2,769.1 10,932.6
Qatar 537 20.7 64.4 46.5 26.3 36.6 48.0 110.8
Saudi Arabia 21,851 1.0 86.9 134.7 55.4 99.8 66.4 221.6
Sudan 29,070 2.5 277.2 459.7 155.5 363.8 217.6 736.9
Syria 16,711 8.3 693.1 686.1 365.0 723.7 290.5 1,379.2
Tunisia 8,442 9.5 399.4 405.5 152.8 426.9 225.2 804.9
United Arab Emirates 2,482 20.8 312.3 204.2 120.0 167.2 229.2 516.5
Yemen 20,253 9.3 723.7 1,162.2 856.4 791.4 238.2 1,885.9
EMME Total * 493,560 7.4 15,074 21,470 11,095 15,950 9,500 36,545
41
Chapter 1
Table 1.16
impaired glucose tolerance (IGT) – European Region
Country Data used

Albaniaa Greece (Katsilambros et al, 1993)68
Andorra Spain (Castell et al, 1999)69
Austriab,c Germany (Rathmann et al, 2003 and Thefeld et al, 1999)70,37
Azerbaijan Republic Turkey (Satman et al, 2002)55
Belarusc Poland (Szurkowska et al and Lopatynski et al, 2001)71,72
Belgium The Netherlands (Mooy et al, 1995)73
Bosnia and Herzegovina Turkey (Satman et al, 2002)55
Bulgaria Turkey (Satman et al, 2002)55
Croatiaa Greece (Katsilambros et al, 1993)68
Cyprusa Greece (Katsilambros et al, 1993)68
Czech Republicc Poland (Szurkowska et al and Lopatynski et al, 2001)71,72
Denmark Sweden (Eliasson et al, 2002)74
Estoniac Poland (Szurkowska et al and Lopatynski et al, 2001)71,72
Finland Finland (Tuomilehto et al, 1986 and 1991)75,76
Francec Italy (Verillo et al, 1985 and Garancini et al, 1995)77,78
Georgia, Republic of Turkey (Satman et al, 2002)55
Germanyb,c Germany (Rathmann et al, 2003 and Thefeld et al, 1999)70,37
Greecea Greece (Katsilambros et al, 1993)68
Hungaryc Poland (Szurkowska et al and Lopatynski et al, 2001)71,72
Iceland d
Iceland (Vilbergsson et al, 1997)79
Ireland, Republic of c United Kingdom (Unwin et al, 1997 and Yudkin et al, 1993)80,81
Israelc,e Israel (Bar-On et al, 1992 and Stern et al, 1999)82,83
Italyc Italy (Verillo et al, 1985 and Garancini et al, 1995)77,78
Kazakhstan Uzbekistan (King et al, 1998)84
Kyrgyzstan Uzbekistan (King et al, 1998)84
Latviac Poland (Szurkowska et al and Lopatynski et al, 2001)71,72
Lithuaniac Poland (Szurkowska et al and Lopatynski et al, 2001)71,72
Luxembourg The Netherlands (Mooy et al, 1995)73
Macedoniaa Greece (Katsilambros et al, 1993)68
Malta Malta (Schranz, 1989)85
Moldova, Republic of c Poland (Szurkowska et al and Lopatynski et al, 2001)71,72
Monaco c
Italy (Verillo et al, 1985 and Garancini et al, 1995)77,78
Netherlands The Netherlands (Mooy et al, 1995)73
Norway Sweden (Eliasson et al, 2002)74
Polandc Poland (Szurkowska et al and Lopatynski et al, 2001)71,72
Portugal Spain (Castell et al, 1999)69
Romaniac Poland (Szurkowska et al and Lopatynski et al, 2001)71,72
Russian Federationc Poland (Szurkowska et al and Lopatynski et al, 2001)71,72
San Marinoc Italy (Verillo et al, 1985 and Garancini et al, 1995)77,78
Serbia and Montenegro a
Greece (Katsilambros et al, 1993)68
Slovakiac Poland (Szurkowska et al and Lopatynski et al, 2001)71,72
Sloveniac Poland (Szurkowska et al and Lopatynski et al, 2001)71,72
Spain Spain (Castell et al, 1999)69
Sweden Sweden (Eliasson et al, 2002)74
Switzerlandc Germany (Rathmann et al, 2003 and Thefeld et al, 1999)70,37
Tajikistan Uzbekistan (King et al, 1998)84
Turkey Turkey (Satman et al, 2002)55
Turkmenistan Uzbekistan (King et al, 1998)84
Ukrainec Poland (Szurkowska et al and Lopatynski et al, 2001)71,72
United Kingdomc United Kingdom (Unwin et al, 1997 and Yudkin et al, 1993)80,81
Uzbekistan Uzbekistan (King et al, 1998)84
a. Because of the absence of data for IGT in the study used for diabetes, IGT figures were calculated from
Turkish data.
b. IGT prevalences were derived from the data of Rathmann et al.
c. The prevalences for the studies based on the German, Italian, Israeli, Polish and the United Kingdom studies
were obtained by combining the data from the two studies respectively.
42
Chapter 1

SR Known diabetes 9,092 20-79
OGTT WHO – 1985 3,839 30-79
SR/OGTT WHO – 1999 8,477 18-79
2BG WHO – 1999 24,788 20+
OGTT WHO – 1985 6,842 35+
OGTT WHO – 1985 2,540 50-74
2BG WHO – 1999 24,788 20+
2BG WHO – 1999 24,788 20+
OGTT WHO – 1985 6,842 35+
OGTT WHO – 1999 6,952 25-74
OGTT WHO – 1985 6,842 35+
OGTT WHO – 1985 3,329 45-79
OGTT WHO – 1980 3,772 20+
2BG WHO – 1999 24,788 20+
SR/OGTT WHO – 1999 8,477 18-79
OGTT WHO – 1985 6,842 35+
OGTT (50-100g) WHO – 1985 18,887 30-79
OGTT WHO – 1985 2,529 25-75
OGTT WHO – 1980/1985 6,918 25-64
OGTT WHO – 1980 3,772 20+
2BG WHO – 1994 1,956 35+
2BG WHO – 1994 1,956 35+
OGTT WHO – 1985 6,842 35+
OGTT WHO – 1985 6,842 35+
OGTT WHO – 1985 2,540 50-74
OGTT WHO – 1985 1,422 35+
OGTT WHO – 1985 6,842 35+
OGTT WHO – 1980 3,772 20+
OGTT WHO – 1985 2,540 50-74
OGTT WHO – 1999 6,952 25-74
OGTT WHO – 1985 6,842 35+
OGTT WHO – 1985 3,839 30-79
OGTT WHO – 1985 6,842 35+
OGTT WHO – 1985 6,842 35+
OGTT WHO – 1980 3,772 20+
OGTT WHO – 1985 6,842 35+
OGTT WHO – 1985 6,842 35+
OGTT WHO – 1985 3,839 30-79
OGTT WHO – 1999 6,952 25-74
SR/OGTT WHO – 1999 8,477 18-79
2BG WHO – 1994 1,956 35+
2BG WHO – 1999 24,788 20+
2BG WHO – 1994 1,956 35+
OGTT WHO – 1985 6,842 35+
OGTT WHO – 1985 2,529 25-75
2BG WHO – 1994 1,956 35+
d. Because of the absence of data for IGT in the study used for diabetes, IGT figures were calculated from
Netherlands data.
e. IGT prevalence for Israel was derived only from the data in Bar-On et al.
43
Chapter 1
Table 1.17
Prevalence estimates of diabetes mellitus (DM), 2003 – European Region

Albania 1,966 3.8 34.9 40.1 4.0 27.2 43.7 75.0
Andorraa 50 7.7 1.9 2.0 0.1 1.3 2.5 3.9
Austria 5,991 9.6 258.5 317.5 38.8 172.7 364.5 576.0
Azerbaijan Republic 5,154 6.9 122.1 235.4 143.6 213.9 44.7 159.8 152.9 357.5
Belarus 7,336 6.9 309.1 374.3 63.4 242.3 377.7 683.4
Belgium 7,531 4.2 140.6 174.5 3.1 71.1 240.9 315.1
Bosnia and Herzegovina 3,074 9.6 117.2 178.2 24.5 141.0 129.9 295.4
Bulgaria 5,894 10.0 135.8 455.4 235.7 355.5 37.6 248.1 305.5 591.2
Croatia 3,412 5.8 82.4 116.7 5.3 56.8 137.1 199.1
Cyprus 541 5.1 12.3 15.4 0.9 9.4 17.5 27.7
Czech Republic 7,734 9.5 365.2 369.6 66.8 286.2 381.9 734.9
Denmark 3,863 6.9 120.9 144.0 23.3 87.0 154.6 264.9
Estonia 991 9.7 43.4 52.9 8.6 33.3 54.4 96.3
Finland 3,775 7.2 130.3 143.2 10.3 56.3 207.0 273.5
France 42,546 6.2 1,306.3 1,347.3 175.0 1,045.3 1,433.3 2,653.6
Georgia, Republic of 3,681 9.0 102.8 229.5 129.0 203.4 25.6 134.7 172.1 332.4
Germany 61,895 10.2 2,879.3 3,415.0 374.0 1,752.7 4,167.6 6,294.3
Greece 8,069 6.1 217.0 276.0 12.9 129.0 351.0 493.0
Hungary 7,350 9.7 336.3 375.1 62.6 259.5 389.2 711.4
Iceland 192 2.0 2.1 1.7 0.2 1.2 2.4 3.7
Ireland, Republic of 2,674 3.4 43.6 46.2 6.0 34.4 49.4 89.8
Israel 3,959 7.1 140.9 140.7 36.8 102.7 142.1 281.6
Italy 43,925 6.6 1,400.2 1,479.9 185.7 1,009.4 1,684.9 2,880.1
Kazakhstan 10,235 5.5 147.3 411.6 305.2 253.8 39.1 288.8 231.1 558.9
Kyrgyzstan 2,896 4.3 57.7 67.1 71.4 53.5 9.1 62.1 53.6 124.8
Latvia 1,758 9.9 77.5 96.1 15.1 58.4 100.1 173.6
Lithuania 2,648 9.4 114.7 134.2 24.6 84.8 139.5 248.9
Luxembourg 327 3.8 5.8 6.8 0.1 3.0 9.3 12.5
Macedonia 1,428 4.9 30.9 39.0 2.5 23.2 44.2 69.9
Malta 280 9.2 10.6 15.3 0.3 9.0 16.5 25.8
Moldova, Republic of 2,915 9.3 117.2 124.6 26.6 97.8 117.3 241.8
Monacoa 23 6.1 0.7 0.7 0.1 0.6 0.8 1.4
Netherlands 11,678 3.7 203.4 228.8 5.3 118.3 308.5 432.2
Norway 3,154 6.7 95.5 116.2 19.8 69.6 122.3 211.7
Poland 27,852 9.0 1,238.7 1,267.8 239.0 1,002.5 1,265.0 2,506.5
Portugal 7,471 7.8 278.5 305.9 14.9 170.9 398.7 584.5
Romania 16,392 9.3 760.0 759.2 154.7 519.0 845.6 1,519.2
Russian Federation 105,244 9.2 4,417.7 5,275.9 899.4 3,637.5 5,156.7 9,693.6
San Marinoa 20 6.1 0.6 0.6 0.1 0.5 0.7 1.2
Serbia and Montenegro 7,542 5.6 182.0 240.1 11.8 127.1 283.2 422.1
Slovakia 3,903 8.7 167.5 171.3 35.9 135.6 167.2 338.7
Slovenia 1,511 9.6 72.2 73.1 13.1 53.5 78.6 145.2
Spain 30,329 9.9 1,209.7 1,794.6 838.4 973.2 1,192.6 3,004.3
Sweden 6,290 7.3 206.4 250.5 36.3 140.1 280.5 456.9
Switzerland 5,310 9.5 235.0 270.0 35.3 166.6 303.1 504.9
Tajikistan 3,174 3.7 62.9 53.8 70.3 46.4 9.6 57.5 49.6 116.7
Turkey 42,411 7.0 514.1 2,444.6 1,254.3 1,704.4 370.4 1,440.7 1,147.7 2,958.7
Turkmenistan 2,648 4.0 42.5 62.5 61.7 43.3 9.7 55.7 39.6 105.0
Ukraine 35,625 9.7 1,552.3 1,901.1 302.2 1,154.7 1,996.6 3,453.4
United Kingdom 42,423 3.9 813.7 857.9 89.4 588.9 993.3 1,671.5
Uzbekistan 14,144 4.0 244.0 316.5 333.0 227.5 48.7 287.7 224.1 560.5
EUR Total * 621,235 7.8 1,429 4,276 22,337 26,041 4,462 17,388 26,528 48,378
a. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that of developed world population 2003.
44
Chapter 1
Table 1.18
Prevalence estimates of diabetes mellitus (DM), 2025 – European Region

Albania 2,559 5.1 61.3 69.9 4.5 43.5 83.2 131.2
Andorraa 52 9.5 2.5 2.5 0.1 1.3 3.5 4.9
Austria 5,887 11.9 338.3 364.5 28.2 187.0 487.5 702.8
Azerbaijan Republic 6,793 9.4 156.8 479.5 259.4 376.9 53.6 285.3 297.3 636.3
Belarus 7,233 10.7 356.5 416.6 58.5 259.3 455.3 773.1
Belgium 7,658 5.2 180.4 214.2 2.6 74.9 317.1 394.6
Bulgaria 4,871 11.6 93.7 471.2 223.1 341.7 28.8 233.3 302.8 564.9
Croatia 3,304 6.7 96.6 123.9 4.6 58.5 157.5 220.5
Cyprus 637 6.3 18.3 21.8 1.0 10.5 28.6 40.1
Czech Republic 7,599 11.7 441.9 445.5 51.9 292.2 543.3 887.4
Denmark 3,988 8.3 148.3 182.2 20.3 83.3 226.8 330.4
Estonia 814 11.0 41.7 47.7 6.4 30.2 52.8 89.4
Finland 3,822 10.0 186.0 198.0 9.3 47.1 327.6 383.9
France 45,141 7.3 1,609.5 1,675.8 156.3 1,058.2 2,070.8 3,285.3
Georgia, Republic of 3,341 10.7 79.0 278.7 142.5 215.2 22.1 143.1 192.5 357.7
Germany 60,030 11.9 3,459.1 3,684.5 293.8 1,852.9 4,997.0 7,143.7
Greece 7,767 7.3 254.3 312.1 9.2 153.4 403.8 566.4
Hungary 6,807 11.2 364.7 397.0 49.4 261.7 450.6 761.7
Iceland 229 2.5 3.2 2.6 0.2 1.4 4.2 5.8
Israel 5,776 8.1 243.4 224.9 48.9 151.2 268.2 468.3
Italy 40,482 7.9 1,583.5 1,614.8 116.4 1,093.1 1,988.8 3,198.3
Kazakhstan 11,358 7.0 153.9 642.6 429.9 366.6 47.7 371.7 377.2 796.5
Kyrgyzstan 4,355 5.8 86.9 164.8 143.6 108.1 16.5 124.0 111.1 251.6
Latvia 1,610 11.1 84.4 93.7 12.7 60.0 105.5 178.2
Lithuania 2,626 10.8 136.0 148.1 21.2 96.8 166.1 284.1
Luxembourg 415 4.4 8.4 9.8 0.2 3.7 14.3 18.1
Macedonia 1,598 6.1 43.6 53.1 2.5 28.7 65.5 96.7
Malta 304 11.6 15.4 19.7 0.3 7.9 26.9 35.1
Monacoa 24 7.2 0.9 0.9 0.1 0.6 1.1 1.7
Netherlands 12,538 5.1 290.9 344.4 4.4 127.8 503.2 635.3
Norway 3,534 8.2 129.3 159.1 18.6 73.0 196.8 288.5
Poland 28,567 11.0 1,545.9 1,606.7 217.8 1,017.5 1,917.3 3,152.6
Portugal 7,456 9.5 344.4 361.8 11.0 210.7 484.5 706.2
Romania 15,860 10.6 834.3 842.7 123.0 645.1 908.8 1,676.9
Russian Federation 98,969 10.9 4,909.1 5,837.5 784.7 3,536.9 6,425.0 10,746.6
San Marinoa 21 7.2 0.7 0.8 0.1 0.5 0.9 1.5
Slovakia 4,127 10.7 219.2 224.1 31.7 153.6 258.1 443.3
Slovenia 1,451 12.0 86.8 86.7 9.5 54.7 109.2 173.5
Spain 29,155 10.1 1,478.9 1,466.0 40.0 874.0 2,030.9 2,944.9
Sweden 6,373 8.6 245.6 302.6 32.9 131.5 383.8 548.2
Switzerland 5,114 12.6 308.0 338.5 24.5 147.2 474.8 646.5
Tajikistan 5,305 5.1 110.1 158.2 158.2 110.1 20.1 139.2 109.0 268.3
Turkey 59,689 9.1 551.7 4,878.5 2,285.4 3,144.8 435.1 2,665.9 2,329.1 5,430.2
Turkmenistan 4,537 5.5 75.6 171.9 142.5 105.0 18.4 127.4 101.6 247.5
Ukraine 31,102 10.8 1,558.4 1,799.5 247.7 1,142.4 1,967.8 3,357.9
United Kingdom 45,322 4.7 1,079.8 1,061.5 79.4 628.2 1,433.7 2,141.4
Uzbekistan 22,883 5.7 422.3 875.0 753.5 543.8 92.7 662.5 542.1 1,297.3
EUR Total * 646,334 9.1 1,730 8,120 27,842 30,796 3,325 19,800 35,512 58,638
a. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that of developed world population
from 2003 to 2025.
45
Chapter 1
Table 1.19
Prevalence estimates of impaired glucose tolerance (IGT), 2003 – European Region

Albania 1,966 6.5 45.2 81.9 35.7 53.9 37.4 127.1
Andorraa 50 9.9 2.0 2.9 1.3 1.8 1.9 4.9
Austria 5,991 5.8 161.0 184.2 0.7 84.2 260.4 345.3
Azerbaijan Republic 5,154 6.5 108.6 228.4 95.2 137.8 104.1 337.0
Belarus 7,336 17.0 487.1 760.0 287.8 484.5 474.7 1,247.1
Belgium 7,531 6.4 237.8 243.7 54.8 141.6 285.0 481.5
Bulgaria 5,894 8.0 162.3 308.5 78.9 188.7 203.2 470.8
Croatia 3,412 7.9 92.1 177.6 46.2 107.6 115.9 269.7
Cyprus 541 7.4 14.2 26.0 7.9 17.5 14.8 40.2
Czech Republic 7,734 17.0 563.8 754.4 300.4 539.5 478.3 1,318.3
Denmark 3,863 8.6 107.3 225.3 62.9 105.7 164.0 332.5
Estonia 991 17.3 67.4 104.3 38.1 65.0 68.6 171.7
Finland 3,775 6.6 101.6 148.3 0.5 42.4 207.0 249.9
France 42,546 5.6 974.6 1,415.2 457.4 829.3 1,103.1 2,389.9
Georgia, Republic of 3,681 7.6 92.2 189.1 54.2 110.3 116.9 281.3
Germany 61,895 6.3 1,849.6 2,049.5 6.4 840.5 3,052.2 3,899.1
Greece 8,069 8.0 232.4 411.6 112.4 239.4 292.2 644.0
Hungary 7,350 17.2 519.4 747.8 281.7 496.7 488.8 1,267.2
Iceland 192 5.5 5.6 4.9 1.6 3.5 5.3 10.5
Israel 3,959 5.4 129.7 82.6 43.3 85.8 83.2 212.3
Italy 43,925 5.8 1,042.0 1,513.3 467.0 800.6 1,287.6 2,555.2
Kazakhstan 10,235 5.4 207.5 344.5 98.2 250.1 203.7 552.0
Kyrgyzstan 2,896 4.9 54.9 88.2 30.7 61.1 51.3 143.1
Latvia 1,758 17.5 120.1 187.3 66.6 114.4 126.4 307.4
Lithuania 2,648 17.0 179.9 271.2 107.8 167.4 175.8 451.1
Luxembourg 327 6.0 9.9 9.7 2.5 6.1 11.0 19.6
Macedonia 1,428 7.3 36.3 67.3 22.1 44.1 37.5 103.6
Malta 280 7.5 10.1 11.0 1.3 10.7 9.1 21.1
Monacoa 23 5.5 0.5 0.8 0.3 0.4 0.6 1.3
Netherlands 11,678 5.9 352.0 334.6 90.5 232.6 363.6 686.6
Norway 3,154 8.5 85.1 183.3 53.8 84.8 129.9 268.4
Poland 27,852 16.6 1,950.2 2,675.6 1,091.8 1,952.2 1,581.8 4,625.8
Portugal 7,471 9.9 290.0 452.6 204.9 242.4 295.2 742.6
Romania 16,392 16.8 1,174.4 1,576.0 692.6 1,000.9 1,057.0 2,750.5
Russian Federation 105,244 16.9 7,009.0 10,793.1 4,050.3 7,255.9 6,495.8 17,802.0
San Marinoa 20 5.5 0.4 0.7 0.2 0.4 0.5 1.1
Slovakia 3,903 16.3 267.3 369.4 163.0 263.9 209.9 636.7
Slovenia 1,511 17.2 111.3 148.3 57.8 103.3 98.5 259.6
Spain 30,329 9.9 1,209.7 1,794.6 838.4 973.2 1,192.6 3,004.3
Sweden 6,290 9.0 181.9 383.7 98.9 169.5 297.2 565.6
Switzerland 5,310 6.1 155.6 169.1 0.5 84.6 239.7 324.8
Tajikistan 3,174 4.5 57.1 86.2 36.7 59.4 47.2 143.3
Turkey 42,411 6.2 910.4 1,735.1 798.9 1,102.9 743.6 2,645.4
Turkmenistan 2,648 4.5 46.6 73.8 30.3 53.7 36.3 120.3
Ukraine 35,625 17.3 2,410.3 3,760.7 1,360.5 2,291.0 2,519.5 6,171.0
United Kingdom 42,423 5.1 1,362.3 783.8 591.3 904.1 650.7 2,146.1
Uzbekistan 14,144 4.6 255.3 392.9 160.3 280.9 207.0 648.2
EUR Total * 621,235 10.2 26,001 37,199 13,404 23,673 26,123 63,200
* The totals may not be the exact sum of the columns due to rounding.
2003.
46
Chapter 1
Table 1.20
Prevalence estimates of impaired glucose tolerance (IGT), 2025 – European Region

Albania 2,559 7.4 70.0 120.0 38.8 79.4 71.8 190.0
Andorraa 52 10.6 2.4 3.2 1.1 1.8 2.6 5.6
Austria 5,887 7.9 230.3 234.4 0.4 102.1 362.1 464.6
Azerbaijan Republic 6,793 7.6 179.4 339.7 103.6 220.6 194.9 519.1
Belarus 7,233 18.3 536.8 787.5 243.2 505.3 575.9 1,324.4
Belgium 7,658 7.4 276.6 287.1 47.3 140.7 375.7 563.7
Bulgaria 4,871 8.7 148.1 276.1 54.0 172.7 197.6 424.2
Croatia 3,304 8.4 100.8 177.9 39.3 106.3 133.1 278.7
Cyprus 637 8.1 19.3 32.3 8.5 19.3 23.9 51.7
Czech Republic 7,599 19.1 637.2 811.9 219.1 556.0 673.9 1,449.1
Denmark 3,988 9.9 128.6 267.4 56.9 99.9 239.2 396.0
Estonia 814 18.6 62.2 88.8 26.6 58.0 66.4 151.0
Finland 3,822 9.4 159.1 200.3 0.5 35.8 323.1 359.3
France 45,141 6.3 1,187.3 1,636.8 411.6 823.7 1,588.8 2,824.0
Georgia, Republic of 3,341 8.3 96.5 181.6 42.5 109.2 126.5 278.2
Germany 60,030 7.9 2,366.1 2,380.4 4.7 1,004.2 3,737.6 4,746.5
Greece 7,767 8.9 258.1 430.4 77.6 273.2 337.8 688.5
Hungary 6,807 18.7 537.6 733.3 210.7 498.6 561.7 1,271.0
Iceland 229 6.6 7.7 7.4 1.6 4.1 9.4 15.1
Israel 5,776 5.9 214.4 129.1 57.4 126.0 160.1 343.5
Italy 40,482 6.5 1,124.3 1,526.3 302.1 832.7 1,515.8 2,650.6
Kazakhstan 11,358 6.3 279.8 431.8 101.7 296.6 313.2 711.5
Kyrgyzstan 4,355 5.7 100.3 147.4 43.6 108.2 95.9 247.7
Latvia 1,610 18.6 125.4 174.6 52.2 114.9 132.8 299.9
Lithuania 2,626 18.4 202.7 279.8 88.5 184.4 209.6 482.5
Luxembourg 415 6.5 13.7 13.5 3.1 7.1 16.9 27.1
Macedonia 1,598 8.1 47.3 81.6 20.8 52.8 55.3 129.0
Malta 303 8.5 12.7 13.0 1.4 9.7 14.6 25.7
Monacoa 24 6.1 0.6 0.9 0.2 0.5 0.8 1.5
Netherlands 12,538 7.3 447.7 463.9 79.5 235.5 596.6 911.5
Norway 3,534 9.8 112.4 234.7 51.7 87.7 207.7 347.1
Poland 28,567 18.5 2,278.3 3,010.0 914.1 1,981.9 2,392.3 5,288.3
Portugal 7,456 10.6 334.2 459.2 148.4 286.5 358.5 793.4
Romania 15,860 18.1 1,246.2 1,631.4 518.0 1,225.8 1,133.8 2,877.6
Russian Federation 98,969 18.5 7,361.1 10,924.1 3,258.1 6,911.1 8,116.0 18,285.2
San Marinoa 21 6.1 0.5 0.8 0.2 0.4 0.7 1.3
Slovakia 4,127 18.3 326.0 427.9 134.1 296.6 323.2 753.9
Slovenia 1,451 19.3 124.0 156.0 40.2 103.6 136.2 280.0
Spain 29,155 10.9 1,395.2 1,780.4 506.9 1,170.3 1,498.3 3,175.5
Sweden 6,373 10.2 212.6 436.7 87.0 158.0 404.3 649.3
Switzerland 5,114 8.4 215.2 212.1 0.4 79.8 347.1 427.3
Tajikistan 5,305 5.2 114.4 163.8 58.0 126.1 94.1 278.2
Turkey 59,689 7.2 1,536.6 2,772.9 898.1 1,941.6 1,469.7 4,309.4
Turkmenistan 4,537 5.3 97.8 143.4 47.4 108.4 85.4 241.2
Ukraine 31,102 18.4 2,339.6 3,385.9 1,027.5 2,212.9 2,485.1 5,725.5
United Kingdom 45,322 5.3 1,507.9 901.2 538.8 917.3 953.0 2,409.1
Uzbekistan 22,883 5.5 521.2 743.0 236.0 571.2 457.0 1,264.2
EUR Total * 646,334 10.9 29,965 40,589 11,097 25,597 33,860 70,553
from 2003 to 2025.
47
Chapter 1
Table 1.21
impaired glucose tolerance (IGT) – North American Region
Country Data used

Anguilla Jamaica (Wilks et al, 1999)86
Antigua and Barbuda Jamaica (Wilks et al, 1999)86
Aruba Jamaica (Wilks et al, 1999)86
Bahamas Jamaica (Wilks et al, 1999)86
Barbados a
Barbados (Hennis et al, 2002)87
Belize Jamaica (Wilks et al, 1999)86
Bermuda Jamaica (Wilks et al, 1999)86
British Virgin Islands Jamaica (Wilks et al, 1999)86
Canada b
Canada (Hux et al, 2002)36
Cayman Islands Jamaica (Wilks et al, 1999)86
Dominica, Commonwealth of Jamaica (Wilks et al, 1999)86
Grenada Jamaica (Wilks et al, 1999)86
Guadeloupe a
Guadeloupe (Costagliola et al, 1991)88
Guyana Jamaica (Wilks et al, 1999)86
Haiti Jamaica (Wilks et al, 1999)86
Jamaica Jamaica (Wilks et al, 1999)86
Martinique a
Guadeloupe (Costagliola et al, 1991)87
Mexicoc,d Mexico (Stern et al, 1992 and Posadas-Romero et al, 1994)89,90
St Kitts and Nevis Jamaica (Wilks et al, 1999)86
St Lucia Jamaica (Wilks et al, 1999)86
St Vincent and the Grenadines a
Barbados (Hennis et al, 2002)87
Trinidad and Tobago Jamaica (Wilks et al, 1999)86
USA USA (Harris et al, 1998)91
Jamaican data.
b. Because of the absence of data for IGT in the study used for diabetes, impaired fasting glucose (IFG) figures
were calculated from USA data.
c. The prevalence was obtained by combining the data from the two studies.
d. Because of the absence of data for IGT in the studies used for diabetes, IGT figures were calculated from
Brazilian data.
48
Chapter 1

OGTT WHO – 1980 1,303 25-74
OGTT WHO – 1980 1,303 25-74
OGTT WHO – 1980 1,303 25-74
OGTT WHO – 1980 1,303 25-74
SR or HbA1c > 10% Known diabetes 4,104 40-79
OGTT WHO – 1980 1,303 25-74
OGTT WHO – 1980 1,303 25-74
OGTT WHO – 1980 1,303 25-74
Registry Known diabetes N/A 20+
OGTT WHO – 1980 1,303 25-74
OGTT WHO – 1980 1,303 25-74
OGTT WHO – 1980 1,303 25-74
SR or FBG > 8.0 WHO – 1980 1,036 18+
OGTT WHO – 1980 1,303 25-74
OGTT WHO – 1980 1,303 25-74
OGTT WHO – 1980 1,303 25-74
SR or FBG > 8.0 WHO – 1980 1,036 18+
OGTT/FBG WHO – 1985 1,451 20-79
OGTT WHO – 1980 1,303 25-74
OGTT WHO – 1980 1,303 25-74
SR or HbA1c > 10% Known diabetes 4,104 40-79
OGTT WHO – 1980 1,303 25-74
FBG ADA – 1997 18,825 20+
49
Chapter 1
Table 1.22
Prevalence estimates of diabetes mellitus (DM), 2003 – North American Region

Anguillaa 8 5.5 0.3 0.1 0.2 0.2 0.1 0.3 0.1 0.4
Antigua and Barbudaa 41 5.8 1.6 0.7 1.2 1.2 0.4 1.4 0.6 2.4
Arubaa 43 9.7 2.1 2.1 0.6 2.5 1.0 4.2
Bahamas 193 9.0 6.1 11.2 2.8 9.5 5.0 17.3
Barbados 189 8.5 5.2 10.9 7.4 8.7 2.1 8.2 5.8 16.1
Belize 124 5.7 2.6 4.5 3.6 3.5 1.5 4.2 1.4 7.1
Bermudaa 39 9.7 1.9 1.9 0.6 2.3 0.9 3.8
British Virgin Islandsa 13 8.3 0.3 0.8 0.5 0.6 0.2 0.6 0.3 1.1
Canada 22,640 9.0 1,099.3 935.0 158.1 871.0 1,005.1 2,034.3
Cayman Islandsa 22 9.7 1.1 1.1 0.3 1.3 0.5 2.2
Dominica, Commonwealth of a 42 8.4 0.6 3.0 1.7 1.8 0.5 2.1 0.9 3.5
Grenadaa 54 6.8 1.6 2.1 1.8 1.9 0.6 2.2 0.9 3.7
Guadeloupe 289 6.5 0.0 18.7 8.8 10.0 2.3 9.3 7.2 18.8
Guyana 457 6.0 11.9 15.7 9.4 18.2 5.0 15.3 7.3 27.6
Haiti 4,113 5.7 109.9 126.4 79.6 156.7 41.4 127.8 67.1 236.3
Jamaica 1,528 7.2 30.0 80.6 39.4 71.3 17.7 58.0 35.0 110.6
Martinique 265 6.5 16.8 0.4 7.9 9.3 2.1 8.0 7.2 17.3
Mexico 59,336 7.4 631.8 3,776.7 1,616.7 2,791.9 646.6 2,168.7 1,593.2 4,408.5
St Kitts and Nevisa 23 6.6 0.7 0.8 0.8 0.8 0.2 0.9 0.4 1.5
St Lucia 101 6.2 2.8 3.5 3.0 3.3 1.1 3.8 1.4 6.3
St Vincent and the Grenadinesa 71 7.7 1.5 4.0 2.7 2.7 0.8 3.3 1.3 5.4
Trinidad and Tobago 861 7.9 9.7 58.3 10.9 57.0 58.4 9.3 0.2 67.9
USA 199,097 8.0 8,040.5 7,979.5 1,550.8 7,507.3 6,962.0 16,020.0
NA Total * 289,550 7.9 827 4,107 10,947 12,070 2,494 10,817 9,705 23,016
a. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that of the world population 2003.
50
Chapter 1
Table 1.23
Prevalence estimates of diabetes mellitus (DM), 2025 – North American Region

Anguillaa 11 6.7 0.4 0.3 0.4 0.4 0.1 0.4 0.2 0.7
Antigua and Barbudaa 57 8.2 1.6 3.1 2.3 2.3 0.6 2.7 1.4 4.6
Arubaa 59 10.9 3.2 3.2 0.8 3.8 1.9 6.4
Bahamas 266 11.4 10.5 19.9 3.1 15.6 11.6 30.3
Barbados 217 12.8 6.2 21.6 13.5 14.3 1.7 11.6 14.4 27.8
Belize 216 7.8 4.6 12.3 8.5 8.5 2.6 10.5 3.8 16.9
Bermudaa 54 10.9 2.9 3.0 0.7 3.4 1.7 5.9
British Virgin Islandsa 18 9.6 0.2 1.5 0.9 0.9 0.2 1.0 0.5 1.7
Canada 27,135 11.2 1,650.9 1,380.5 162.0 941.6 1,927.8 3,031.5
Cayman Islandsa 31 10.9 1.7 1.7 0.4 2.0 1.0 3.4
Dominica, Commonwealth of a 58 9.8 0.7 5.0 2.8 2.9 0.7 3.3 1.7 5.7
Grenadaa 74 8.4 1.9 4.3 3.1 3.1 0.8 3.6 1.8 6.2
Guadeloupe 345 8.2 0.0 28.3 13.4 14.9 2.0 12.1 14.1 28.3
Guyana 480 9.5 13.5 32.0 14.2 31.3 4.1 24.3 17.1 45.5
Haiti 6,679 7.0 150.1 314.2 156.5 307.7 79.8 251.1 133.3 464.2
Jamaica 2,197 9.6 39.7 170.1 75.1 134.7 24.0 110.7 75.2 209.8
Martinique 305 8.2 0.4 24.6 11.8 13.1 1.8 11.0 12.2 25.0
Mexico 87,640 10.3 968.8 8,065.8 3,234.7 5,800.0 800.9 4,452.3 3,781.4 9,034.6
St Kitts and Nevisa 32 8.0 1.0 1.6 1.3 1.3 0.3 1.5 0.8 2.6
St Lucia 132 8.4 3.7 7.4 5.4 5.7 1.3 6.6 3.2 11.1
St Vincent and the Grenadinesa 97 9.4 1.5 7.7 4.5 4.6 1.1 5.3 2.7 9.1
Trinidad and Tobago 1,042 11.8 12.2 111.0 43.7 79.5 10.9 62.0 50.3 123.2
USA 247,219 9.3 11,735.1 11,345.4 1,753.7 8,099.7 13,227.0 23,080.5
NA Total * 374,364 9.7 1,207 8,811 16,996 19,179 2,854 14,036 19,285 36,175
a. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that of world population growth
from 2003 to 2025.
51
Chapter 1
Table 1.24
Prevalence estimates of impaired glucose tolerance (IGT), 2003 – North American Region

Anguillaa 8 11.3 0.4 0.5 0.2 0.4 0.3 0.9
Antigua and Barbudaa 41 11.3 1.9 2.8 1.3 1.9 1.5 4.6
Arubaa 43 11.3 2.0 2.9 1.3 2.0 1.5 4.9
Bahamas 193 10.7 7.7 13.0 6.5 8.5 5.7 20.7
Barbados 189 11.6 8.5 13.6 5.6 9.6 6.8 22.1
Belize 124 9.8 4.7 7.3 4.6 4.5 3.0 12.1
Bermudaa 39 11.3 1.8 2.6 1.2 1.8 1.4 4.4
British Virgin Islandsa 13 11.3 0.6 0.9 0.4 0.6 0.5 1.5
Canadab 22,640 7.1 1,002.7 601.7 277.2 723.1 604.1 1,604.4
Cayman Islandsa 22 11.3 1.0 1.5 0.7 1.0 0.8 2.5
Dominica, Commonwealth of a 42 11.3 1.9 2.8 1.3 1.9 1.5 4.8
Grenadaa 54 11.3 2.5 3.6 1.7 2.5 1.9 6.1
Guadeloupe 289 11.9 13.7 20.8 8.5 14.4 11.6 34.5
Guyana 457 10.2 16.3 30.3 16.6 18.6 11.4 46.5
Haiti 4,113 10.0 144.2 268.1 148.6 158.3 105.4 412.3
Jamaica 1,528 10.8 63.8 101.5 51.6 62.9 50.8 165.3
Martinique 265 12.2 12.8 19.6 7.8 12.7 11.9 32.4
Mexico 59,336 6.6 1,715.4 2,199.7 1,506.0 1,548.6 860.5 3,915.1
St Kitts and Nevisa 23 11.3 1.1 1.6 0.7 1.1 0.8 2.7
St Lucia 101 10.7 4.1 6.7 3.5 4.3 3.0 10.7
St Vincent and the Grenadinesa 71 11.3 3.3 4.7 2.2 3.3 2.5 8.0
Trinidad and Tobago 861 11.1 38.1 57.5 26.6 41.4 27.6 95.5
USAb 199,097 7.0 8,650.6 5,255.8 2,481.1 6,292.6 5,132.6 13,906.4
NA Total * 289,550 7.0 11,699 8,619 4,555 8,916 6,847 20,318
a. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that of world population 2003.
b. Prevalence figures are for impaired fasting glucose (IFG) (not IGT) as only fasting specimens were measured for the majority of NHANES III
participants.
52
Chapter 1
Table 1.25
Prevalence estimates of impaired glucose tolerance (IGT), 2025 – North American Region

Anguillaa 11 12.5 0.6 0.8 0.3 0.5 0.5 1.3
Antigua and Barbudaa 57 12.5 3.0 4.0 1.5 2.8 2.7 7.1
Arubaa 59 12.5 3.2 4.2 1.6 2.9 2.8 7.4
Bahamas 266 12.5 13.4 19.9 7.1 13.6 12.6 33.3
Barbados 217 14.7 14.4 17.5 4.3 12.2 15.4 31.9
Belize 216 11.3 10.0 14.2 6.7 10.5 7.1 24.3
Bermudaa 54 12.5 2.9 3.8 1.5 2.7 2.6 6.7
British Virgin Islandsa 18 12.5 1.0 1.3 0.5 0.9 0.9 2.3
Canadab 27,135 8.1 1,344.0 866.0 283.6 766.2 1,160.2 2,210.0
Cayman Islandsa 31 12.5 1.7 2.2 0.8 1.5 1.5 3.9
Dominica, Commonwealth of a 58 12.5 3.1 4.1 1.6 2.9 2.8 7.2
Grenadaa 74 12.5 4.0 5.3 2.0 3.7 3.6 9.3
Guadeloupe 345 14.1 21.1 27.5 7.7 18.2 22.7 48.6
Guyana 480 12.7 22.6 38.2 12.0 26.3 22.6 60.8
Haiti 6,679 10.5 247.1 452.1 233.4 282.2 183.6 699.2
Jamaica 2,197 12.2 110.8 157.8 60.9 110.7 97.0 268.6
Martinique 305 14.1 18.7 24.4 6.7 16.7 19.7 43.2
Mexico 87,640 7.6 2,832.7 3,841.9 1,719.9 2,987.2 1,967.4 6,674.5
St Kitts and Nevisa 32 12.5 1.7 2.3 0.9 1.6 1.5 4.0
St Lucia 132 12.6 7.0 9.6 3.5 6.9 6.2 16.6
St Vincent and the Grenadinesa 97 12.5 5.2 6.9 2.6 4.9 4.7 12.2
Trinidad and Tobago 1,042 13.7 61.6 80.9 23.9 57.6 61.0 142.4
USAb 247,219 7.8 11,790.3 7,505.9 2,826.9 6,709.0 9,760.2 19,296.2
NA Total * 374,364 7.9 16,520 13,091 5,210 11,042 13,359 29,611
a. Population number as described in the CIA World Factbook 2002125, with age distribution adjustment to that
of world population growth from 2003 to 2025.
b. Prevalence figures are for IFG (not IGT) as only fasting specimens were measured for the majority of
NHANES III participants.
53
Chapter 1
Table 1.26
impaired glucose tolerance (IGT) – South and Central American Region
Country Data used

Argentinaa,b Argentina (Hernandez et al, 1987)92
Bolivia Bolivia (Barceló et al, 2001)93
Brazil Brazil (Oliveira et al, 1996 and Malerbi et al, 1992)94,95
Chile Paraguay (Jimenez et al, 1998)96
Colombia Colombia (Aschner et al, 1993)97
Costa Ricac Mexico (Stern et al, 1992 and Posadas-Romero et al, 1994)89,90
Cuba Jamaica (Wilks et al, 1999)86
Dominican Republic Jamaica (Wilks et al, 1999)86
Ecuador Bolivia (Barceló et al, 2001)93
El Salvadorc Mexico (Stern et al, 1992 and Posadas-Romero et al, 1994)89,90
French Guiana Suriname (Schaad et al, 1985)98
Guatemala c
Mexico (Stern et al, 1992 and Posadas-Romero et al, 1994)89,90
Honduras c
Netherlands Antillesb Barbados (Hennis et al, 2002)87
Nicaraguac Mexico (Stern et al, 1992 and Posadas-Romero et al, 1994)89,90
Panama c
Paraguay Paraguay (Jimenez et al, 1998)96
Peru Bolivia (Barceló et al, 2001)93
Puerto Rico Jamaica (Wilks et al, 1999)86
Suriname Suriname (Schaad et al, 1985)98
Uruguay Paraguay (Jimenez et al, 1998)96
Venezuela Brazil (Oliveira et al, 1996 and Malerbi et al, 1992)94,95
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)97
Netherlands Antilles: Jamaica (Wilks et al, 1999)86
c. Diabetes prevalence was derived by combining the data of the two studies indicated.
IGT prevalence was calculated from Brazilian data.
54
Chapter 1

2BG (50g) WHO – 1980 809 20-74
2BG WHO – 1985 2,948 25+
OGTT WHO – 1985 23,898 30-69
OGTT WHO – 1985 1,606 20-74
2BG WHO – 1985 670 30-79
OGTT/FBG WHO – 1985 1,451 20-79
OGTT WHO – 1980 1,303 25-74
OGTT WHO – 1980 1,303 25-74
2BG WHO – 1985 2,948 25+
OGTT/FBG WHO – 1985 1,451 20-79
OGTT WHO – 1980 1,218 30+
OGTT/FBG WHO – 1985 1,451 20-79
OGTT/FBG WHO – 1985 1,451 20-79
SR or HbA1c > 10% Known Diabetes 4,104 40-79
OGTT/FBG WHO – 1985 1,451 20-79
OGTT/FBG WHO – 1985 1,451 20-79
OGTT WHO – 1985 1,606 20-74
2BG WHO – 1985 2,948 25+
OGTT WHO – 1980 1,303 25-74
OGTT WHO – 1980 1,218 30+
OGTT WHO – 1985 1,606 20-74
OGTT WHO – 1985 23,898 30-69
55
Chapter 1
Table 1.27
Prevalence estimates of diabetes mellitus (DM), 2003 – South and Central American Region

Argentina 23,958 5.4 69.6 1,234.8 562.6 741.8 313.0 456.9 534.5 1,304.5
Bolivia 4,480 4.8 43.4 173.5 99.6 117.3 32.8 110.7 73.4 216.9
Brazil 109,901 5.2 548.1 5,133.9 2,496.0 3,186.0 732.3 2,733.7 2,216.1 5,682.0
Chile 9,864 5.6 45.3 511.9 231.2 326.0 77.7 268.2 211.2 557.1
Colombia 25,524 4.3 150.3 948.2 491.6 606.9 118.4 615.9 364.2 1,098.5
Costa Rica 2,493 6.9 52.4 119.5 66.3 105.6 22.7 87.5 61.8 172.0
Cuba 7,980 13.2 124.7 928.4 386.1 667.0 144.8 548.1 360.1 1,053.0
Dominican Republic 4,991 10.0 100.1 399.6 190.8 308.9 84.0 279.9 135.9 499.7
Ecuador 7,548 4.8 79.3 281.5 170.9 189.9 55.5 185.9 119.3 360.7
El Salvador 3,620 6.2 79.9 145.2 79.5 145.6 32.3 104.8 88.0 225.1
French Guiana 100 11.1 1.3 9.7 4.9 6.1 2.3 6.5 2.3 11.0
Guatemala 5,620 5.5 127.9 180.6 117.0 191.5 48.1 147.5 113.0 308.5
Honduras 3,302 5.7 65.0 122.4 70.6 116.9 30.7 90.3 66.5 187.5
Netherlands Antilles 148 12.3 3.1 15.2 7.4 10.8 1.6 9.5 7.1 18.2
Nicaragua 2,567 6.1 32.4 125.0 58.0 99.4 26.7 78.5 52.1 157.4
Panama 1,779 7.3 33.5 95.9 50.0 79.4 17.1 64.4 47.9 129.4
Paraguay 2,979 3.9 31.0 84.2 51.7 63.5 21.9 58.2 35.1 115.2
Peru 15,397 5.1 120.1 672.3 367.4 425.1 118.4 402.9 271.2 792.5
Puerto Rico 2,671 13.2 47.7 303.6 115.5 235.8 40.3 183.4 127.7 351.3
Suriname 251 8.6 6.5 15.1 8.4 13.3 5.7 10.0 6.0 21.7
Uruguay 2,217 6.8 6.5 143.6 54.5 95.6 15.6 60.1 74.5 150.1
Venezuela 14,460 5.2 47.7 697.8 341.3 404.2 100.9 366.2 278.3 745.5
SACA Total * 251,850 5.6 1,816 12,342 6,021 8,137 2,043 6,869 5,246 14,158
56
Chapter 1
Table 1.28
Prevalence estimates of diabetes mellitus (DM), 2025 – South and Central American Region

Argentina 31,775 5.8 68.6 1,773.8 836.1 1,006.3 377.6 667.3 797.5 1,842.4
Bolivia 7,927 5.7 58.1 391.6 209.1 240.7 60.1 231.7 158.0 449.8
Brazil 150,418 7.1 671.8 9,984.9 4,555.5 6,101.2 855.0 4,613.8 5,188.0 10,656.7
Chile 13,327 6.8 55.1 851.2 356.0 550.3 91.9 376.9 437.5 906.3
Colombia 39,178 5.8 217.4 2,057.0 1,024.6 1,249.8 157.5 1,131.9 985.0 2,274.4
Costa Rica 3,909 9.4 77.2 290.5 139.3 228.4 33.3 164.3 170.2 367.7
Cuba 8,749 17.3 124.2 1,388.1 541.3 970.9 109.3 747.1 655.8 1,512.3
Dominican Republic 7,081 13.0 123.8 796.4 331.6 588.6 109.4 483.5 327.3 920.2
Ecuador 11,887 6.4 112.0 651.1 357.0 406.0 81.1 389.3 292.7 763.1
El Salvador 5,775 8.2 120.9 353.0 168.0 305.9 49.4 242.2 182.3 473.9
French Guiana 190 13.7 2.2 23.9 11.4 14.7 9.4 9.1 7.7 26.1
Guatemala 11,171 6.5 214.5 513.2 271.4 456.3 105.7 368.6 253.3 727.7
Honduras 6,123 7.2 105.0 336.2 163.9 277.2 60.1 219.5 161.6 441.1
Netherlands Antilles 180 15.4 3.3 24.3 11.3 16.3 1.8 10.1 15.6 27.6
Nicaragua 5,124 7.7 56.5 338.5 146.0 249.0 53.4 200.9 140.8 395.0
Panama 2,590 10.0 47.0 213.1 96.7 163.4 21.7 120.7 117.7 260.1
Paraguay 5,533 4.8 47.8 217.6 114.9 150.5 41.2 124.8 99.4 265.4
Peru 23,753 6.7 169.8 1,418.3 724.1 864.0 168.3 815.2 604.7 1,588.2
Puerto Rico 3,251 15.6 48.8 459.3 168.4 339.7 43.7 252.5 211.8 508.1
Suriname 315 12.3 8.0 30.7 15.6 23.2 5.7 21.4 11.7 38.7
Uruguay 2,627 7.2 5.8 182.6 71.6 116.8 17.7 78.1 92.6 188.4
Venezuela 22,997 6.6 67.5 1,455.4 686.4 836.5 145.4 657.4 720.1 1,522.9
SACA Total * 363,881 7.2 2,405 23,751 11,000 15,156 2,599 11,926 11,631 26,156
57
Chapter 1
Table 1.29
Prevalence estimates of impaired glucose tolerance (IGT), 2003 – South and Central American Region

Argentina 23,958 9.8 798.0 1,551.5 498.7 1,188.4 662.4 2,349.4
Bolivia 4,480 7.1 124.2 193.1 103.3 115.9 98.0 317.2
Brazil 109,901 6.8 3,232.8 4,264.5 2,605.6 3,193.6 1,698.1 7,497.3
Chile 9,864 9.8 335.6 632.5 224.9 520.2 223.0 968.1
Colombia 25,524 4.5 445.4 690.9 457.7 436.8 241.8 1,136.3
Costa Rica 2,493 6.8 76.8 92.4 59.2 71.6 38.4 169.2
Cuba 7,980 12.2 407.4 563.4 241.3 388.3 341.1 970.7
Dominican Republic 4,991 10.4 206.1 313.0 168.6 214.2 136.3 519.1
Ecuador 7,548 7.1 216.3 319.0 172.2 198.1 165.0 535.2
El Salvador 3,620 6.5 103.1 133.9 93.0 88.0 56.0 237.0
French Guiana 100 7.3 2.6 4.7 2.7 3.4 1.2 7.3
Guatemala 5,620 6.3 162.5 191.9 147.8 130.2 76.4 354.4
Honduras 3,302 6.3 94.4 112.7 88.1 76.6 42.4 207.1
Netherlands Antilles 148 12.3 7.1 11.1 3.9 8.5 5.8 18.2
Nicaragua 2,567 6.2 70.8 87.8 69.1 59.8 29.6 158.5
Panama 1,779 6.9 55.1 66.8 42.6 50.4 28.9 121.9
Paraguay 2,979 8.5 91.3 161.0 75.1 132.8 44.4 252.3
Peru 15,397 7.2 441.6 668.1 351.7 406.3 351.7 1,109.7
Puerto Rico 2,671 12.2 126.3 199.9 76.5 130.8 118.9 326.2
Suriname 251 7.1 6.0 11.9 7.8 6.4 3.6 17.9
Uruguay 2,217 10.3 75.9 152.2 43.8 111.8 72.4 228.1
Venezuela 14,460 6.7 433.5 535.6 350.3 411.1 207.7 969.1
SACA Total * 251,850 7.3 7,513 10,958 5,884 7,943 4,643 18,470
58
Chapter 1
Table 1.30
Prevalence estimates of impaired glucose tolerance (IGT), 2025 – South and Central American Region

Argentina 31,775 10.4 1,139.2 2,162.5 630.0 1,701.4 970.2 3,301.7
Bolivia 7,927 7.5 244.5 352.2 169.1 226.9 200.8 596.7
Brazil 150,418 7.8 4,935.4 6,809.5 2,818.1 5,081.0 3,845.8 11,744.9
Chile 13,327 10.6 494.0 922.4 260.8 696.9 458.8 1,416.5
Colombia 39,178 5.0 734.3 1,211.5 577.8 739.5 628.5 1,945.8
Costa Rica 3,909 7.6 133.8 163.2 78.1 120.9 98.0 297.0
Cuba 8,749 14.6 582.3 698.2 180.3 502.3 597.9 1,280.5
Dominican Republic 7,081 12.0 349.8 500.7 202.0 346.7 301.8 850.5
Ecuador 11,887 8.3 425.8 561.3 223.0 385.6 378.4 987.0
El Salvador 5,775 7.2 177.4 239.6 123.8 186.6 106.6 417.1
French Guiana 190 7.6 5.2 9.2 4.9 5.7 3.8 14.4
Guatemala 11,171 6.6 327.1 407.0 280.7 298.8 154.6 734.1
Honduras 6,123 6.7 183.0 229.8 149.8 169.0 93.9 412.8
Netherlands Antilles 180 14.0 10.6 14.4 4.2 8.5 12.3 25.1
Nicaragua 5,124 6.7 151.4 192.3 124.4 143.7 75.7 343.8
Panama 2,590 7.8 88.6 112.4 49.4 85.8 65.9 201.0
Paraguay 5,533 9.2 184.2 327.5 130.8 261.2 119.7 511.7
Peru 23,753 8.3 831.2 1,144.3 444.6 780.1 750.7 1,975.4
Puerto Rico 3,251 13.5 179.2 259.4 76.6 173.2 188.9 438.6
Suriname 315 8.1 8.2 17.1 7.0 12.1 6.3 25.4
Uruguay 2,627 10.7 96.7 184.3 49.0 141.0 91.0 281.0
Venezuela 22,997 7.5 758.6 956.0 478.1 709.2 527.2 1,714.6
SACA Total * 363,881 8.1 12,041 17,475 7,062 12,776 9,677 29,515
59
Chapter 1
Table 1.31
impaired glucose tolerance (IGT) – South-East Asian Region
Country Data used

Bangladesh Bangladesh (Sayeed et al, 1997a, 1997b)99,100
Bhutan India (Ramachandran et al, 2001)101
India India (Ramachandran et al, 2001)101
Maldives Sri Lanka (Fernando et al, 1994)102
Mauritius Mauritius (Dowse et al, 1990)49
Nepal India (Ramachandran et al, 2001)101
Sri Lanka Sri Lanka (Fernando et al, 1994)102
Table 1.32
Prevalence estimates of diabetes mellitus (DM), 2003 – South-East Asian Region

Bangladesh 75,020 3.9 1,945.2 970.2 1,496.3 1,419.1 951.6 1,360.1 603.7 2,915.4
Bhutan 1,054 3.7 28.9 9.8 19.1 19.5 7.9 19.0 11.7 38.7
India 603,677 5.9 13,290.5 22,213.1 17,969.8 17,533.8 7,147.9 18,239.4 10,116.4 35,503.6
Maldives 144 1.8 1.4 1.2 1.3 1.2 0.5 1.6 0.4 2.6
Mauritius 786 10.7 34.4 50.1 41.2 43.3 14.8 45.4 24.3 84.5
Nepal 12,004 4.1 307.8 180.6 245.2 243.2 106.7 247.0 134.6 488.4
Sri Lanka 12,607 2.1 158.9 104.1 137.7 125.4 38.9 176.6 47.5 263.0
SEA Total * 705,292 5.6 15,767 23,529 19,911 19,386 8,268 20,089 10,939 39,296
Table 1.34
Prevalence estimates of impaired glucose tolerance (IGT), 2003 – South-East Asian Region

Bangladesh 75,020 7.1 2,746.9 2,596.3 2,273.6 2,137.1 932.5 5,343.2
Bhutan 1,054 14.1 73.8 74.3 77.5 47.4 23.2 148.1
India 603,677 14.2 44,069.0 41,561.5 42,484.2 30,100.3 13,046.0 85,630.4
Maldives 144 3.1 2.3 2.2 1.2 2.5 0.8 4.4
Mauritius 786 16.2 50.0 77.0 46.4 57.2 23.3 127.0
Nepal 12,004 14.0 850.8 833.5 897.4 551.3 235.7 1,684.3
Sri Lanka 12,607 3.7 240.4 220.8 93.2 281.7 86.3 461.2
SEA Total * 705,292 13.2 48,033 45,365 45,873 33,178 14,348 93,399
60
Chapter 1

OGTT WHO – 1980 2,371 20+
OGTT WHO – 1999 11,216 20+
OGTT WHO – 1999 11,216 20+
OGTT WHO – 1985 633 30-64
OGTT WHO – 1985 4,929 25-74
OGTT WHO – 1999 11,216 20+
OGTT WHO – 1985 633 30-64
Table 1.33
Prevalence estimates of diabetes mellitus (DM), 2025 – South-East Asian Region

Bangladesh 130,288 4.8 3,034.1 3,273.0 3,217.9 3,089.2 1,439.0 3,355.1 1,513.0 6,307.1
Bhutan 2,044 4.3 51.1 37.7 44.2 44.5 19.7 44.4 24.6 88.7
India 909,790 8.1 18,553.8 54,922.1 37,275.7 36,200.2 11,827.7 37,417.5 24,230.7 73,475.9
Maldives 304 2.1 2.6 3.9 3.3 3.2 1.2 4.2 1.1 6.5
Mauritius 986 14.7 42.4 102.4 68.7 76.1 15.9 66.4 62.5 144.8
Nepal 21,644 5.1 498.5 609.8 552.7 555.6 235.8 568.6 303.9 1,108.3
Sri Lanka 15,971 2.7 192.8 242.6 217.3 218.1 45.0 279.2 111.1 435.3
SEA Total * 1,081,026 7.5 22,375 59,191 41,380 40,187 13,584 41,735 26,247 81,567
Table 1.35
Prevalence estimates of impaired glucose tolerance (IGT), 2025 – South-East Asian Region

Bangladesh 130,288 7.8 5,154.7 4,951.2 3,491.0 4,394.1 2,220.8 10,105.9
Bhutan 2,044 14.1 144.2 143.4 152.0 94.7 40.9 287.6
India 909,790 14.5 68,123.4 63,865.6 55,892.0 50,190.2 25,906.8 131,989.0
Maldives 304 3.3 5.1 4.9 2.5 5.9 1.7 10.0
Mauritius 986 17.7 70.8 104.1 45.2 74.5 55.1 174.9
Nepal 21,644 14.1 1,538.6 1,511.5 1,584.0 1,032.7 433.4 3,050.1
Sri Lanka 15,971 4.2 337.1 338.7 95.5 398.8 181.5 675.8
SEA Total * 1,081,026 13.5 75,374 70,919 61,262 56,191 28,840 146,293
61
Chapter 1
Table 1.36
impaired glucose tolerance (IGT) – Western Pacific Region
Country Data used

Australia Australia (Dunstan et al, 2002)103
Brunei Darussalam Singapore (Ministry of Health Survey, 1999)104
Cambodiaa Thailand (National Health Examination Survey, 1996 )105
China, Hong Kong b
Hong Kong (Janus et al, 2000 and Cockram et al, 1993)106,107
China, Macau Hong Kong (Janus et al, 2000 and Cockram et al, 1993)106,107
China, People’s Republic of People’s Republic of China (Pan et al, 1997)108
Cook Islands Rarotonga (King et al, 1986)109
East Timor c
Indonesia (Waspadji et al, 1983)110
Fiji Fiji (Zimmet et al, 1983)111
French Polynesia Samoa (Collins et al, 1994)112
Guam Kiribati (King et al, 1984)113
Indonesia Indonesia (Waspadji et al, 1983)110
Japanb Japan (Ohmura et al, 1993 and Sekikawa et al, 2000)114,115
Kiribati Kiribati (King et al, 1984)113
Korea, Democratic People’s Republic of Republic of Korea (Park et al, 1995)116
Korea, Republic of Republic of Korea (Park et al, 1995)116
Lao People’s Democratic Republic Vietnam (Quoc et al, 1994)117
Malaysia Singapore (Ministry of Health Survey, 1999)104
Marshall Islands Kiribati (King et al, 1984)113
Micronesia Kiribati (King et al, 1984)113
Mongolia Mongolia (Suvd et al, 2002)118
Myanmar Vietnam (Quoc et al, 1994)117
Nauru Nauru (Zimmet et al, 1984)119
New Caledonia New Caledonia (Zimmet et al, 1982)120
New Zealandc New Zealand (Ministry of Health, 2002)121
Niue Niue (King et al, 1986)109
Palau Kiribati (King et al, 1984)113
Papua New Guinea Fiji Melanesians (Zimmet et al, 1983)111
Philippinesa Thailand (National Health Examination Survey, 1996 )105
Samoa Samoa (Collins et al, 1994)112
Singapore, Republic of Singapore (Ministry of Health Survey, 1999)104
Solomon Islands Fiji Melanesians (Zimmet et al, 1983)111
Taiwanb Taiwan (Chou et al, 1992, 1994)122,123
Thailanda Thailand (National Health Examination Survey, 1996 )105
Tokelau Samoa (Collins et al, 1994)112
Tonga Tonga (Colagiuri et al, 2002)124
Tuvalu Samoa (Collins et al, 1994)112
Vanuatu Fiji Melanesians (Zimmet et al, 1983)111
Vietnam Vietnam (Quoc et al, 1994)117
unpublished Indonesian data (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. Because of the absence of data for IGT in the study used for diabetes, IGT figures were calculated from
Australian data.
62
Chapter 1

OGTT WHO – 1999 11,247 25+
OGTT WHO – 1985 3,568 18-69
FBG WHO – 1980 13,519 15+
OGTT WHO -1985 4,413 20-79
OGTT WHO -1985 4,413 20-79
OGTT WHO – 1985 213,515 25-64
OGTT WHO – 1985 1,127 20+
OGTT WHO – 1985 2,704 15+
OGTT WHO – 1980 2,638 20+
OGTT WHO – 1985 1,776 25-74
OGTT WHO – 1980 2,938 20+
OGTT WHO – 1985 2,704 15+
OGTT WHO – 1985 5,211 40+
OGTT WHO – 1980 2,938 20+
OGTT WHO – 1985 2,520 30+
OGTT WHO – 1985 2,520 30+
OGTT WHO – 1985 4,912 15+
OGTT WHO – 1985 3,568 18-69
OGTT WHO – 1980 2,938 20+
OGTT WHO – 1980 2,938 20+
OGTT WHO – 1999 2,996 35+
OGTT WHO – 1985 4,912 15+
OGTT WHO – 1980 1,583 20+
OGTT WHO – 1980 707 20+
SR Known Diabetes 7,862 25+
OGTT WHO – 1985 1,149 20+
OGTT WHO – 1980 2,938 20+
OGTT WHO – 1980 1,340 20+
FBG WHO – 1980 13,519 15+
OGTT WHO – 1985 1,776 25-74
OGTT WHO – 1985 3,568 18-69
OGTT WHO – 1980 1,340 20+
OGTT WHO – 1985 4,287 30-79
FBG WHO – 1980 13,519 15+
OGTT WHO – 1985 1,776 25-74
OGTT WHO – 1999 1,024 15+
OGTT WHO – 1985 1,776 25-74
OGTT WHO – 1980 1,340 20+
OGTT WHO – 1985 4,912 15+
63
Chapter 1
Table 1.37
Prevalence estimates of diabetes mellitus (DM), 2003 – Western Pacific Region

Australia 13,805 6.2 475.6 378.8 39.4 319.8 495.1 854.4
Brunei Darussalam 209 10.7 3.4 18.8 9.6 12.6 2.3 14.5 5.4 22.2
Cambodia 6,332 2.0 78.0 47.2 44.3 80.9 32.4 65.0 27.7 125.2
China, Hong Kong 5,424 8.8 232.7 247.2 46.7 204.2 229.0 479.9
China, Macau 323 8.2 12.7 13.9 2.7 13.7 10.2 26.6
China, People’s Republic of 877,935 2.7 11,106.7 12,702.3 10,750.5 13,058.5 2,068.1 11,022.2 10,718.7 23,809.0
Cook Islandsa 13 6.6 0.0 0.0 0.3 0.5 0.2 0.4 0.2 0.8
East Timor 403 1.4 4.8 0.8 2.8 2.8 0.5 3.0 2.0 5.6
Fiji 480 8.3 19.0 20.7 18.4 21.3 6.9 24.4 8.4 39.7
French Polynesia 147 8.0 3.5 8.2 5.3 6.4 1.0 7.0 3.8 11.7
Guam 93 6.7 2.1 4.2 3.3 2.9 1.2 3.4 1.6 6.2
Indonesia 132,849 1.9 1,028.8 1,518.7 1,194.8 1,352.7 242.4 1,213.4 1,091.7 2,547.5
Japan 97,090 6.9 3,476.7 3,252.2 365.5 2,617.3 3,746.0 6,728.9
Kiribatia 60 6.2 1.3 2.4 1.8 1.9 0.8 1.9 1.0 3.7
Korea, Democratic People’s Republic of 14,835 5.2 171.5 602.9 430.9 343.4 147.4 375.7 251.2 774.4
Korea, Republic of 34,147 6.4 1,209.7 976.2 383.4 1,120.1 682.4 2,185.9
Lao People’s Democratic Republic 2,658 1.1 14.9 13.0 6.0 21.9 6.8 9.8 11.3 27.9
Malaysia 13,280 9.4 323.5 928.1 527.3 724.3 134.6 688.4 428.6 1,251.6
Marshall Islandsa 46 8.6 0.4 3.6 2.0 2.0 0.8 2.1 1.2 4.0
Micronesiaa 82 6.7 1.6 3.9 2.7 2.8 1.1 2.8 1.6 5.5
Mongolia 1,451 1.4 4.3 15.9 9.9 10.3 5.2 11.2 3.9 20.2
Myanmar 28,474 1.1 166.2 145.4 68.8 242.9 70.8 116.1 124.7 311.6
Naurua 8 30.2 0.0 0.0 1.1 1.2 0.5 1.3 0.5 2.3
New Caledoniab 140 3.8 0.5 4.8 2.1 3.2 0.8 2.5 2.0 5.3
New Zealand 2,603 7.6 96.8 99.8 20.3 87.6 88.8 196.6
Niuea 1 6.8 0.0 0.0 0.0 0.1 0.0 0.1 0.0 0.1
Palaua 12 8.7 0.1 0.9 0.5 0.5 0.2 0.5 0.3 1.0
Papua New Guinea 2,551 1.9 23.8 25.3 20.4 28.7 4.3 25.2 19.5 49.1
Philippines 42,133 2.4 269.0 741.2 399.2 611.1 239.5 519.3 251.4 1,010.2
Samoa 74 5.9 3.0 1.4 1.9 2.5 0.4 2.0 2.0 4.4
Singapore, Republic of 3,032 12.3 172.3 201.3 32.2 191.6 149.7 373.6
Solomon Islands 221 2.1 2.0 2.5 1.9 2.6 0.4 2.2 1.9 4.5
Taiwana 13,767 5.6 307.1 458.7 94.9 326.5 344.3 765.7
Thailand 42,236 2.1 574.9 306.6 348.4 533.1 206.3 440.6 234.5 881.5
Tokelaua 1 6.4 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.1
Tongaa 65 12.4 4.1 4.0 3.5 4.6 1.6 4.4 2.2 8.2
Tuvalua 7 8.6 0.2 0.4 0.2 0.3 0.0 0.3 0.2 0.6
Vanuatu 101 2.2 1.0 1.2 0.9 1.3 0.2 1.1 0.9 2.2
Vietnam 46,620 1.0 319.7 161.5 95.0 386.2 112.2 161.3 207.7 481.2
WP Total * 1,383,705 3.1 14,128 17,286 19,938 23,091 4,274 19,603 19,152 43,029
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.
64
Chapter 1
Table 1.38
Prevalence estimates of diabetes mellitus (DM), 2025 – Western Pacific Region

Australia 16,950 7.7 720.5 580.1 41.9 377.1 881.6 1,300.6
Brunei Darussalam 332 15.0 5.1 44.9 22.1 27.9 3.3 22.5 24.2 50.0
Cambodia 12,191 2.1 119.4 140.4 98.0 161.8 67.7 120.6 71.5 259.8
China, Hong Kong 6,765 12.8 386.6 476.8 40.1 275.6 547.7 863.4
China, Macau 425 12.9 23.5 31.4 3.0 15.4 36.4 54.8
China, People’s Republic of 1,079,641 4.3 14,475.7 31,654.3 19,913.2 26,216.7 2,091.9 19,172.6 24,865.4 46,130.0
Cook Islandsa 17 7.3 0.0 0.0 0.5 0.8 0.2 0.6 0.4 1.3
East Timor 764 1.6 9.7 2.9 6.2 6.4 1.2 6.1 5.2 12.6
Fiji 641 10.3 22.2 43.8 31.2 34.8 7.6 37.1 21.3 66.0
French Polynesia 217 10.8 5.3 18.1 10.1 13.3 1.3 12.6 9.5 23.4
Guam 148 7.5 2.5 8.7 5.7 5.4 2.0 4.8 4.4 11.2
Indonesia 186,983 2.8 1,374.0 3,835.6 2,507.1 2,702.5 321.6 2,543.9 2,344.1 5,209.6
Japan 90,130 7.9 3,654.0 3,495.2 265.7 2,509.8 4,373.7 7,149.1
Kiribatia 82 7.9 1.5 5.0 3.3 3.2 1.0 3.2 2.2 6.5
Korea, Democratic People’s Republic of 18,008 6.3 177.6 957.0 635.4 499.2 150.3 586.5 397.8 1,134.6
Korea, Republic of 39,095 8.3 1,819.7 1,423.4 293.4 1,515.9 1,433.8 3,243.1
Lao People’s Democratic Republic 4,933 1.1 28.8 25.2 12.2 41.8 12.2 19.5 22.3 54.0
Malaysia 21,032 12.4 449.0 2,153.1 1,088.4 1,513.7 205.9 1,207.1 1,189.1 2,602.1
Marshall Islandsa 64 10.3 0.5 6.1 3.3 3.2 1.0 3.3 2.3 6.6
Micronesiaa 113 8.5 1.8 7.8 4.8 4.8 1.5 4.8 3.3 9.6
Mongolia 2,355 2.0 6.8 39.4 22.7 23.5 7.8 27.6 10.9 46.3
Myanmar 41,135 1.3 294.5 257.7 136.0 416.1 86.4 201.3 264.4 552.2
Naurua 10 33.0 0.0 0.0 1.7 1.7 0.6 1.9 0.9 3.5
New Caledoniab 217 4.7 0.6 9.7 3.9 6.4 1.1 4.4 4.8 10.3
New Zealand 3,106 9.0 135.2 143.0 20.6 96.2 161.3 278.1
Niuea 2 7.6 0.0 0.0 0.1 0.1 0.0 0.1 0.0 0.1
Palaua 16 10.3 0.1 1.6 0.9 0.8 0.2 0.8 0.6 1.7
Papua New Guinea 4,546 2.9 45.9 84.7 52.1 78.5 11.5 65.2 53.9 130.6
Philippines 69,936 3.0 363.3 1,707.8 811.3 1,259.8 375.0 1,066.1 630.0 2,071.2
Samoa 109 6.1 3.7 2.9 3.4 3.3 0.8 3.6 2.3 6.6
Solomon Islands 480 2.9 4.1 10.0 5.4 8.7 1.5 7.1 5.5 14.1
Taiwana 18,911 6.6 480.5 759.2 115.2 498.1 626.5 1,239.8
Thailand 55,716 2.6 940.2 518.1 570.4 887.9 198.5 719.0 540.8 1,458.3
Tokelaua 1 7.6 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.1
Tongaa 90 15.9 6.3 8.0 6.2 8.1 2.2 7.6 4.5 14.3
Tuvalua 9 10.8 0.2 0.8 0.4 0.6 0.1 0.5 0.4 1.0
Vanuatu 195 3.2 2.0 4.2 2.4 3.8 0.6 2.9 2.7 6.2
Vietnam 71,403 1.4 523.6 458.0 255.7 725.9 146.2 358.6 476.7 981.6
WP Total * 1,750,653 4.3 18,865 42,006 33,765 41,997 4,513 31,735 39,514 75,762
from 2003 to 2025.
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.
65
Chapter 1
Table 1.39
Prevalence estimates of impaired glucose tolerance (IGT), 2003 – Western Pacific Region

Australia 13,805 9.4 561.0 730.0 212.0 552.1 526.9 1,291.0
Brunei Darussalam 209 20.6 22.8 20.1 16.7 22.6 3.8 43.0
Cambodia 6,332 9.0 271.2 298.7 216.5 231.7 121.7 569.9
China, Hong Kong 5,424 10.9 318.1 274.2 91.7 268.7 231.9 592.2
China, Macau 323 10.4 17.9 15.6 5.1 18.1 10.4 33.6
China, People’s Republic of 877,935 3.8 9,277.2 23,874.7 4,812.7 16,268.9 12,070.4 33,152.0
Cook Islandsa 13 10.0 0.6 0.7 0.3 0.5 0.4 1.3
East Timor 403 9.4 20.7 17.4 12.9 16.2 9.1 38.1
Fiji 480 10.2 20.3 28.8 18.1 22.1 8.9 49.1
French Polynesia 147 6.0 3.7 5.1 2.4 4.3 2.1 8.8
Guam 93 17.7 7.9 8.5 5.1 8.1 3.2 16.5
Indonesia 132,849 9.7 6,924.2 5,989.0 4,391.5 4,819.9 3,701.8 12,913.2
Japan 97,090 13.0 5,554.2 7,057.8 2,294.1 5,049.1 5,268.7 12,612.0
Kiribatia 60 17.1 4.6 5.6 3.5 4.5 2.1 10.2
Korea, Democratic People’s Republic of 14,835 8.4 634.5 605.0 272.7 559.9 406.9 1,239.5
Korea, Republic of 34,147 8.4 1,455.9 1,408.9 583.5 1,367.8 913.6 2,864.8
Lao People’s Democratic Republic 2,658 1.3 5.9 29.4 9.4 14.1 11.7 35.2
Malaysia 13,280 17.7 1,173.7 1,174.3 919.9 1,131.3 296.9 2,348.0
Marshall Islandsa 46 17.1 3.6 4.3 2.7 3.5 1.7 7.9
Micronesiaa 82 17.1 6.4 7.7 4.9 6.3 3.0 14.1
Mongolia 1,451 7.7 40.7 70.7 52.1 37.2 22.1 111.4
Myanmar 28,474 1.4 66.4 326.3 98.0 166.3 128.4 392.7
Naurua 8 20.3 0.8 0.8 0.6 0.6 0.3 1.5
New Caledonia 140 4.6 2.6 3.8 1.8 2.8 1.8 6.4
New Zealand 2,603 9.4 105.0 140.0 40.2 106.6 98.1 244.9
Niuea 1 6.9 0.0 0.0 0.0 0.0 0.0 0.1
Palaua 12 17.1 0.9 1.1 0.7 0.9 0.4 2.0
Papua New Guinea 2,551 9.1 86.7 144.9 95.9 96.2 39.6 231.7
Philippines 42,133 9.3 2,060.4 1,846.9 1,442.7 1,499.4 965.2 3,907.2
Samoa 74 5.3 1.7 2.3 1.2 1.6 1.2 4.0
Solomon Islands 221 9.0 7.4 12.5 8.6 7.6 3.8 19.9
Taiwana 13,767 3.1 196.1 235.0 103.0 177.0 151.1 431.1
Thailand 42,236 9.9 2,223.4 1,962.5 1,359.9 1,657.6 1,168.3 4,185.9
Tokelaua 1 6.4 0.0 0.0 0.0 0.0 0.0 0.1
Tongaa 65 7.2 2.1 2.6 1.2 2.5 1.0 4.7
Tuvalua 7 6.4 0.2 0.3 0.1 0.2 0.1 0.4
Vanuatu 101 9.4 3.5 6.0 3.8 3.9 1.8 9.4
Vietnam 46,620 1.4 111.3 524.3 165.2 246.5 223.9 635.6
WP Total * 1,383,705 5.7 31,445 47,088 17,384 34,663 26,487 78,534
66
Chapter 1
Table 1.40
Prevalence estimates of impaired glucose tolerance (IGT), 2025 – Western Pacific Region

Australia 16,950 10.6 798.4 1,003.6 224.3 638.5 939.3 1,802.0
Brunei Darussalam 332 20.8 36.7 32.4 22.6 30.6 16.0 69.1
Cambodia 12,191 9.2 567.4 554.4 429.6 397.0 295.2 1,121.8
China, Hong Kong 6,765 14.6 479.5 505.9 78.5 350.5 556.4 985.3
China, Macau 425 14.6 28.8 33.2 5.8 19.4 36.9 62.0
China, People’s Republic of 1,079,641 5.0 14,118.8 40,145.7 4,298.8 24,699.1 25,266.6 54,264.5
Cook Islandsa 17 11.2 0.9 1.1 0.4 0.8 0.8 1.9
East Timor 764 10.2 43.1 34.6 24.3 31.1 22.4 77.8
Fiji 641 11.3 30.1 42.7 20.4 31.2 21.1 72.7
French Polynesia 217 7.1 6.7 8.6 2.9 7.1 5.3 15.3
Guam 148 17.3 12.1 13.6 8.3 9.8 7.6 25.7
Indonesia 186,983 11.2 11,801.3 9,138.8 4,925.0 8,796.2 7,219.0 20,940.2
Japan 90,130 14.1 5,663.7 7,014.4 1,633.4 4,881.6 6,163.0 12,678.0
Kiribatia 82 18.1 6.9 8.0 4.2 6.7 3.9 14.9
Korea, Democratic People’s Republic of 18,008 9.5 873.1 830.3 264.9 823.3 615.2 1,703.4
Korea, Republic of 39,095 10.8 2,164.0 2,043.9 446.2 1,838.2 1,923.6 4,208.0
Lao People’s Democratic Republic 4,933 1.4 11.6 56.2 16.9 27.9 22.9 67.8
Malaysia 21,032 18.4 1,933.5 1,926.4 1,299.5 1,802.8 757.7 3,860.0
Marshall Islandsa 64 18.1 5.3 6.2 3.3 5.2 3.1 11.5
Micronesiaa 113 18.1 9.5 11.0 5.8 9.2 5.4 20.5
Mongolia 2,355 8.7 84.6 120.5 65.2 84.9 54.9 205.0
Myanmar 41,135 1.7 122.5 558.3 121.3 286.5 272.9 680.7
Naurua 10 21.2 1.1 1.1 0.7 0.9 0.6 2.2
New Caledonia 217 5.2 5.1 6.2 2.3 4.8 4.2 11.3
New Zealand 3,106 10.8 146.5 187.6 40.8 115.3 177.9 334.1
Niuea 2 7.4 0.1 0.1 0.0 0.1 0.0 0.1
Palaua 16 18.1 1.4 1.6 0.8 1.3 0.8 3.0
Papua New Guinea 4,546 9.7 165.6 275.9 158.0 189.0 94.5 441.6
Philippines 69,936 10.4 4,002.7 3,271.1 2,105.7 2,864.0 2,304.1 7,273.8
Samoa 109 5.5 2.7 3.3 1.9 2.7 1.4 5.9
Solomon Islands 480 9.5 16.7 28.7 17.4 18.8 9.2 45.4
Taiwana 18,911 3.5 307.9 357.6 123.6 265.3 276.7 665.6
Thailand 55,716 12.0 3,773.1 2,891.3 1,302.6 2,679.0 2,682.9 6,664.4
Tokelaua 1 7.1 0.0 0.0 0.0 0.0 0.0 0.1
Tongaa 90 7.8 3.2 3.8 1.5 3.7 1.8 7.0
Tuvalua 9 7.1 0.3 0.4 0.1 0.3 0.2 0.7
Vanuatu 195 9.9 7.0 12.3 6.9 7.9 4.5 19.3
Vietnam 71,403 1.7 222.8 980.5 207.5 508.1 487.7 1,203.3
WP Total * 1,750,653 6.9 47,807 72,441 17,998 51,727 50,522 120,248
from 2003 to 2025.
67
Chapter 1
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14:491-498. Alberti KG, Moreno-Azorero R. Prevalence of diabetes
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83. Stern E, Raz I, Weitzman S. Prevalence of diabetes mellitus Khan AK. Effect of socioeconomic risk factors on the
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71
Chapter 1
1.2 Complications of Diabetes
Introduction mainly to the rapid rise in its prevalence

that has occurred in the latter part of
Over the last 30 years, type 2 diabetes the 20th century. The main relevance of
has changed from being seen as a diabetes complications in a public health
relatively mild ailment associated perspective is the relationship to human
with ageing and the elderly (‘just a suffering and disability, and the huge
touch of sugar’) to one of the major socio-economic costs through premature
contemporary causes of premature morbidity and mortality (1).
mortality and morbidity in most
countries. In virtually every developed Chronic elevation of blood glucose, even
society, diabetes is ranked among the when no symptoms are present to alert
leading causes of blindness, renal failure the individual to the presence of diabetes,
and lower limb amputation. Through will eventually lead to tissue damage,
its effects on cardiovascular disease with consequent, and often serious,
(70-80% of people with diabetes die of disease. Whilst evidence of tissue damage
cardiovascular disease), it is also now one can be found in many organ systems, it
of the leading causes of death. is the kidneys, eyes, peripheral nerves
and vascular tree, which manifest the
The changing perceptions of diabetes most significant, and sometimes fatal,
relate partly to a better appreciation diabetic complications. Indeed, diabetic
of its devastating complications, but complications are those aspects of the
disease that are most feared (such as
blindness and amputation), and account
The major diabetic complications 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 myocardial infarction,
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.
72
Chapter 1
Major diabetic complications Figure 1.11

Number of people with diabetes entering the Australian
Over the last two or three decades, there dialysis register, 1980-2000 (4)
has been an increasing awareness of the
��
magnitude of the problem presented
by diabetic complications. The major
complications are:
��
• Cardiovascular disease
��

Cardiovascular disease is the major
��
cause of death in diabetes, and
people with diabetes without previous
myocardial infarction have been shown ��
to have as high a risk of myocardial
infarction as have non-diabetic patients
with previous myocardial infarction (2) ��
(see Chapter 3).
• Nephropathy �
��
Diabetes is an increasingly important
cause of renal failure (see Figure 1.11), ��
and indeed has now become the single

most common cause of end stage renal
disease (ie that which requires either
dialysis or kidney transplantation) in • Amputation
the USA (3). Through effects on peripheral nerves
and arteries, diabetes can lead to foot
• Neuropathy ulceration, infection and the need for
Diabetes leads to a wide range of amputation. People with diabetes carry
effects on the peripheral nervous a risk of amputation that may be more
system, but the most common than 25 times greater than that seen in
manifestation of diabetic neuropathy those without diabetes (7).
is sensory loss in the feet. Although
neuropathy can sometimes lead to Methods
severe pain, it is often silent. However,
even in the absence of symptoms, it Details of the methods used in this report
puts the individual at high risk of foot on diabetes complications are found in
ulceration and amputation. Appendix 1.2. The main principles in
collating available prevalence data were:
• Retinopathy
Diabetic retinopathy is probably the 1 Studies were identified through
most characteristic, easily identifiable a detailed literature search, as
and treatable complication of diabetes, well as contact with IDF member
but remains an important cause of organizations.
visual loss in the developed world (5). 2 Studies with ≥100 participants were
Since type 2 diabetes often remains included; where more than one
undiagnosed for several years, a study was available for a country,
significant number of people, even preference was given to larger and
in developed countries, already have population-based studies, those
retinopathy and other complications at published after 1989, and those with
the time of diagnosis of diabetes (6). the fewest restrictions.
73
Chapter 1
3 Prevalences are reported for age range of the population was not
myocardial infarction, stroke, available, the mean or median age is
retinopathy, neuropathy and reported.
nephropathy, and incidence and 5 Diagnostic criteria for each
prevalence for lower extremity complication are recorded, as
amputations. variation in definitions can affect the
4 Where possible, the age ranges of the prevalences reported.
populations are reported. Where the
Profile: Janelle Colquhoun
Janelle Colquhoun was determined not to let diabetes

interrupt her plans to perform onstage when diagnosed
with type 1 diabetes at the age of 10. Headstrong,
independent and driven since childhood, Janelle became
the successful opera singer that she had always wanted
to be.
But now at 37, “I am not dead, but I am paying the

penalty for my years of careless control,” Janelle says.
“My diabetes always came second to the rest of my life,
having to fit in when I had time for it.” Janelle is blind,
has kidney failure and has lost sensation in her hands
and feet.
“While my doctor tried to convince me that I needed to take good care of my diabetes, I heard
his words as ‘live a boring and non-eventful life, doing and eating exactly the same things
at the same time each day’,” says Janelle, recalling her earlier years. “I wanted to have an
exciting life, travel the world, keep long hours in a theatre and do things when it suited me.”
His further threats of “if you don’t get better diabetic control you’ll be dead by the time you’re
30”, only pushed Janelle towards partying harder, taking greater risks, and cramming more
into life before reaching 30.
Although it is too late to reverse the complications, Janelle has well-controlled diabetes now.
The turning point in her diabetes control came when she was sent to a live-in diabetic clinic
for one month after she had nearly died due to hyperglycaemia caused by an extreme weight-
reduction diet. The clinic changed her into an educated person with diabetes. Says Janelle:
“This was the first time I became aware that I could control my diabetes and live a full and
exciting life.”
“The clinic rather than lecturing me about being a bad diabetic taught me how to be a good
doctor,” she explains. “We were given the same information that the doctors base their advice
on to give us best control, as they explained we are living with diabetes every minute and need
to make the day-to-day choices.”
At the clinic in Germany, where she was living at the time, Janelle learnt about all aspects
of diabetes and how to manage it. Although it required hard work on her part, Janelle
found that she was in a position to make her own decisions. “We tried out different injection
74
Chapter 1
6 For some countries, results from more numbers of individuals within a country
than one study are presented. This is who may have complications are not
usually because they cover different estimated, nor is a national prevalence.
aspects of the diabetic population. Furthermore, data have not been
projected from one country onto other
There are some important differences countries. This is for two reasons: firstly,
between this section and Chapter 1.1 on such calculations require knowledge of
diabetes prevalence and IGT. The total the age and sex structure of both the
regimes under the doctor’s supervision until we worked out a regime to suit our lifestyle
and circumstances. For the first time I was allowed to use my own intellect to make decisions
and could plan a regime that suited my timetable and lifestyle.”
Before reaching this point, Janelle was busy fulfilling her dreams to perform onstage. She
sang with the Australian Opera, and subsequently travelled the world. She then lived in
Germany, singing with the Frankfurt Opera. “Often I did not even bother to blood test, as
I knew it would be high,” recalls Janelle, “I always had a fear of having a hypoglycaemia
onstage and never working again so purposely left it this way.”
She lost her eyesight due to diabetic retinopathy while living in Germany. She went through
painful laser treatment before undergoing 12 eye operations to save her sight. After a
prolonged period in hospital, the eye specialists released her into a world of blackness, and
she returned home to Australia.
Adjusting to life without sight was more difficult than for a person without diabetes. Since
Janelle had lost all sensation in her feet and hands many years earlier due to diabetic
neuropathy, identifying surfaces, temperature, even learning to walk along the street
with a white cane was near impossible. Obviously learning Braille was out of the question.
Fortunately, technology has helped with the use of screen reading computers and it has
allowed Janelle to read and write again, and participate in the world around her.
With the help of her husband, Janelle established Salubrious Productions, a growing company
which represents professional artistes with disability. Not long after her marriage, Janelle
discovered a large lump in her breast, which was surgically removed and diagnosed as
diabetic mastopathy, one of the lesser known complications.
Janelle’s return to the stage and an active life was cut short again when her kidneys began to
fail due to diabetic nephropathy. Janelle recalls that difficult year: “I had an important year
planned with many major singing engagements. I spent most of the year in bed, often unable
to get up and mostly too exhausted to sing.”
“I wish I had made educated choices when I was younger,” says Janelle, “however I am not
without hope for the future.” She is on a waiting list for pancreas/kidney transplant and has
hopes that advances in science and technology will bring her sight back. She regularly speaks
at conferences and is active in Diabetes Australia. “Life continues to be full and eventful for
people experiencing diabetes, and for those of us with complications also.”
75
Chapter 1
original study population, and of the type 2 diabetes, the prevalence of overt
target (national diabetic) population. In nephropathy ranged from 5.4% to 20.0%
most cases, neither of these is known. in clinic-based populations and from 9.2%
Secondly, many studies are clinic based, to 32.9% in population-based studies.
and so their generalizability is limited.
For microalbuminuria, fifty percent of
Results the prevalences were between 18.3% and
24.5% for type 1 diabetes, and between
The results are provided in Tables 1.41 21.4% and 42.0% for type 2 diabetes.
– 1.50. A brief summary of results for For overt nephropathy, fifty percent of
each complication is presented below. the prevalences in type 1 diabetes were
Comments have excluded studies between 6.0% and 15.3%, and between
focusing on children. 9.2% and 19.1% for type 2 diabetes.
Cardiovascular disease Neuropathy

The prevalence of coronary heart disease The prevalence of neuropathy in those
(CHD) in those with diabetes (both type 1 with type 1 diabetes ranged from 3.0%
and type 2) ranged from 1.0% to 25.2% in to 65.8% in clinic-based populations and
clinic-based populations and from 1.8% from 12.8% to 54.0% in population-based
to 43.4% in population-based studies. studies.
The prevalence of stroke in those with
diabetes (type 1 and type 2) ranged from Among those with type 2 diabetes,
1% to 11.3% in clinic-based populations the prevalence of neuropathy ranged
and from 2.8% to 12.5% in population- from 7.6% to 68.0% in clinic-based
based studies. populations and from 13.1% to 45.0% in
population-based studies. Fifty percent
For CHD, fifty percent of the prevalences of the neuropathy prevalences for type 1
were between 0.5% and 8.7% for type 1 diabetes were between 22.4% and 30.1%,
diabetes, and between 9.8% and 22.3% and between 19.3% and 33.7% for type 2
for type 2 diabetes. For stroke, fifty diabetes.
percent of the prevalences in type 1
diabetes were between 0.5% and 4.3%, Retinopathy
and between 4.1% and 6.7% for type 2 The prevalence of retinopathy in those
diabetes. with type 1 diabetes ranged from 10.8%
to 60.0 % in clinic-based populations
Nephropathy and from 14.5% to 79.0% in population-
The prevalence of microalbuminuria based studies. Among those with type 2
in those with type 1 diabetes ranged diabetes, the prevalence of retinopathy
from 4.3% to 37.6% in clinic-based ranged from 10.6% to 47.3% in clinic-
populations and from 12.3% to 27.2% in based populations and from 10.1% to
population-based studies. Among those 55.0% in population-based studies. Fifty
with type 2 diabetes the prevalence of percent of the retinopathy prevalences for
microalbuminuria ranged from 2.5% to type 1 diabetes were between 33.5% and
57.0% in clinic-based population and 53.5%, and between 24.8% and 36.1% for
from 18.9% to 42.1% in population-based type 2 diabetes.
studies.
Amputation
The prevalence of overt nephropathy in The prevalence of lower extremity
those with type 1 diabetes ranged from amputations ranged from 0.2% to 4.8%
0.7% to 27% in clinic-based populations and the incidence ranged from 46.1 per
and from 0.3% to 24% in population- 100,000 diabetic population to 810 per
based studies. Among those with 100,000 diabetic population. Fifty percent
76
Chapter 1
of the amputation prevalences were defined as the absence of ankle reflexes

between 0.9% and 2.4%, and between 169 in one study (9), and as the presence
per 100,000 diabetic population and 457 of symptoms and clinical signs (using
per 100,000 diabetic population for the validated scales) in another (10). The
incidence of amputations. inconsistent use of diagnostic tools to
classify a complication has been shown
Discussion to dramatically affect the prevalence
reported. The Diabetes Control and
The aims of this section were to describe Complications Trial (DCCT) compared
the burden of diabetic complications, the prevalence of neuropathy using 11
and to be able to examine the differences different criteria and found that within
existing between countries and between the one population, the prevalence of
ethnic groups. In order to do this with neuropathy varied from 0.3%, using
confidence, it is necessary that there is a sensory examination, reflexes and
degree of uniformity in the methodology symptoms, through to 21.8% using nerve
of the different studies. This, however, conduction tests (11).
was not the case.
Another example of the variability
For each of the complications, a brought about by changing methodology
wide range of results was found, but is highlighted by a study on amputation.
understanding the underlying causes of A study by Humphrey compared the
this diversity is difficult. For example, incidence of lower extremity amputations
the low prevalence of neuropathy seen in one population, when primary or all
in Mauritius (8) could be due to a low amputations were included (12). The
inherent risk for neuropathy in that incidence of lower extremity amputations
population, the availability of high quality varied from 276 per 100,000 person
diabetes care, the relative youth of a years (primary amputation) to 388 per
population in a developing country, the 100,000 person years (all amputations).
methods used in the study for defining Further differences in amputation
neuropathy or the population-based incidences are likely to be due to the
study design. In the absence of similar (rather imprecise) method of estimating
studies, it is almost impossible to the total diabetic population from which
determine which of these explanations those with amputations were drawn.
may be correct.
One large study, EURODIAB, examined
The problem of accurately describing the the prevalence of retinopathy, neuropathy
burden and making comparisons is made and nephropathy in type 1 diabetes
particularly difficult by the relative lack of across several European countries
population-based studies. Studies based (13,14). This study used standard
in secondary care tend to over-represent methodology, making it possible to gain
those with advanced disease, as those some insight into whether observed
requiring more intensive monitoring differences in prevalence estimates are
are generally referred on for specialist due to methodological problems or
care. Furthermore, prevalences in clinic represent actual differences. The study
populations will depend on local referral found the prevalence of complications
patterns, which are likely to vary widely did vary between centres. The prevalence
around the world. of retinopathy ranged from 21% in a clinic
in Germany to 60% in a Portuguese clinic.
Neither the diagnostic tools nor However, much less variation was seen
diagnostic thresholds used to define for neuropathy and microalbuminuria,
a complication were equivalent across for which the prevalences clustered fairly
studies. For example, neuropathy was tightly around 25% and 23% respectively.
77
Chapter 1
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, but notably was above this
in five out of the six studies reported
from the Asian and Pacific island
nations of the Western Pacific Region.
• Of the six population-based studies
giving figures for neuropathy in type
2 diabetes, the two with the highest
prevalence were both from the USA.
• Populations from Europe had high
rates of heart disease and stroke,
while migrant Indian (Mauritius and
Fiji) populations 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
population-based 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.
78
Chapter 1
Table 1.41
Data sources: prevalence of cardiovascular disease
Region Country Data used Study type Sample size Age sample
AFR
South Africa Rotchford et al, 200215 Clinic (secondary care) 253 21-81
EMME
Pakistan Hashim et al, 199916 Clinic (primary care) 805 31->70
Sudan Elmahdi et al, 199117 Clinic (secondary care) 413 20+
EUR
Austria Mühlhauser et al, 199218 Clinic (primary care) 375 median=67
Belgium Van Acker et al, 200119 Clinic (secondary care) 1,653 21-69
Denmark Gall et al, 199120 Clinic (secondary care) 549 <76
Estonia Vides et al, 200121 Register 181 15-82
Finland Hu, 200322 Population based 172 25-64
Isomaa et al, 200123 Clinic (primary care) 1,697 35-70
France Le Floch et al, 200024 Clinic (primary care) 7,391 mean=63
Delcourt et al, 199825 Clinic (secondary care) 427 35-74
Germany Liebl et al, 200226 Clinic (primary and secondary care) 2,701 mean=67
Netherlands Reenders et al, 199327 Clinic (primary care) 387 mean=68

de Visser et al, 200228 Population based 281 22-96
Verhoeven et al, 199129 Clinic (primary care) 137 mean=68
Serbia and Montenegro Miljus, 200230 N/A N/A N/A
Vlajinac et al, 199231 Population based 152 35-54
Slovakia Slovakian Diabetes Societya, 32 Clinic (secondary care) N/A N/A
Spain Diamante, 199733 Clinic (secondary care) 1,822 >18
Esmatjes et al, 199634 Clinic (primary and secondary care) 1,157 45-70
Sweden Lundman et al, 199835 Clinic (primary and secondary care) 4,027 ≥18
United Kingdom Morgan et al, 200036 Clinic (primary and secondary care) 10,287 mean=61
NA
USA Maser at al, 199137 Clinic (secondary care) 657 mean=28
Alexander et al, 200038 Population based N/A ≥20
Qureshi et al, 199839 Population based 1,532 40-74
Barzilay et al, 200140 Population based 479 ≥65
SEA
Bangladesh Chuang et al, 2002c, 41 Clinic (secondary care) 1,607 10-91
Sayeed et al, 199842 Clinic (secondary care) 693 30-60
India Ramachandran et al, 1999c, 43 Clinic (secondary care) 3,010 mean=52
Ramachandran et al, 200044 Clinic (secondary care) 617 10-50
Mauritius Collins et al, 199345 Population based 259 35-74
Sri Lanka Chuang et al, 2002c, 41 Clinic (secondary care) 1,213 14-91
Fernando et al, 199346 Clinic (secondary care) 500 mean=52
WP
China, People’s Republic of Chuang et al, 2002c, 41 Clinic (secondary care) 2,430 7-92
Chi et al, 200147 Clinic (secondary care) 447 35-54
Fiji (Asian Indian) Tuomilehto et al, 198848 Population based 151 N/A
Indonesia Chuang et al, 2002c, 41 Clinic (secondary care) 2,093 22-89
Japan Kuzuya et al, 199449 Clinic (secondary care) 2,120 <24->75
Korea, Republic of Chuang et al, 2002c, 41 Clinic (secondary care) 952 15-92
Lee et al, 199550 Clinic (secondary care) 631 30-75
Malaysia Chuang et al, 2002c, 41 Clinic (secondary care) 1,045 15-87
Nauru Collins et al, 199345 Population based 215 35-80
New Zealand (European) Simmons et al, 199651 Population based 176 median=61
New Zealand (Maori) Simmons et al, 199651 Population based 286 median=50
New Zealand (Pacific Islanders) Simmons et al, 199651 Population based 495 median=52
80
Chapter 1
Duration DM (yrs) Diagnostic criteria – CHD# Diagnostic criteria – stroke+
4 ± N/A N/A Self-report / medical record review
N/A Medical record review / self-report (MI, angina) Medical record review (includes TIA)
<5->15 Self-report confirmed by ECG (CHD) Self-report (stroke, TIA)
median=6 Self-report (MI) Self-report (stroke)

range 5-27 Medical record review (CHD) Medical record review (CBVD)
range 0-20 ECG (Minnesota codes) N/A
11 ± 10 ECG / self-report / medical record review (CHD) Self-report / medical record review (CBVD)
N/A Self-report Self-report
N/A Self-report / medical record review (MI) Self-report / medical record review (stroke)
11 ± 0.1 Self-report / medical record review (CHD) Self-report / medical record review (CBVD)
11 ± 7 Self-report / ECG (MI) N/A
N/A Medical record review (MI, angina, congestive heart failure, Medical record review (stroke)
coronary bypass surgery)
8±6 Medical record review (MI, angina) Medical record review (stroke)
8±7 Medical record review (MI, PTCA, coronary artery bypass) Medical record review (stroke, TIA)
8±7 ECG (Minnesota codes) N/A
N/A N/A N/A
N/A ECG (Minnesota codes) questionnaire (MI, angina) N/A
N/A N/A N/A
14 ± 9 Self-report (CHD) Self-report (stroke)
9±7 Self-report (CHD) Self-report (stroke)
10 ± 7 Medical record review (MI, angina) Medical record review (stroke)
N/A Hospital codes and primary care audit (CHD) Hospital codes and primary care audit (CBVD)
19 ± 8 ECG / medical record review (MI, angina) N/A

N/A Self-report, Rose questionnaire (MI, angina) N/A
N/A Self-report (MI) Self-report (stroke)
N/A Medical record review (MI, angina, congestive heart failure, Medical record review (stroke, TIA)
coronary bypass surgery)
8±6 Medical record review (CHD) Medical record review (CBVD)

0–2 ECG and Self-report (MI, angina) N/A
8±6 ECG (Minnesota codes) / medical record review (MI) N/A
median=4 ECG (Minnesota codes) / medical record review (MI) N/A
N/A ECG (Minnesota codes) N/A
8 ± N/A ECG (Minnesota codes) Questionnaire

range <7-14 ECG (Minnesota codes) / self-report (MI, angina) Self-report (stroke)
11 ± N/A Doctor questionnaire (CHD) Doctor questionnaire (CBVD)
11 ± 7 Medical record review (CHD) Medical record review (CBVD)
8±7 ECG (Minnnesota codes) / self-report (MI, angina) Self-report (stroke)
N/A Self-report (MI) N/A
81
Chapter 1
Philippines Chuang et al, 2002c, 41 Clinic (secondary care) 2,657 7-93
Singapore, Republic of Chuang et al, 2002c, 41 Clinic (secondary care) 1,674 4-91
Thai et al, 199052 Population based 117 18+
Taiwan Chuang et al, 2002c, 41 Clinic (secondary care) 2,420 15-92
Fuh, 2002a, 53 Clinic (secondary care) 4,535 N/A
Thailand Tatsanavivat et al, 199854 Population based 278 ≥30
Thai Multicenter Group, 199455 Clinic (secondary care) 1,747 24-88
Tandhanand et al, 200156 Clinic (secondary care) 2,379 mean=59
Vietnam Chuang et al, 2002c, 41 Clinic (secondary care) 1,169 3-89
a. Unpublished data
b. Abstract only
c. Extra details supplied by authors
CBVD cerebrovascular disease

CHD coronary heart disease
DM diabetes mellitus
ECG electrocardiogram
MI myocardial infarction
N/A not available
PTCA percutaneous transluminal coronary angioplasty
TIA transient ischaemic attack
Diagnostic tool:
# – The type of CHD (eg MI or MI and angina) reported is stated. If this was not reported in the study, the term CHD is used.
+ – The type of CBVD (eg stroke or stroke and TIA) reported is stated. If this was not reported in the study, the term CBVD is used.
82
Chapter 1
Duration DM (yrs) Diagnostic criteria – CHD# Diagnostic criteria – stroke+

N/A ECG (Minnesota codes) / self-report (MI, angina) N/A
10 ± 7 Medical record review (CHD) Medical record review (stroke)
N/A N/A N/A
8±7 ECG Self-report (CBVD) / examination
83
Chapter 1
Table 1.42
Prevalence of cardiovascular disease
Prevalence of cardiovascular disease (%)

Coronary heart disease Stroke
Region Country Total DM UnDM Type 1 DM Type 2 DM Total DM UnDM Type 1 DM Type 2 DM
AFR
South Africa 7.5
EMME
Pakistan 19.8 6.2
Sudan 5.1 4.4
EUR
Austria 11.3 6.2
Belgium 21.0 6.2 30.8
Denmark 26.4
Estonia 7.7 2.8
Finland 8.1 7.6
13.4 5.2
France 13.5 16.3 13.3 4.1 4.3 4.1
8.4
Germany 10.6 6.7
Netherlands 9.0 5.0
20.9 9.1
40.0
Serbia and Montenegro 3.3
35.5
Slovakia 6.0 5.6
Spain 0.5 0.5
11.0 5.0
Sweden 11.5 4.7 12.3 11.3 3.1 12.3
United Kingdom 25.2 9.6
NA
USA 3.4
9.8
10.7 5.0
(incl UnDM) (incl UnDM)
43.4 12.5
SEA
Bangladesh 2.0 1.0
18.6
India 11.4
0.5
Mauritius Male 22.0
Female 33.7
Sri Lanka 6.0 2.0
12.0 3.6
WP
China, People’s Republic of 1.0 5.0
8.7 3.4
Fiji (Asian Indian) 31.3
Indonesia 5.0 4.0
Japan 2.1 5.7
Korea, Republic of 3.0 6.0
7.8 8.4
Malaysia 12.0 6.0
Nauru 15.8
New Zealand (European) 11.0
New Zealand (Maori) 11.0
New Zealand (Pacific Islanders) 6.0
Philippines 3.0 6.0
84
Chapter 1
Prevalence of cardiovascular disease (%)

Coronary heart disease Stroke
Singapore, Republic of 5.0 3.0
12.8
(incl UnDM)
Taiwan 4.0 6.0
18.1 4.7
Thailand 1.8
10.5 3.7
3.0 3.0
Vietnam 1.0 3.0
Total DM previously diagnosed diabetes (both type 1 and type 2)
UnDM undiagnosed diabetes
85
Chapter 1
Table 1.43
Data sources: prevalence of diabetic nephropathy
AFR
Ethiopia Rahlenbeck et al, 199757 Clinic (secondary care) 170 mean=42
Nigeria Erasmus et al, 199258 Clinic (secondary care) 113 mean=51
South Africa Kalk et al, 199759 Clinic (secondary care) 448 mean=54
Rotchford et al, 200215 Clinic (secondary care) 253 21-81
Levitt et al, 199760 Clinic (primary care) 243 20-85
Zambia Rolfe, 198861 Population based 600 mean=49
EMME
Egypt Herman et al, 199862 Population based 283 20+
Saudi Arabia Alzaid et al, 199463 Clinic (secondary care) 211 56
Sudan Elmahdi et al, 199117 Clinic (secondary care) 413 20+
EUR
Austria Mühlhauser et al, 199218 Clinic (primary care) 375 median=67
EuroDiab, 1994c, 13 Clinic (secondary care) 111 15-60
Belgium Bouten et al, 199664 Clinic (secondary care) 271 mean=37
Van Acker et al, 200119 Clinic (secondary care) 1,653 21-69
Croatia EuroDiab, 1994c, 13 Clinic (secondary care) 138 15-60
Czech Republic Perusicova et al, 1993b, 65 Register 1,443 >18
Czech Health Statistics, 2002a, 66 Population based N/A N/A
Denmark Mortensen et al, 199067 Clinic (secondary care) 957 <20
Gall et al, 199120 Clinic (secondary care) 549 <76
Finland EuroDiab, 1994c, 13 Clinic (secondary care) 139 15-60
France EuroDiab, 1994c, 13 Clinic (secondary care) 116 15-60
Delcourt et al, 199825 Clinic (secondary care) 427 35-74
Germany Bennett et al, 200168 Clinic (secondary care) 214 N/A
EuroDiab, 1994c,d, 13 Clinic (secondary care) 241 15-60
Greece EuroDiab, 1994c, 13 Clinic (secondary care) 231 15-60
Ireland, Republic of EuroDiab, 1994c, 13 Clinic (secondary care) 112 15-60
Hungary EuroDiab, 1994c,d, 13 Clinic (secondary care) 131 15-60
Israel Norymberg et al, 199169 Clinic (secondary care) 1,019 31+
Italy EuroDiab, 1994c,d, 13 Clinic (secondary care) 944 15-60
Luxembourg EuroDiab, 1994c, 13 Clinic (secondary care) 102 15-60
Netherlands EuroDiab, 1994c, 13 Clinic (secondary care) 128 15-60
Reenders et al, 199327 Clinic (primary care) 376 mean=68
Verhoeven et al, 199129 Clinic (primary care) 137 mean=68
Norway Joner et al, 199270 Population based 351 8-30
Poland EuroDiab, 1994c, 13 Clinic (secondary care) 116 15-60
Bennett et al, 200168 Clinic (secondary care) 186 N/A
Portugal EuroDiab, 1994c, 13 Clinic (secondary care) 137 15-60
Romania EuroDiab, 1994c, 13 Clinic (secondary care) 110 15-60
Slovakia Slovakian Diabetes Societya, 32 Clinic (secondary care) N/A N/A
Spain Diamante, 199733 Clinic (secondary care) 1,822 >18
Esmatjes et al, 199634 Clinic (primary and secondary care) 1,157 45-70
Sweden Lundman et al, 199835 Clinic (secondary care) 4,027 18+
Ukraine Kravchenko et al, 199671 Clinic (secondary care) 4,123 14-75
United Kingdom Higgs et al, 199272 Population based 358 6-92
Harvey et al, 2001c, 73 Population based 903 3-80
NA
USA Garg et al, 200274 Population based 1,192 20-80+
Orchard et al, 199075 Clinic (secondary care) 592 18-30+
SACA
Brazil Foss et al, 198976 Clinic (secondary care) 546 25-84
86
Chapter 1
Overt Microalbuminuria
Duration DM (yrs) Diagnostic criteria Diagnostic criteria
6±5 Albuminuria 30-299 mg/le Albuminuria >300mg/le

5±1 Albuminuria 20-199 µg/min e
N/A
6±6 A/CR 3.0-19.9 mg/mmol A/CR >19.9 mg/mmol
4 ± N/A Men A/CR 2.6-19.9 mg/mmol, women A/CR 3.6-19.9 mg/mmol A/CR ≥20 mg/mmol
8±8 A/CR >3.4 mg/mmole N/A
9±6 N/A Grade 2 proteinuria
N/A A/CR 100 – 299 mg/g A/CR ≥300 mg/g

10 ± 5 AER 30-300 mg/24hr Dipstick proteinuria
<5->15 N/A Proteinuria >0.5g/24h or blood urea of >40mg% e
median=6 Albuminuria 21-200 mg/l Albuminuria >200 mg/l

16 ± 10 AER 20-199 µg/min AER ≥200 µg/min
15 ±10 AER 20-200 µg/mine N/A
range 5-27 Albuminuria ≥ 30mg/dl N/A
N/A N/A N/A
N/A N/A N/A
5±3 AER >20-150µg/mine AER>150µg/mine
range 0-20 AER 31-299 mg/24hr AER ≥300 mg/24hr
11 ± 7 AER 31-300mg/24hr AER >300 mg./24hr or proteinuria >0.5g/24h
N/A A/CR 30-299 mg/g A/CR ≥300 mg/g
12 ± 9 N/A Proteinuria >30mg/dle
14 ± 9 AER 20-199 µg/min AER >200 µg/min
8±6 AER 20-200 mg/le AER >200 mg/le
8±7 Albuminuria 20-200 µg/min Proteinuria >0.5 g/24h
10 ± 3 AER 16 -200 µg/mine AER >200 µg/mine
N/A A/CR 30-299 mg/g A/CR ≥ 300 mg/g
N/A N/A N/A
14 ± 9 AER 20-200 µg/mine AER >200 µg/mine
9±7 AER 20-200 µg/mine AER >200 µg/mine
10 ± 7 N/A Proteinuria ≥300mg/ge
N/A Albuminuria ≥20 mg/l e
N/A
11 ± N/A A/CR ≥2.5 mg/mmol Albustix reading ≥0.3 g/l
N/A AER 20-200 µg/mine AER >200 µg/mine
N/A A/CR 3.0-37.8mg/mmol A/CR >37.8mg/mmol

16 ± N/A AER 20-200µg/mine AER >200 µg/mine
8±7 N/A Proteinuria >200 mg/24hre
87
Chapter 1
SEA
India Ramachandran et al, 200044 Clinic (secondary care) 617 10-50
Ramachandran et al, 1999c, 43 Clinic (secondary care) 3,010 mean=52
Mohan et al, 200077 Clinic (secondary care) 1,848 mean=52
Mauritius Dowse et al, 199878 Population based 746 25+
Sri Lanka Weerasuriya et al, 199879 Clinic (primary care) 597 25-65
WP
Australia AusDiab Study Group, 200280 Population based 459 25+
China, Hong Kong Ko et al, 199981 Clinic (secondary care) 150 <40
Chan et al, 199382 Clinic (secondary care) 397 mean=57
China, People’s Republic of Chi et al, 200147 Clinic (secondary care) 447 35-54
Indonesia Diabcare Asia, 2003a, 83 Clinic (primary care) 717 25-85
Japan Kuzuya et al, 199449 Clinic (secondary care) 2,120 <24->75

Kawano et al, 20019 Clinic 6,472 mean=61
Korea, Republic of Lee et al, 199550 Clinic (secondary care) 631 30-75
Malaysia Shriwas et al, 199684 Clinic (secondary care) 131 0-80+
Nauru Collins et al, 198985 Population based 318 25+
New Zealand (European) Simmons et al, 199486 Clinic (primary and secondary care) 297 18-79
New Zealand (Pacific Islanders) Simmons et al, 199486 Clinic (primary and secondary care) 123 18-79
Philippines Lantion-Ang, 200087 Clinic (primary care) 359 7-93
Samoa Collins et al, 199588 Population based 141 25-74
Singapore, Republic of Thai et al, 199052 Population based 117 18+
Taiwan Fuh, 2002a, 53 Clinic (secondary care) 4,535 N/A
Thailand Thai Multicenter Group, 199455 Clinic (secondary care) 2,060 24-88
Vietnam Diabcare Asia, 2003a, 83 Clinic (primary care) 521 1-85
a. Unpublished data
b. Abstract only
d. More than one centre used to derive prevalence figure
e. Diagnosis of nephropathy required two or more urine samples
A/CR albumin/creatinine ratio

AER albumin excretion rate
N/A not available
88
Chapter 1
Duration DM (yrs) Diagnostic criteria Diagnostic criteria
median=4 N/A Proteinuria ≥500 mg/24hre

8±6 N/A Proteinuria ≥500 mg/24hre
7±6 Proteinuria 150-499 mg/24hr e
Proteinuria ≥500 mg/24hre
6 ± N/A Albuminuria 30-299 mg/ml Albuminuria ≥300 mg/ml
0±0 N/A Albuminuria >50 mg/l
median=5 A/CR 3.5-19.9 mg/mmol A/CR ≥20 mg/mmol

5±0 A/CR ≥3.5 mg/mmol and AER ≥20 µg/mine N/A
range 0-30 A/CR 5.4-40.3 mg/mmole A/CR >40.3 mg/mmole
N/A N/A Semi quantitative test
7±6 Albuminuria 20-300mg/l / A/CR 2.5-25mg/mol (men) Albuminuria >300 mg/l / A/CR >25 mg/mol
A/CR 3.5-25 mg/mol (females)
11 ± N/A Doctor report Doctor report
10 ± 10 Doctor report Doctor report
8±7 AER 20-200 µg/mine AER >200 µg/mine
range <5->20 N/A Dipstick proteinuria or creatinine > 97µmol/l
range 0->15 Albuminuria 30 -299 µg/ml Albuminuria ≥300 µg/ml
range 0-47 AER 30-299 mg/24hr AER ≥300mg/24hr
range 0-32 AER 30-299 mg/24hr AER ≥300mg/24hr
9±7 Albuminuria 20-300 mg/l Albuminuria >300 mg/l
4 ± N/A Albuminuria 30-299 µg/ml Albuminuria ≥300 µg/ml
N/A N/A Albuminuria ≥30 mg/dl or creatinine ≥1.5 mg/dl
N/A N/A A/CR >300 mg/g or blood urea >26 mg/dl or serum creatinine
>1.3 mg/dl
8±7 N/A Dipstick proteinuria 2+
7±5 Albuminuria 20-300mg/l / A/CR 2.5-25mg/mol (men) Albuminuria >300 mg/l / A/CR >25 mg/mol
A/CR 3.5-25 mg/mol (females)
89
Chapter 1
Table 1.44
Prevalence of diabetic nephropathy
Prevalence of diabetic nephropathy (%)

AFR
Ethiopia 17.1 34.1
Nigeria 57.0
South Africa 14.5 31.0
13.4 32.8
5.3 36.7a
Zambia 23.8
EMME
Egypt 6.7 6.8 14.3 14.1
Saudi Arabia 12.8 36.0
Sudan 9.2
EUR
Austria 15.0 32.0
3.6 23.4
Belgium 14.0
35.4a 37.6a 35.6a
13.0 25.2
Croatia 15.9 29.0
Czech Republic 13.8
7.3a
Denmark 0.7 4.3
14.0 27.0
Finland 15.1 23.7
France 11.2 21.6
6.1 21.8
Germany 7.9 14.5
7.5 21.6
Greece 6.5 23.8
Ireland, Republic of 12.5 17.9
Hungary 6.1 19.8
Israel 7.0
Italy 6.9 19.3
Luxembourg 3.9 23.5
Netherlands 7.0 23.4
13.0 44.0
16.0 42.0
Norway 0.3 12.3
Poland 8.6 19.8
9.7 18.8
Portugal 15.8 24.8
Romania 17.3 26.4
Slovakia 7.6
Spain 5.0 14.1
5.4 23.1
Sweden 12.1 11.8 12.1
Ukraine 9.6
9.6 27.2
(cumulative (cumulative
prevalence) prevalence)
5.7 21.7
NA
USA 6.1 28.1
26.4 21.6
90
Chapter 1
Prevalence of diabetic nephropathy (%)

SACA
Brazil 11.3
SEA
India 7.1
19.7
(persistant
5.5%)
10.7 2.5
Mauritius 3.8 10.7
Sri Lanka 29.0a
WP
Australia 8.9 3.9 9.2 19.2 10.5 18.9
China, Hong Kong 22.7a 24.8a
20.0 27.0
China, People’s Republic of 57.1
Indonesia 3.3 4.6
Japan 20.1 27.0 19.5
27.3
Korea, Republic of 14.0 20.0
Malaysia 28.2
Nauru 24.4 32.9 38.9 42.1
New Zealand (European) 5.4 22.1
New Zealand (Pacific Islanders) 13.0 33.3
Philippines 1.0 48.7
Samoa 5.0 19.9
(incl UnDM) (incl UnDM)
Singapore, Republic of 18.3
Taiwan 19.0
Thailand 18.7
Vietnam 6.1 14.2
a. Includes both micro and macroalbuminuria
91
Chapter 1
Table 1.45
Data sources: prevalence of diabetic neuropathy
Region Country Data used Study type Sample size

AFR
South Africa Levitt et al, 199760 Clinic (primary care) 243
Tanzania Wikblad et al, 199789 Clinic (secondary care) 153
Zambia Rolfe, 198890 Clinic (secondary care) 600
EMME
Egypt Herman et al, 199862 Population based 509
Saudi Arabia Akbar et al, 200091 Clinic (secondary care) 237
Nielsen, 199892 Clinic (secondary care) 375
Sudan Elmahdi et al, 199117 Clinic (secondary care) 413
EUR
Austria Mühlhauser et al, 199218 Clinic (primary care) 395
EuroDiab, 1996c, 14 Clinic (secondary care) 116
Belgium Van Acker et al, 200119 Clinic (secondary care) 1,653
Croatia EuroDiab, 1996c, 14 Clinic (secondary care) 132
Czech Republic Perusicova et al, 1993b, 65 Register 1,443
Finland Partanen et al, 199593 Clinic 132
France EuroDiab, 1996c, 14 Clinic (secondary care) 104
Detournay et al, 200094 Clinic (primary and secondary care) 4,119
Delcourt et al, 199825 Clinic (secondary care) 427
Germany EuroDiab, 1996c,d, 14 Clinic (secondary care) 229
Greece Manes et al, 200295 Population based 821
EuroDiab, 1996c,d, 14 Clinic (secondary care) 216
Hungary EuroDiab, 1996c, 14 Clinic (secondary care) 138
Ireland, Republic of EuroDiab, 1996c, 14 Clinic (secondary care) 116
Israel Norymberg et al, 199169 Clinic (secondary care) 1,019
Italy Veglio et al, 199396 Clinic (secondary care) 379
EuroDiab, 1996c,d, 14 Clinic (secondary care) 894
Fedele et al, 199797 Clinic (secondary care) 8,757
Luxembourg EuroDiab, 1996c, 14 Clinic (secondary care) 107
Netherlands Reenders et al, 199327 Clinic (primary care) 387
Verhoeven et al, 199129 Population based 137
Poland EuroDiab, 1996c, 14 Clinic (secondary care) 117
Portugal EuroDiab, 1996c, 14 Clinic (secondary care) 130
Romania EuroDiab, 1996c, 14 Clinic (secondary care) 114
Spain Esmatjes et al, 199634 Clinic (primary and secondary care) 1,157
Cabezas-Cerrato, 199898 Population based 2,644
Sweden Lundman et al, 199835 Clinic (primary and secondary care) 4,027
Turkey Bolukbasi, 1998b, 99 Clinic (secondary care) 297
Ukraine Kravchenko et al, 199671 Clinic (secondary care) 4,123
United Kingdom Abbott et al, 2002100 Clinic (primary and secondary care) 9,710
Kumar et al, 1994101 Clinic (primary care) 811
Walters et al, 1992102 Population based 1,077
Young et al, 1993103 Clinic (secondary care) 6,487
NA
USA Orchard et al, 199075 Clinic (secondary care) 588
Franklin et al, 1990104 Population based 279
Dyck et al, 199310 Population based 359
SACA
Brazil Foss et al, 1989b,c, 76 Clinic (secondary care) 546
SEA
India Ramachandran et al, 200044 Clinic (secondary care) 617
Ramachandran et al, 199943 Clinic (secondary care) 3,010
92
Chapter 1
Age sample Duration DM (yrs) Diagnostic criteria
20-85 8±8 Clinical score

mean=44 5±6 Clinical store, quantitative sensory testing (NDS, NSS)
≥35 7±6 Clinical score
≥20 N/A Quantitative sensory testing

mean=54 11 ± 7 Clinical score (DNI)
median=50 median=8 Clinical score
20+ N/A Clinical score
mean=67 N/A Quantitative sensory testing

15-60 16 ± 10 Clinical score, quantitative sensory testing, autonomic function tests
21-69 range 5-27 Quantitative sensory testing
>18 N/A N/A
45-65 0±0 Clinical score, electrophysiology
mean=66 9 ± N/A Medical record review
35-74 11 ± 7 Clinical score, quantitative sensory testing
18-70 8±7 Clinical score (NDS, NSS), quantitative sensory testing
≥31 12 ± 9 Clinical score
15-59 N/A Clinical score, autonomic function tests
18-70 12 ± 9 Clinical score (DNI)
mean=68 8±6 Clinical score, autonomic function tests
mean=68 8±7 Clinical score
45-70 9±7 Clinical score
15-74 10 ± 0 Clinical score (NDS, NSS)
≥18 10 ± 7 Clinical score, quantitative sensory testing
N/A N/A Clinical score, electrophysiology
14-75 N/A Clinical score
mean=61 9 ± 11 Clinical score (NDS)
34-96 7 ± N/A Clinical score (NDS), quantitative sensory testing
30-80+ N/A Clinical score, quantitative sensory testing
18-90 range 0-62 Clinical score (NDS, NSS)
mean=24 16 ± N/A Clinical score

57 N/A Clinical score (NSS, NDS, NSP), quantitative sensory testing,
electrophysiology, autonomic function tests
25-84 8±7 Clinical score, quantitative sensory testing
10-50 median=4 Clinical score

mean=52 8±6 Clinical score, quantitative sensory testing
93
Chapter 1

Mauritius Shaw et al, 19988 Population based 847
Sri Lanka Weerasuriya et al, 199879 Clinic (primary care) 597
Fernando, 1996105 Clinic (secondary care) 500
WP
Australia Tapp et al, 2003106 Population based 398
China, Hong Kong Ko et al, 199981 Clinic (secondary care) 150

China, People’s Republic of Chuang et al, 2002c, 41 Clinic (secondary care) 2,344
Indonesia Chuang et al, 2002c, 41 Clinic (secondary care) 2,084
Japan Kawano et al, 20019 Clinic 6,472
Korea, Republic of Chuang et al, 2002c, 41 Clinic (secondary care) 948
Malaysia Chuang et al, 2002c, 41 Clinic (secondary care) 1,045
Philippines Chuang et al, 2002c, 41 Clinic (secondary care) 2,635
Singapore, Republic of Chuang et al, 2002c, 41 Clinic (secondary care) 1,625
Thai et al, 199052 Population based 117
Taiwan Wang et al, 2000107 Population based 219
Fuh, 2002a, 53 Clinic (secondary care) 4,535
Thailand Tandhanand et al, 200156 Clinic (secondary care) 2,314
Vietnam Chuang et al, 2002c, 41 Clinic (secondary care) 1,179
a. Unpublished data
b. Abstract only
DNI diabetic neuropathy index
N/A not available
NDS neuropathy disability score
NSP neuropathy symptom profile
NSS neuropathy symptom score
94
Chapter 1

≥25 N/A Quantitative sensory testing
25-65 0±0 Clinical score (NSS, NDS), quantitative sensory testing
30-60 5±6 Clinical score (NSS, NDS), quantitative sensory testing
≥25 median=5 Clinical score (NSS, NDS), quantitative sensory testing, autonomic function
tests
<40 5±0 Clinical score, quantitative sensory testing
7-92 8±6 Medical record review
mean=61 10 ± 10 Clinical score
15-92 11 ± 7 Medical record review
18+ N/A Clinical score
N/A N/A Quantitative sensory testing
mean=59 10 ± 7 Medical record review
95
Chapter 1
Table 1.46
Prevalence of diabetic neuropathy
Prevalence of diabetic neuropathy (%)

Region Country Total DM UnDM Type 1 DM Type 2 DM
AFR
South Africa 27.6
Tanzania 28.1
Zambia 31.2
EMME
Egypt 21.9 13.6
Saudi Arabia 56.0
19.7
Sudan 31.5
EUR
Austria 26.0
23.3
Belgium 33.7 25.7 38.3
29.3
Croatia 57.6
Czech Republic 32.8
Finland 8.3
26.1
France 21.2
8.8
28.8
Germany 20.1
Greece 33.5
25.5
Hungary 29.0
Ireland, Republic of 24.1
Israel 23.4
Italy 28.5
26.0
32.3
Luxembourg 21.5
Netherlands 68.0
18.0
23.9
Poland 25.6
Portugal 36.9
Romania 65.8
Spain 20.0
22.7 12.9 24.1
Sweden 27.3 22.8 27.9
Turkey 26.9
Ukraine 27.9
United Kingdom 22.4
41.6
22.7
16.8 12.8 17.2
28.5 22.7 32.1
NA
USA 32.4
27.8
47.6 54.0 45.0
SACA
Brazil 50.9
96
Chapter 1
Prevalence of diabetic neuropathy (%)

Region Country Total DM UnDM Type 1 DM Type 2 DM
SEA
India 3.0
27.5
Mauritius 12.7 3.6
Sri Lanka 10.0
30.6
WP
Australia 7.1 13.1
China, Hong Kong 7.3 7.6
Indonesia 55.0
Japan 41.4
Korea, Republic of 33.0
Malaysia 61.0
Philippines 42.0
15.9
(incl UnDM)
Taiwan 32.4
24.4
Thailand 27.0
Vietnam 44.0
97
Chapter 1
Table 1.47
Data sources: prevalence of diabetic retinopathy

AFR
Cameroon Moukouri Dit Nyolo et al, 1995123 Clinic (secondary care) 284
Ethiopia Seyoum et al, 2001124 Clinic (secondary care) 302
Nigeria Erasmus et al, 1989125 Clinic (secondary care) 377
South Africa Kalk et al, 199759 Clinic (secondary care) 507
Rotchford et al, 200215 Clinic (secondary care) 251
Levitt et al, 199760 Clinic (primary care) 243
Zambia Rolfe et al, 1988126 Clinic (secondary care) 600
Zimbabwe Bartels et al, 1999127 Clinic (secondary care) 117
EMME
Egypt Herman et al, 199862 Population based 376
Oman el Haddad et al, 1998128 Clinic (secondary care) 500
Sudan Elmahdi et al, 199117 Clinic (secondary care) 413
EUR
Austria EuroDiab, 199413 Clinic (secondary care) 122
Mühlhauser et al, 199218 Clinic (primary care) 375
Belgium Van Acker et al, 200119 Clinic (secondary care) 1,653
EuroDiab, 199413 Clinic (secondary care) 123
Croatia EuroDiab, 199413 Clinic (secondary care) 140
Czech Republic Perusicova et al, 1993b, 65 Register 1,443
Czech Health Statistics, 2002a, 66 Population based N/A
Denmark Gall et al, 199120 Clinic (secondary care) 549
Finland EuroDiab, 199413 Clinic (secondary care) 141
Falck et al, 1993129 Clinic (secondary care) 194
France EuroDiab, 199413 Clinic (secondary care) 127
Detournay et al, 200095 Clinic (primary and secondary care) 4,119
Delcourt et al, 199825 Clinic (secondary care) 427
Germany EuroDiab, 1994d, 13 Clinic (secondary care) 229
Hesse et al, 2001b, 130 Population based 2,801
Greece EuroDiab, 1994d, 13 Clinic (secondary care) 244
Hungary EuroDiab, 199413 Clinic (secondary care) 140
Ireland, Republic of EuroDiab, 199413 Clinic (secondary care) 124
Israel Norymberg et al, 199169 Clinic (secondary care) 1,019
Italy EuroDiab, 1994d, 13 Clinic (secondary care) 989
Segato et al, 1991131 Population based 1,291
Garancini et al, 1989132 Clinic (secondary care) 748
Luxembourg EuroDiab, 199413 Clinic (secondary care) 116
Netherlands EuroDiab, 199413 Clinic (secondary care) 136
Reenders et al, 199327 Clinic (primary care) 360
Verhoeven et al, 199129 Population based 137
Norway Joner et al, 199270 Population based 371
Hapnes et al, 1996133 Population based 210
Poland Luzniak et al, 1997b, 134 Clinic (secondary care) 1,334
Portugal Pinto-Figueiredo et al, 1992135 Clinic (secondary care) 1,302
Russia Betts et al, 1999136 Clinic (secondary care) 266
Slovakia Slovakian Diabetes Societya, 32 Clinic (secondary care) N/A
Spain Esmatjes et al, 199634 Clinic (primary and secondary care) 1,157
Fernandez-Vigo et al, 1993137 Clinic (primary and secondary care) 1,179
Sweden Kernell et al, 1997138 Population based 557
Henricsson et al, 1996139 Population based 2,232
Larsson et al, 1999140 Population based 285
Falkenberg et al, 1994141 Population based 117
Ukraine Kravchenko et al, 199671 Clinic (secondary care) 4,123
United Kingdom Higgs et al, 199272 Population based 291
Sparrow et al, 1993142 Population based 101
Broadbent et al, 1999143 Clinic (primary care) 357
98
Chapter 1
10-79 range 0-20 Clinical fundoscopy

14-85 9±5 Clinical fundoscopy
11-60+ range 0-22 Clinical fundoscopy
mean=54 7±7 Fundus photography
21-81 4 ± N/A Clinical fundoscopy
mean=49 9±6 Clinical fundoscopy
N/A N/A Clinical fundoscopy
20+ N/A Fundus photography

20+ <5->15 Clinical fundoscopy
15-60 16 ± 10 Fundus photography

median=67 median=6 Clinical fundoscopy or fundus photography
21-69 range 5-27 Medical record review
>18 N/A N/A
N/A N/A N/A
<76 range 0-20 Clinical fundoscopy
4-17 5±3 Fundus photography
mean=66 9 ± N/A Questionnaire
31-71+ 12 ± 9 Clinical fundoscopy
mean=60 range <5->20 Clinical fundoscopy
14-89 range <5->20 Clinical fundoscopy
mean=68 8±7 Clinical fundoscopy and fundus photography
mean=66 9±8 Clinical fundoscopy and fundus photography
N/A N/A N/A
<9-79 10 ± 10 Clinical fundoscopy and fundus photography
<16 3 ± N/A Clinical fundoscopy
N/A N/A N/A
8-93 range <5->15 Clinical fundoscopy and fundus photography
mean=15 5 ± N/A Fundus photography
<75 8±8 Fundus photography
15-50 17 ± 11 Clinical fundoscopy and fundus photography
<70 8±5 Fundus photography
14-75 N/A Clinical fundoscopy
6-92 11 ± N/A Fundus photography
28-91 7±6 Clinical fundoscopy and fundus photography
13-92 N/A Clinical fundoscopy and fundus photography
99
Chapter 1

NA
Barbados Leske et al, 1999144 Population based 636
Mexico Gonzalez Villalpando et al, 1994145 Population based 210
USA Dyck et al, 199310 Population based 380
Klein et al, 1992146 Population based 435
USA (Mexican Americans) Harris et al, 1998147 Population based 308
USA (Non-Hispanic Blacks) Harris et al, 1998147 Population based 261
USA (Non-Hispanic Whites) Harris et al, 1998147 Population based 345
SACA
Brazil Foss et al, 1989b, 76 Clinic (secondary care) 546
SEA
Bangladesh Chuang et al, 2002c, 41 Clinic (secondary care) 1,608
India Ramachandran et al, 200044 Clinic (secondary care) 617
Rema et al, 1996148 Clinic (secondary care) 6792
Ramachandran et al, 199943 Clinic (secondary care) 3010
Dandona et al, 1999149 Population based 119
Mauritius Dowse et al, 199878 Population based 746
Sri Lanka Fernando et al, 1993150 Clinic (secondary care) 1,003
Weerasuriya et al, 199879 Clinic (primary care) 597
WP
Australia Tapp et al, 2003151 Population based 703
Fairchild et al, 1994152 Clinic (secondary care) 255
McKay et al, 2000153 Population based 234
China, Hong Kong Ko et al, 199981 Clinic (secondary care) 150
Wang et al, 1998154 Clinic (secondary care) 465
China, People’s Republic of Chuang et al, 2002c, 41 Clinic (secondary care) 2,228
Hu et al, 1991155 Clinic (primary care) 423
Chi et al, 200147 Clinic (secondary care) 447
Fiji Brooks et al, 1999156 Population based 403
Indonesia Chuang et al, 2002c, 41 Clinic (secondary care) 2,062
Japan Kawano et al, 20018 Clinic 6,472
Kuzuya et al, 199449 Clinic (secondary care) 2,120
Korea, Republic of Chuang et al, 2002c, 41 Clinic (secondary care) 934
Lee et al, 199550 Clinic (secondary care) 631
Malaysia Chuang et al, 2002c, 41 Clinic (secondary care) 1,045
Shriwas et al, 199684 Clinic (secondary care) 140
New Zealand Florkowski et al, 2001157 Population based 286
Phillipines Chuang et al, 2002c, 41 Clinic (secondary care) 2,398
Samoa Collins et al, 199588 Population based 166
Singapore, Republic of Chuang et al, 2002c, 41 Clinic (secondary care) 1,578
Lau et al, 1995158 Clinic (primary care) 13,296
Taiwan Fuh, 2002a, 53 Clinic (secondary care) 4,535
Chen et al, 1992159 Population based 527
Thailand Tandhanand et al, 200156 Clinic (secondary care) 2,034
Thai Multicenter Group, 199455 Clinic (secondary care) 2,060
Vietnam Chuang et al, 2002c, 41 Clinic (secondary care) 1,113
a. Unpublished data
b. Abstract only
N/A not available
100
Chapter 1
40-84 median=5 Clinical fundoscopy and fundus photography

35-65 8±7 Fundus photography
mean=57 range 0-64 Fundus photography
43-84 range 0-20+ Fundus photography
40+ range 0-15+ Fundus photography

10-50 median=4 Clinical fundoscopy
31-86 range 0-20+ Clinical fundoscopy
≥25 6 ± N/A Fundus photography
≥25 median=5 Fundus photography

median=15 2 ± 18 Fundus photography
40+ 9.1 ± N/A Fundus photography
<40 5±0 Clinical fundoscopy
mean=54 N/A Clinical fundoscopy
35-54 range <7-14 Clinical fundoscopy
mean=56 8 ± N/A Clinical fundoscopy
mean=61 10 ± 10 Doctor report
<24->75 11 ± N/A Doctor report
0-80+ range <5->20 Clinical fundoscopy
mean=30 10 ± 6 Clinical fundoscopy
25-74 4 ± N/A Fundus photography
<30->70 N/A Fundus photography
N/A N/A N/A
40+ <4->10 Clinical fundoscopy
101
Chapter 1
Table 1.48
Prevalence of diabetic retinopathy
Prevalence of diabetic retinopathy (%)

Proliferative
Total retinopathy retinopathy
Region Country Total DM UnDM Type 1 DM Type 2 DM Total DM
AFR
Cameroon 37.3
Ethiopia 37.8 34.1 41.0 1.7
Nigeria 15.1 0.0
South Africa 39.3
40.3 5.6
55.4 4.3
Zambia 34.0 4.0
Zimbabwe 35.9
EMME
Egypt 41.5 15.7
Oman 42.4 12.8
Sudan 17.4
EUR
Austria 23.0
23.3
Belgium 38.5 43.6 35.0
47.0
Croatia 59.0
Czech Republic 42.2
11.3 2.4
Denmark 35.3 4.2
Finland 54.0
10.8
France 35.0
10.6
33.5 1.4
Germany 21.0
16.1
Greece 46.7
Hungary 51.0
Ireland, Republic of 53.0
Israel 28.0
Italy 40.8
26.2 46.2 24.6 1.8
37.3 7.6
Luxembourg 30.0
Netherlands 47.0
13.5
35.0 4.0
Norway 32.8 0.0
13.8 34.4 10.1 2.4
Poland 31.4
Portugal 41.6 7.3
60.0
Russian Federation 12.0 1.1
Slovakia 17.4
Spain 29.0
44.7 5.8
Sweden 14.5 2.3
43.6 64.0 36.0 6.7
75.1 21.8
26.5 3.4
Ukraine 22.4
102
Chapter 1
Prevalence of diabetic retinopathy (%)

Proliferative
Total retinopathy retinopathy
Region Country Total DM UnDM Type 1 DM Type 2 DM Total DM
52.0 4.0
51.0
33.6 36.7 36.2 1.1
NA
Barbados 28.5 0.9
Mexico 49.5 5.7
USA 62.1 79.0 55.0 8.9
(incl UnDM) 36.8 10.2 68.4 1.8
USA (Mexican Americans) 33.4 5.6
USA (Non-Hispanic Blacks) 26.5 1.8
USA (Non-Hispanic Whites) 18.2 0.9
SACA
Brazil 29.1
SEA
Bangladesh 11.0
India 13.4 1.9
34.1 3.4
23.7 3.7
23.5 0.8
Mauritius (incl UnDM) 30.2 14.8 44.3 1.3
Sri Lanka 31.3 5.9
15.2
WP
Australia 24.5 6.2 21.9 2.1
42.0 0.0
29.1 4.2
China, Hong Kong 14.0 11.4
21.9
31.0 2.8
47.4
Fiji 52.6
Indonesia 17.0
Japan 34.5
38.3 56.0 35.9 10.3
Korea, Republic of 33.0
35.2 8.2
Malaysia 37.0
48.6 47.3 3.6
New Zealand 37.4
Phillipines 18.0
Samoa 15.4 43.2 4.5
21.8 0.6
Taiwan 25.1
35.0 2.2
Thailand 21.0
32.1 6.6
Vietnam 13.0
103
Chapter 1
Table 1.49
Data sources: prevalence and incidence of lower limb amputations
Region Country Data used Study type

AFR
South Africa Levitt et al, 199760 Clinic (primary care)
EMME
Saudi Arabia Nielsen, 199892 Clinic (secondary care)
EUR
Austria Mühlhauser et al, 199218 Clinic (primary care)
Belgium Van Acker et al, 200119 Clinic (secondary care)
Czech Republic Czech Health Statistics, 2002a, 66 Population based
Denmark Ebskov et al, 1996108 Register
Holstein et al, 2000109 Clinical records
Finland Siitonen et al, 1993110 Operating theatre records
Germany Trautner et al, 2001111 Operating theatre records
Netherlands Reenders et al, 199327 Clinic (primary care)
van Houtum et al, 1996112 Hospital discharge records
Norway Witso et al, 2001113 Hospital records
Poland Nazim, 2001b, 114 Hospital records and limb fitting centre
Slovakia Slovakian Diabetes Societya, 32 Clinic (secondary care)
Spain Calle-Pascual et al, 19975 Operating theatre records, hospital discharge records, medical records
Almaraz et al, 2000b, 115 Hospital records
Sweden Lundman et al, 199835 Clinic (primary and secondary care)
Larsson et al, 1995116 Amputation register
United Kingdom Abbott et al, 2002100 Clinic (primary and secondary care)
Deerochanawong et al, 1992117 Operation records and hospital discharge records
Morris et al, 1998118 Hospital discharge records and database of rehabilitation service
NA
Canada Lawee et al, 1992119 Hospital discharge records
Trinidad and Tobago Gulliford et al, 2002120 Clinic (secondary care)
USA Humphrey et al, 199412 Hospital discharge codes
SACA
Brazil Spichler et al, 2001121 Register
SEA
India Ramachandran et al, 199943 Clinic (secondary care)
Mauritius Shaw et al, 19988 Population based
Sri Lanka Fernando, 1996105 Clinic (secondary care)
WP
China, People’s Republic of Chi et al, 200147 Clinic (secondary care)
Japan Kuzuya et al, 199449 Clinic (secondary care)
Nauru Humphrey et al, 1996122 Operating theatre records, welfare office and health survey data
Taiwan Wang et al, 2000107 Population based
Thailand Tandhanand et al, 200156 Clinic (secondary care)
Thai Multicenter Group, 199455 Clinic (secondary care)
a. Unpublished data
b. Abstract only
N/A not available
104
Chapter 1
Sample size Age sample No. of amputees Lowest level of amputation
243 20-85 3 N/A
375 N/A 5 N/A
375 N/A 13 below ankle

1,653 21-69 69 toe
N/A N/A N/A
25-97 2,848 ray
N/A 463 ankle
all 254 toe
all 39 toe
387 mean=68 5 N/A
all 1,575 toe
all 74 toe
N/A 139 toe
N/A N/A N/A
all 48 toe
N/A 316 N/A
4,027 >18 73 toe
all 21 toe
9,710 mean=62 122 toe
N/A 93 toe
7,079 all 52 toe
all 926 toe

2,106 all 84 toe
2,015 N/A 57 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 <24-75+ 13 N/A
375 25+ 46 toe
219 35-85 3 N/A
2,378 N/A N/A N/A
2,060 24-88 27 toe
105
Chapter 1
Table 1.50
Prevalence and incidence of lower limb amputations
Prevalence Incidence per 100,000

Region Country (%) diabetic population
AFR
South Africa 1.4
EMME
Saudi Arabia (below ankle only) 1.3
EUR
Austria 3.5
Belgium 4.2
Czech Republic 0.9
Denmark 156a
430b
Finland 480a
Germany 463a
Netherlands (type 2 DM) 1.5
251b
(age adjusted)
Norway 440a
Poland 165b
Slovakia 1.3
Spain 46.1a
136b
Sweden 1.8
410a
United Kingdom 1.3
570b
367a
NA
Canada 400b
Trinidad and Tobago 4.0
USA 271a
SACA
Brazil 181b
SEA
India (type 2 DM) 0.7
Mauritius (incl UnDM) 0.2
Sri Lanka (type 2 DM) 4.8
WP
Japan 0.6
Nauru 810a
Taiwan (incl UnDM) 1.4
Thailand 1.0
1.3
a. First amputation
b. All amputations or not stated
106
Chapter 1
16. Hashim R, Khan FA, Khan DA, Shaukat A. Prevalence of

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111
Diabetes in the Young: a Global Perspective
Chapter 2
Diabetes in the Young: Chapter 2

a Global Perspective
D iabetes is increasing in children and

adolescents in many countries. The
increase in incidence in type 1 diabetes
has been shown in countries having
both high and low prevalence with an
indication of a steeper increase in some
of the low prevalence countries. Although
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.
At the same time, there is a growing

awareness that type 2 diabetes in the
young is an emerging problem with
potentially serious outcomes. Yet our
2.1 Global Trends in Childhood
understanding of the worldwide burden
Type 1 Diabetes
of this disease is somewhat fractured,
2.2 Type 2 Diabetes in the Young with many studies reporting on specific
communities or ethnic groups.
The purpose of this chapter is to look

at the global trends in childhood type 1
diabetes and to bring together for the
first time, the available epidemiological
data on type 2 diabetes incidence and
prevalence in the young from around the
world. By the inclusion of such data it
is hoped to highlight deficiencies in the
knowledge of the disease and also to
promote strategies to deal with it.
113

Chapter 2
2.1 Global Trends in Childhood Type 1 Diabetes
Type 1 diabetes in an adult may

At a glance
masquerade as type 2 diabetes at
presentation with a slow deterioration
Type 1 diabetes (0-14 years) 2003 in metabolic control, and subsequent
progression to insulin dependency.
Total child population (billion) 1.8 This form is called latent autoimmune
Type 1 diabetes prevalence (%) 0.02 diabetes mellitus in adults (LADA) (9), and
Number of children with type 1 diabetes 430,000 in the new WHO classification, LADA falls
Annual increase of incidence (%) 3 within type 1 autoimmune diabetes but in
Estimated number of newly-diagnosed cases per year 65,000 a slowly progressive form.
The predominant cause of

hyperglycaemia in type 1 diabetes is
an autoimmune destruction of the beta
cells leading to absolute dependence
on insulin treatment and a high rate
Introduction of complications typically occurring at
relatively young ages. Therefore type
The incidence of childhood onset 1 diabetes places a particularly heavy
diabetes is increasing in many countries burden on the individual, the family and
in the world with an estimated overall the health services.
annual increase of around 3% (1-3).
There is some indication that incidence The continued mapping of global
is increasing more steeply in some of trends in incidence of type 1 diabetes
the low prevalence countries. Moreover, in all age groups is thus important,
several European studies have suggested and in conjunction with other scientific
that, in relative terms, increases are research may provide a logical basis for
greatest in young children (4-6). intervention studies and future primary
prevention strategies which must be the
Analyses of cumulative incidence rates ultimate goal.
into the fourth decade of life (7,8)
suggest that incidence is not increasing Methods
among young adults indicating rather
a shift to a younger age at onset. The Systematic searches of bibliographic
causes of these changes with time are databases were performed as explained
unknown but the rapidity of the changes in Appendix 1.3 to identify studies that
and the almost universally increasing provided incidence or prevalence rates of
trends in younger age groups are unlikely type 1 diabetes in children. Criteria were
to be due to changes in the genetic then applied to select the most suitable
background of the disease. Historically, study in a given country or, if necessary,
studies have tended to record incidence results from a number of studies were
data only up to the age of 15 years pooled.
although recently studies reporting
results up to the age of 30 or 35 years For countries that had no incidence or
have become more common. However, prevalence rates available the choice
the distinction between type 1 and type 2 of country to use for extrapolation was
diabetes becomes more difficult in these based on proximity, the state of economic
older age groups since people with type 2 development measured by the gross
diabetes may receive insulin therapy. domestic product (GDP) per capita and
114

Chapter 2
the ethnic composition as assessed from Figure 2.1

the Central Intelligence Agency (CIA) Estimated number of prevalent cases of type 1 diabetes
World Factbook 2002 (10). The choice in children by region
was also influenced by the quality rating
��
of the studies in the various countries.
The majority of studies found by the ��

literature search provided incidence
rates rather than prevalence rates, and
��
the method used to translate incidence
��
rates to prevalence rates is described in
Appendix 1.3. ��
The quality of estimates was assessed ��

using the following simple rating system:
A Studies from the country in question
��
that were based on registers that
were population based with validated
ascertainment levels of 90% or more. �
��
B Other studies from the country
in question, provided population
denominators were given to enable
rates to be calculated (so excluding
case-series studies which provided no
population denominator). It is estimated that on an annual basis
X Extrapolation using rates from a some 65,000 children aged under 15
different country, the identity of the years develop type 1 diabetes worldwide.
chosen country being indicated. Of the estimated total of approximately
430,000 prevalent cases of type 1
Results diabetes in childhood, more than a
quarter come from the South-East Asian
The Tables contain information on (SEA) Region, and more than a fifth from
population size in the 0-14 age group the European (EUR) Region where reliable,
together with estimated numbers of up-to-date estimates of incidence were
prevalent cases in 2003, organized by available for the majority of countries,
region. In those countries for which rates as shown in Figure 2.1. The smallest
were found in the literature search the contribution (approximately 5%) comes
following information is given: from the Western Pacific (WP) Region,
• geographical coverage; despite it having the largest childhood
• calendar period; population.
• number of cases;
• estimated completeness of Africa
ascertainment; and The need for extrapolation of rates
• a classification of the source as either of childhood type 1 diabetes was
A or B using the criteria described particularly evident in the sub-Saharan
under ‘Methods’. Countries for African (AFR) Region. Published rates
which no rates were found in the were found for only three of the countries
literature search were assigned the in this region, and some of the studies
classification X (extrapolated from a were of poor quality and based on
source in another country) and the small numbers. Consequently imperfect
country whose rate was used in the estimates of rates from Nigeria, Zambia
extrapolation is identified. and Tanzania have had to be used for
115

Chapter 2
widespread extrapolations because of the with small populations, and therefore any
dearth of published studies. error associated with the extrapolation
will have little impact on the estimate of
Mortality among children with diabetes the region’s total. The countries making
is likely to be high in parts of this the largest contribution to the total rates
region, but as numbers of cases in for childhood type 1 diabetes were United
these countries were mainly derived Kingdom, Germany and Russia reflecting
directly from prevalence rates rather to some degree the large childhood
than indirectly from incidence rates the populations in these countries. It is worth
effects of mortality are incorporated noting that the estimates for Russia were
in the estimates in Table 2.2. Tropical based on a study from Novosibirsk which
and malnutrition diabetes may account may not be representative of such a large
for a proportion of cases in this region, country.
but reliable data are lacking. For these
reasons the validity of the estimates North America
of numbers of children with type 1 Although no published rates were
diabetes in many parts of this region available for childhood type 1 diabetes
are questionable and must therefore be in many of the smaller Caribbean islands
treated with considerable caution. in the North American (NA) Region, it
was usually possible to extrapolate
Eastern Mediterranean and rates from an island in close proximity,
Middle East although such rates were often based on
In contrast to the situation in sub- very small numbers of cases. The USA
Saharan Africa, reliable data are available estimate, which accounts for more than
for childhood type 1 diabetes rates three-quarters of the region’s total, and to
in a number of the African countries a lesser extent the estimate for Canada
bordering the Mediterranean Sea. In the predominate.
Eastern Mediterranean and Middle East
(EMME) Region as a whole about half of South and Central America
the countries have published incidence Although the incidence of childhood
rates. By far the largest contribution to type 1 diabetes in the South and Central
the total number of estimated childhood American (SACA) Region is generally low,
type 1 cases for this region comes from there are some sharp contrasts between
Egypt whose estimate accounts for the rates in neighbouring countries.
about a quarter of the region’s total. In This means that occasionally the choice
Egypt the incidence of type I diabetes is of country to use for extrapolation can
reported as 8 per 100,000 population make a considerable difference to the
per year below the age of 15 years, resulting estimate (eg Bolivia, Ecuador).
while in Pakistan it is only 1 per 100,000 Such estimates must therefore be
population. interpreted with caution. The Brazilian
estimate accounts for more than half of
Europe the region’s total.
Compared with other regions, the
European Region has by far the most South-East Asia
complete and reliable data on the rates Only two countries in the South-East
of childhood type 1 diabetes with a large Asian Region have published rates
proportion of countries having registries for type 1 diabetes in childhood and
that are either nationwide or cover therefore extrapolation of rates was
several different parts of the country. necessary. The rate from China, although
outside the region, was used for some
Where extrapolation for the incidence rate extrapolations, but the rate for India was
was necessary it was usually for countries more frequently used and it therefore
116

Chapter 2
plays a pivotal role in the estimates for extrapolated far into the Pacific Ocean,
this region. although any error induced in the region’s
total by this extrapolation is likely to be
Two sources of rates for India were small because of the generally low rates
available, both from urban Madras and and small populations involved.
therefore probably not representative
of the country as a whole. The first was The rate for Thailand was used
a small prevalence study (11) giving an extensively for extrapolation in the
equivalent incidence rate which was Indo-China peninsula. Despite its very
less than half that of the second, larger low incidence, China accounts for almost
study (12), the rate from the latter study half of the region’s total. However,
having needed correction for under- the Western Pacific Region makes the
ascertainment. Given that even the lower smallest contribution of all to the world
of these two rates far exceeds the rates total of type 1 diabetes even though it
reported from other countries in the area has the largest childhood population.
and that the incidence in urban Madras is
likely to be higher than that for India as a Comments
whole, the decision was made to use the
lower of these two rates even though it The global distribution of childhood type
was based on the smaller study. 1 diabetes clearly indicates large area to
area variations. This variability may partly
The large childhood population in be due to different distributions of risk
India and the widespread use of the genes for the disease as well as different
Indian data for extrapolation in this distributions of environmental exposures,
region means that this decision has but part of the apparent variability both
important consequences not only for between countries and regions may also
the total in the region but also for the be due to methodological problems:
worldwide estimate, both of which
would be considerably larger had the • The available incidence data
higher estimate of incidence been sometimes covers only one small part
used. Notwithstanding the use of the of a large country. For example, in
lower rate, the South-East Asian Region India incidence data were extrapolated
contributes more than any other to the from studies performed in Madras and
worldwide childhood type 1 diabetes data from Russia were extrapolated
total. from a small dataset from Novosibirsk.
Obviously there may be considerable
Diabetes-associated mortality and tropical variability within such large countries
or malnutrition diabetes are also likely in both the distribution of risk genes
to play important roles in this region, and environmental exposures such
but unfortunately there is inadequate as climate and lifestyle related
information to address these issues. factors (13).
These points reinforce the need for much
more detailed data on childhood diabetes • The need for extrapolation was
in this region. particularly evident in the African
continent, especially in sub-Saharan
Western Pacific Africa. Here rates from undesirably
With the exception of Australia and New small datasets have had to be used in
Zealand, the rates of childhood type 1 extrapolations because of the lack of
diabetes in the Western Pacific Region published studies.
appear uniformly low. Few of the Pacific
islands had published data and the • Another problem was the need to
rate for Papua New Guinea had to be make extrapolations involving isolated
117

Chapter 2
island populations such as in Polynesia allow for mortality was not justified.
where both genetic predisposition and In sub-Saharan Africa, where mortality
lifestyle habits may be very different. among children with diabetes are
reported to be high (14, 15), numbers
• For some extrapolations, eg in parts of cases were mainly derived from
of South America, a choice had to Nigerian and Zambian prevalence rates
be made between countries whose rather than indirectly from incidence
reported incidence rates were very rates so that adjustment for mortality
different, possibly on occasions was not necessary. In such countries
because they were based on small the relationship between incidence
datasets. rate and prevalence rate is difficult to
predict, and consequently incidence
• Another methodological problem is rates are not given for sub-Saharan
the lack of data on mortality rates Africa except for Tanzania (Table 2.2).
among children with diabetes in
most populations. In less developed In addition to the geographical variation
countries, in which mortality could in the incidence of childhood type 1
have a significant impact, the diabetes there are also well-documented
disease rates were often based secular trends over time, which may
on small numbers of cases or on also differ from country to country and
extrapolation so that the application from region to region within a country.
of an adjustment to incidence data to Such time trends have not explicitly been
Map 2.1
Published incidence rates of type 1 diabetes in children (0-14 age range)
(cases per 100,000 population per year)
��
��
��
� � ��
��
��
� ��
118

Chapter 2
incorporated in these estimates since of fat cells both leading to insulin

reliable data are available for only a very resistance and thereby an overloading
small number of countries, but these of the beta cell. Although autoimmune
trends are of considerable importance for mechanisms are responsible for the
healthcare planning. beta cell destruction leading to type 1
diabetes, overload factors may accelerate
The causes of such changes over time this process (29-31). Overload through
are unknown and although migration accelerated child growth and body
might slowly change the genetic fat accumulation in association with a
background within a population, the lifestyle with a low physical activity are
rapid changes in incidence rate reported potentially preventable risk factors.
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
destruction (13).
Potential risk factors which may initiate

the autoimmune process include
early fetal events eg blood group
incompatibility (16), maternal viral
infections during pregnancy (17,18),
early exposure to cow’s milk components
and other nutritional factors such as
nitrosamines (19). Population-based
case-control studies have identified
some protective factors, including a
long duration of breast feeding (19),
early vitamin D supplementation (20),
pre-school day care (as a proxy
measure of infections) (21) and atopic
diseases (22).
Since type 1 diabetes in childhood is

associated with estimates of general
wealth such as GDP (23) 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.
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 diabetes (24-28). Rapid
growth is associated with high growth
hormone levels and an increased number
119

Chapter 2
Table 2.1
Data sources: estimates of type 1 diabetes in children – African Region
Country Data used Period Geography No. of cases Completeness Classification

Angola Zambia (Rolfe et al, 1989)a, 32 X
Benin Nigeria (Afoke et al, 1992)b, 33 X
Botswana Zambia (Rolfe et al, 1989)a, 32 X
Burkina Faso Nigeria (Afoke et al, 1992)b, 33 X
Burundi Tanzania (Swai et al, 1993)34 X
Cameroon Nigeria (Afoke et al, 1992)b, 33 X
Cape Verde Nigeria (Afoke et al, 1992)b, 33 X
Central African Republic Nigeria (Afoke et al, 1992)b, 33 X
Chad Nigeria (Afoke et al, 1992)b, 33 X
Comoros Tanzania (Swai et al, 1993)34 X
Congo, Democratic Republic of Zambia (Rolfe et al, 1989)a, 32 X
Congo, Republic of Zambia (Rolfe et al, 1989)a, 32 X
Côte d’Ivoire Nigeria (Afoke et al, 1992)b, 33 X
Djibouti Sudan (Elamin et al, 1992)35 X
Equatorial Guinea Nigeria (Afoke et al, 1992)b, 33 X
Eritrea Tanzania (Swai et al, 1993)34 X
Ethiopia Tanzania (Swai et al, 1993)34 X
Gabon Nigeria (Afoke et al, 1992)b, 33 X
Gambia Nigeria (Afoke et al, 1992)b, 33 X
Ghana Nigeria (Afoke et al, 1992)b, 33 X
Guinea Nigeria (Afoke et al, 1992)b, 33 X
Guinea-Bissau Nigeria (Afoke et al, 1992)b, 33 X
Kenya Tanzania (Swai et al, 1993)34 X
Lesotho Zambia (Rolfe et al, 1989)a, 32 X
Liberia Nigeria (Afoke et al, 1992)b, 33 X
Madagascar Mauritius (Karvonen et al, 2000)36 X
Malawi Zambia (Rolfe et al, 1989)a, 32 X
Mali Nigeria (Afoke et al, 1992)b, 33 X
Mauritania Nigeria (Afoke et al, 1992)b, 33 X
Mozambique Tanzania (Swai et al, 1993)34 X
Namibia Zambia (Rolfe et al, 1989)a, 32 X
Niger Nigeria (Afoke et al, 1992)b, 33 X
Nigeria Nigeria (Afoke et al, 1992)b, 33 1990 Anambra 14 N/A B
Reunion Mauritius (Karvonen et al, 2000)36 X
Rwanda Tanzania (Swai et al, 1993)34 X
Sao Tome and Principe Nigeria (Afoke et al, 1992)b, 33 X
Senegal Nigeria (Afoke et al, 1992)b, 33 X
Seychelles Mauritius (Karvonen et al, 2000)36 X
Sierra Leone Nigeria (Afoke et al, 1992)b, 33 X
Somalia Tanzania (Swai et al, 1993)34 X
South Africa Zambia (Rolfe et al, 1989)a, 32 X
Swaziland Zambia (Rolfe et al, 1989)a, 32 X
Tanzania Tanzania (Swai et al, 1993)34 1982-91 Dar es Salaam 36 100% A
Togo Nigeria (Afoke et al, 1992)b, 33 X
Uganda Tanzania (Swai et al, 1993)34 X
Western Sahara Algeria (Karvonen et al, 2000)36 X
Zambia Zambia (Rolfe et al, 1989)a, 32 pre-1989 Copperbelt 37 90% B
Zimbabwe Zambia (Rolfe et al, 1989)a, 32 X
a. Gives prevalence for <20 years

b. Gives prevalence for 5-17 years
N/A not available
120

Chapter 2
Table 2.2
Estimates of type 1 diabetes in children – African Region
Incidence rates
Population size (cases per 100,000 Estimated no.
(000’s) population per year)b of prevalent cases
Country 0-14 yrsa 0-14 yrs (000’s)
Angola 6,951 0.3
Benin 3,095 0.6
Botswana 648 0.0
Burkina Faso 6,102 1.1
Burundi 3,162 0.2
Cameroon 6,703 1.2
Cape Verde 174 0.0
Central African Republic 1,677 0.3
Chad 4,043 0.7
Comoros 327 0.0
Congo, Democratic Republic of 27,527 1.4
Congo, Republic of 1,540 0.1
Côte d’Ivoire 6,939 1.2
Djibouti 284 0.1
Equatorial Guinea 218 0.0
Eritrea 1,813 0.1
Ethiopia 30,596 1.7
Gabon 541 0.1
Gambia 560 0.1
Ghana 8,184 1.5
Guinea 3,704 0.7
Guinea-Bissau 564 0.1
Kenya 13,615 0.8
Lesotho 814 0.0
Liberia 1,510 0.3
Madagascar 7,745 0.7
Malawi 5,559 0.3
Mali 5,725 1.0
Mauritania 1,289 0.2
Mozambique 8,493 0.5
Namibia 800 0.0
Niger 6,046 1.1
Nigeria 54,789 9.9
Reunion 204 0.0
Rwanda 3,607 0.2
Sao Tome and Principec 81 0.0
Senegal 4,431 0.8
Seychellesc 22 0.0
Sierra Leone 2,263 0.4
Somalia 4,815 0.3
South Africad 14,818 4.9
Swaziland 393 0.0
Tanzania 16,670 0.9 0.5
Togo 2,144 0.4
Uganda 12,679 0.7
Western Sahara 101 0.0
Zambia 5,168 0.3
Zimbabwe 5,905 0.3
AFR Total 295,037 § 35.1
a. UN population projections – medium variant 2003

b. Likely high mortality rate and shortage of good-quality incidence studies makes it problematic to derive
incidence from prevalence in these countries
c. Population estimates extracted from CIA World Factbook 200210
d. Adjusted to take account of the higher rates in those of European origin
121

Chapter 2
Table 2.3
Data sources: estimates of type 1 diabetes in children – Eastern Mediterranean and
Middle East Region

Afghanistan Uzbekistan (Rakhimova et al, 2002)37 X
Algeria Algeria (Karvonen et al, 2000)36 1990 Oran 23 N/A B
Armenia Ukraine (Timchenko et al, 1996)38 X
Bahrain Oman (Soliman et al, 1996)39 X
Egypt Egypt (Arab et al, 1992)40 pre-1992 Alexandria, N/A N/A B
Damahour
Iran Pakistan (Staines et al, 1997)41 X
Iraq Jordan (Ajlouni et al, 1999)42 X
Jordan Jordan (Ajlouni et al, 1999)42 1992-96 Whole country 275 96% A
Kuwait Kuwait (Shaltout et al, 2002)43 1992-97 Whole country 364 90-96% A
Lebanon Jordan (Ajlouni et al, 1999)42 X
Libya Libya (Kadiki, 1998)44 1991-95 Benghazi 126 100% A
Morocco Algeria (Karvonen et al, 2000)36 X
Occupied Palestinian Jordan (Ajlouni et al, 1999)42 X
Territories
Oman Oman (Soliman et al, 1996)39 1993-94 Whole country 31 96% A
Pakistan Pakistan (Staines et al, 1997)41 1989-93 Karachi 240 N/A B
Qatar Qatar (Al-Zyoud et al, 1997)a, 45 1992-96 Whole country 80 N/A B
Saudi Arabia Saudi Arabia (Kulaylat et al, 2000)46 1986-97 Eastern Province 46 100% A
Sudan Sudan (Elamin et al, 1992)35 1987-90 Khartoum 311 95% A
Syria Jordan (Ajlouni et al, 1999)42 X
Tunisia Tunisia (Karvonen et al, 2000)36 1990-94 Beja, Gafsa, 168 N/A B
Kairoan, Monastir
United Arab Emirates Oman (Soliman et al, 1996)39 X
Yemen Oman (Soliman et al, 1996)39 X
a. Only to 12 years
N/A not available
122

Chapter 2
Table 2.4
Estimates of type 1 diabetes in children – Eastern Mediterranean and
Middle East Region
Incidence rates
(000’s) population per year) of prevalent cases
Afghanistan 10,501 1.2 0.8
Algeria 10,530 5.7 3.9
Armenia 768 8.1 0.4
Bahrain 178 2.5 0.0
Egypt 23,775 8.0 11.8
Iran 24,940 1.0 1.5
Iraq 10,085 3.2 2.0
Jordan 2,117 3.2 0.3
Kuwait 540 20.9 0.8
Lebanon 1,078 3.2 0.2
Libya 1,842 9.3 0.7
Morocco 10,515 5.7 3.7
Occupied Palestinian Territories 1,634 3.2 0.3
Oman 1,198 2.5 0.2
Pakistan 62,839 1.0 3.4
Qatar 154 11.4 0.1
Saudi Arabia 9,338 12.3 5.7
Sudan 13,182 8.0 6.5
Syria 6,704 3.2 1.3
Tunisia 2,693 6.6 1.1
United Arab Emirates 653 2.5 0.1
Yemen 10,557 2.5 1.6
EMME Total 205,822 § 46.6
123

Chapter 2
Table 2.5
Data sources: estimates of type 1 diabetes in children – European Region

Albania Macedonia (Green et al, 2001)3 X
Andorra Spain (Green et al, 2001)3 X
Austria Austria (Green et al, 2001)3 1989-98 Whole country 1,314 98% A
Azerbaijan Republic Uzbekistan (Rakhimova et al, 2002)37 X
Belarus Belarus (Martinucci et al, 2002)47 1986-99 Gomel approx 280 100% A
Belgium Belgium (Green et al, 2001)3 1989-98 Antwerp 191 96% A
Bosnia and Herzegovina Bosnia and Herzegovina (Bratina et al, 1990-98 Tuzla 43 100% A
2001)48
Bulgaria Bulgaria (Green et al, 2001)3 1989-98 Whole country 885 100% A
Croatia Croatia (Green et al, 2001)3 1989-98 Zagreb A
Cyprus Cyprus (Skordis et al, 1997)49 1990-94 Greek population 81 N/A B
Czech Republic Czech Republic (Green et al, 2001)3 1989-98 Whole country A
Denmark Denmark (Svensson et al, 2002)50 1996-2000 Whole country 839 99% A
Estonia Estonia (Green et al, 2001)3 1989-98 Whole country 365 100% A
Finland Finland (Tuomilehto et al, 1999)51 1987-96 Whole country 3,613 100% A
France France (EURODIAB ACE, 2000)2 1989-94 Four regions 837 99% A
Georgia, Republic of Ukraine (Timchenko et al, 1996)38 X
Germany Germany (Green et al, 2001)3 1989-98 Dusseldorf, Baden 2,535 90-97% A
Wurttemberg
Greece Greece (Green et al, 2001)3 1989-98 Attica, five northern 623 100% A
regions
Hungary Hungary (Green et al, 2001)3 1989-98 Eighteen counties 1,385 100% A
Iceland Iceland (Green et al, 2001)3 1989-98 Whole country 89 100% A
Ireland, Republic of Ireland (Roche et al, 2002)52 1997 Whole country 140 91% A
Israel Israel (EURODIAB ACE, 2000)2 1989-94 Whole country 433 100% A
Italy Italy (Green et al, 2001)3 1989-98 Lazio, eastern Sicily 255 86-99% A/B
Kazakhstan Uzbekistan (Rakhimova et al, 2002)37 X
Kyrgyzstan Uzbekistan (Rakhimova et al, 2002)37 X
Latvia Latvia (Green et al, 2001)3 1989-98 Whole country 386 100% A
Lithuania Lithuania (Green et al, 2001)3 1989-98 Whole country 638 100% A
Luxembourg Luxembourg (Green et al, 2001)3 1989-98 Whole country 84 100% A
Macedonia Macedonia (Green et al, 2001)3 1989-98 Whole country 175 98% A
Malta Malta (Schranz, 1998)53 1990-96 Whole country 90 N/A B
Moldova, Republic of Romania (Green et al, 2001)3 X
Monaco France (EURODIAB ACE, 2000)2 X
Netherlands Netherlands (EURODIAB ACE, 2000)2 1989-94 Five regions 421 96% A
Norway Norway (Joner et al, 2000)54 1989-98 Whole country 1,866 100% A
Poland Poland (Green et al, 2001)3 1989-98 Gliwice, three cities 1,175 100% A
Portugal Portugal (Green et al, 2001)3 1989-98 Algarve, Madeira 136 85-100% A/B
Romania Romania (Green et al, 2001)3 1989-98 Bucharest 227 100% A
Russian Federation Russia (Shubnikov et al, 1999)55 1992-97 Novosibirsk N/A N/A B
San Marino Italy (Green et al, 2001)3 X
Serbia and Montenegro Serbia and Montenegro (Vlajinac et al, 1982-92 Belgrade 259 90% A
1995)56
Slovakia Slovakia (Green et al, 2001)3 1989-98 Whole country 1,156 100% A
Slovenia Slovenia (Green et al, 2001)3 1989-98 Whole country 327 100% A
Spain Spain (Green et al, 2001)3 1989-98 Catalonia 1,336 94% A
Sweden Sweden (Pundziute-Lycka et al, 2002)7 1995-98 Whole country approx 1,800 96-99% A
Switzerland Switzerland (EURODIAB ACE, 2000)2 1991-94 Whole country 353 N/A B
Tajikistan Uzbekistan (Rakhimova et al, 2002)37 X
Turkey Jordan (Ajlouni et al, 1999)42 X
Turkmenistan Uzbekistan (Rakhimova et al, 2002)37 X
Ukraine Ukraine (Timchenko et al, 1996)38 1985-92 Whole country N/A N/A B
United Kingdom United Kingdom (Green et al, 2001)3 1989-98 Leeds, Oxford, Northern 3,419 95-100% A
Ireland, Leicester
Uzbekistan Uzbekistan (Rakhimova et al, 2002)37 2000 Whole country N/A N/A B
N/A not available
124

Chapter 2
Table 2.6
Estimates of type 1 diabetes in children – European Region
Incidence rates
Albania 905 3.6 0.2
Andorrab 10 12.8 0.0
Austria 1,275 9.5 0.8
Azerbaijan Republic 2,112 1.2 0.2
Belarus 1,668 5.7 0.6
Belgium 1,713 11.8 1.3
Bosnia and Herzegovina 706 3.5 0.1
Bulgaria 1,108 8.8 0.7
Croatia 815 6.6 0.3
Cyprus 175 10.5 0.1
Czech Republic 1,567 9.8 1.0
Denmark 982 19.4 1.2
Estonia 210 11.4 0.2
Finland 899 37.4 2.5
France 10,970 8.3 5.6
Georgia, Republic of 963 8.1 0.5
Germany 12,028 12.2 10.1
Greece 1,537 9.1 0.9
Hungary 1,581 9.6 1.1
Iceland 64 13.9 0.1
Ireland, Republic of 817 16.3 0.9
Israel 1,783 5.9 0.6
Italy 8,033 9.5 5.6
Kazakhstan 3,968 1.2 0.3
Kyrgyzstan 1,603 1.2 0.1
Latvia 359 7.1 0.2
Lithuania 641 7.8 0.3
Luxembourg 84 11.9 0.1
Macedonia 434 3.6 0.1
Malta 75 15.6 0.1
Moldova, Republic of 879 5.0 0.3
Monacob 5 8.3 0.0
Netherlands 2,864 13 2.5
Norway 876 22.5 1.3
Poland 6,662 6.7 3.0
Portugal 1,674 11.5 1.3
Romania 3,694 5.0 1.2
Russian Federation 22,389 7.2 12.4
San Marinob 4 9.5 0.0
Serbia and Montenegro 1,976 8.1 1.0
Slovakia 970 9.2 0.6
Slovenia 288 8.5 0.2
Spain 5,664 12.8 4.4
Sweden 1,498 28.0 3.1
Switzerland 1,139 7.9 0.6
Tajikistan 2,244 1.2 0.2
Turkey 20,561 3.2 4.1
Turkmenistan 1,793 1.2 0.1
Ukraine 7,651 8.1 3.8
United Kingdom 10,923 18.9 13.7
Uzbekistan 8,623 1.2 0.6
EUR Total 161,460 § 90.1

b. Population estimates extracted from CIA World Factbook 200210
125

Chapter 2
Table 2.7
Data sources: estimates of type 1 diabetes in children – North American Region

Anguilla Antigua and Barbuda (Tull et al, 1997)a, 57 X
Antigua and Barbuda Antigua and Barbuda (Tull et al, 1997)a, 57 1989-93 Antigua 4 100 A
Aruba Venezuela (Karvonen et al, 2000)36 X
Bahamas Cuba (Karvonen et al, 2000)36 X
Barbados Barbados (Karvonen et al, 2000)36 1990-93 Whole country 5 N/A B
Belize Mexico (Karvonen et al, 2000)36 X
Bermuda Cuba (Karvonen et al, 2000)36 X
British Virgin Islands Antigua and Barbuda (Tull et al, 1997)a, 57 X
Canada Canada (Karvonen et al, 2000)36 1990-94 Alberta, Prince 204 75-100% A/B
Edward Island
Cayman Islands Cuba (Karvonen et al, 2000)36 X
Dominica, Dominica (Karvonen et al, 2000)36 1990-93 Whole country 5 N/A B
Commonwealth of
Grenada Barbados (Karvonen et al, 2000)36 X
Guadeloupe Dominica (Karvonen et al, 2000)36 X
Guyana Venezuela (Karvonen et al, 2000)36 X
Haiti Puerto Rico (Karvonen et al, 2000)36 X
Jamaica Cuba (Karvonen et al, 2000)36 X
Martinique Barbados (Karvonen et al, 2000)36 X
Mexico Mexico (Karvonen et al, 2000)36 1990-93 Veracruz 9 100% B
St Kitts and Nevis Antigua and Barbuda (Tull et al, 1997)a, 57 X
St Lucia Barbados (Karvonen et al, 2000)36 X
St Vincent and the Barbados (Karvonen et al, 2000)36 X
Grenadines
Trinidad and Tobago Barbados (Karvonen et al, 2000)36 X
USA USA (Karvonen et al, 2000)36 1990-94 Allegheny, 607 51-100% A/B
Jefferson,
Chicago
a. Relates to 0-19 years age range
N/A not available
126

Chapter 2
Table 2.8
Estimates of type 1 diabetes in children – North American Region
Incidence rates
Anguillab 3 3.5 0.0
Antigua and Barbudab 19 3.5 0.0
Arubab 15 0.1 0.0
Bahamas 91 2.9 0.0
Barbados 53 2.0 0.0
Belize 87 1.5 0.0
Bermudab 12 2.9 0.0
British Virgin Islandsb 5 3.5 0.0
Canada 5,759 24.1 9.1
Cayman Islandsb 8 2.9 0.0
Dominica, Commonwealth of b 20 5.7 0.0
Grenadab 32 2.0 0.0
Guadeloupe 105 5.7 0.0
Guyana 228 0.1 0.0
Haiti 3,305 17.4 3.6
Jamaica 798 2.9 0.1
Martinique 84 2.0 0.0
Mexico 32,799 1.5 2.6
St Kitts and Nevisb 11 3.5 0.0
St Lucia 48 2.0 0.0
St Vincent and the Grenadinesb 34 2.0 0.0
Trinidad and Tobago 293 2.0 0.0
USA 61,383 13.8 49.2
NA Total 105,192 § 64.7

127

Chapter 2
Table 2.9
Data sources: estimates of type 1 diabetes in children – South and Central American Region

Argentina Argentina (Karvonen et al, 2000)36 1990-94 Avellaneda, Cordoba, 89 88-100% A/B
Corrientes, Tierra del
Fuego
Bolivia Peru (Karvonen et al, 2000)36 X
Brazil Brazil (Karvonen et al, 2000)36 1990-92 Sao Paulo 34 70-95% B
Chile Chile (Santos et al, 2001)58 1997-98 Santiago 61 100% A
Colombia Colombia (Karvonen et al, 2000)36 1990 Santa Fé de Bogotá 56 97% A
Costa Rica Colombia (Karvonen et al, 2000)36 X
Cuba Cuba (Karvonen et al, 2000)36 1990-94 Whole country 349 75-100% A
Dominican Republic Puerto Rico (Karvonen et al, 2000)36 X
Ecuador Colombia (Karvonen et al, 2000)36 X
El Salvador Mexico (Karvonen et al, 2000)36 X
French Guiana Venezuela (Karvonen et al, 2000)36 X
Guatemala Mexico (Karvonen et al, 2000)36 X
Honduras Mexico (Karvonen et al, 2000)36 X
Netherlands Antilles Venezuela (Karvonen et al, 2000)36 X
Nicaragua Mexico (Karvonen et al, 2000)36 X
Panama Colombia (Karvonen et al, 2000)36 X
Paraguay Paraguay (Karvonen et al, 2000)36 1990-94 Whole country 79 N/A B
Peru Peru (Karvonen et al, 2000)36 1990-91 Lima 16 88% B
Puerto Rico Puerto Rico (Karvonen et al, 2000)36 1990-94 Whole country 844 90-97% A
Suriname Venezuela (Karvonen et al, 2000)36 X
Uruguay Uruguay (Karvonen et al, 2000)36 1992 Montevideo 26 97% A
Venezuela Venezuela (Karvonen et al, 2000)36 1992 Caracas 43 N/A B
N/A not available
128

Chapter 2
Table 2.10
Estimates of type 1 diabetes in children – South and Central American Region
Incidence rates
Argentina 10,408 6.4 4.1
Bolivia 3,454 0.4 0.1
Brazil 48,424 8.0 23.8
Chile 4,322 4.1 1.1
Colombia 14,048 3.8 3.3
Costa Rica 1,326 3.8 0.3
Cuba 2,240 2.9 0.4
Dominican Republic 2,806 17.4 3.0
Ecuador 4,323 3.8 1.0
El Salvador 2,304 1.5 0.2
French Guiana 65 0.1 0.0
Guatemala 5,252 1.5 0.5
Honduras 2,782 1.5 0.3
Netherlands Antilles 52 0.1 0.0
Nicaragua 2,283 1.5 0.2
Panama 892 3.8 0.2
Paraguay 2,266 0.9 0.1
Peru 8,578 0.4 0.2
Puerto Rico 934 17.4 1.1
Suriname 121 0.1 0.0
Uruguay 837 8.3 0.4
Venezuela 8,322 0.1 0.1
SACA Total 126,041 § 40.4
129

Chapter 2
Table 2.11
Data sources: estimates of type 1 diabetes in children – South-East Asian Region

Bangladesh India (Ramachandran et al, 1992)59 X
Bhutan People’s Republic of China (Karvonen X
et al, 2000)36
India India (Ramachandran et al, 1992)59 1991 Madras 30 N/A B
Maldives India (Ramachandran et al, 1992)59 X
Mauritius Mauritius (Karvonen et al, 2000)36 1990-94 Whole country 21 35-100% B
Nepal People’s Republic of China (Karvonen X
et al, 2000)36
Sri Lanka India (Ramachandran et al, 1992)59 X
N/A not available
Table 2.12
Estimates of type 1 diabetes in children – South-East Asian Region
Incidence rates
Bangladesh 54,846 4.2 14.3
Bhutan 941 0.6 0.0
India 341,094 4.2 88.8
Maldives 135 4.2 0.0
Mauritius 296 1.4 0.0
Nepal 10,048 0.6 0.4
Sri Lanka 4,877 4.2 1.3
SEA Total 412,236 § 104.8
130

Chapter 2
Table 2.13
Data sources: estimates of type 1 diabetes in children – Western Pacific Region

Australia Australia (Craig et al, 2000)60 1990-96 New South Wales 1,591 99% A
Brunei Darussalam Thailand (Tuchinda et al, 2002)61 X
Cambodia Thailand (Tuchinda et al, 2002)61 X
China, Hong Kong Hong Kong (Huen et al, 2000)62 1984-96 Whole country 227 N/A B
China, Macau Hong Kong (Huen et al, 2000)62 X
China, People’s Republic of People’s Republic of China (Karvonen 1990-94 Twenty-one 462 69-100% A/B
et al, 2000)36 regions
Cook Islands Papua New Guinea (Ogle et al, 2001)63 X
East Timor Thailand (Tuchinda et al, 2002)61 X
Fiji Papua New Guinea (Ogle et al, 2001)63 X
French Polynesia Papua New Guinea (Ogle et al, 2001)63 X
Guam Papua New Guinea (Ogle et al, 2001)63 X
Indonesia Thailand (Tuchinda et al, 2002)61 X
Japan Japan (Karvonen et al, 2000)36 1990-93 Chiba, Hokkaido, 167 77-100% A/B
Okinawa
Kiribati Papua New Guinea (Ogle et al, 2001)63 X
Korea, Democratic People’s Republic of Korea (Ko et al, 1994)64 X
Republic of
Korea, Republic of Republic of Korea (Ko et al, 1994)64 1985-88 Seoul 71 N/A B
Lao People’s Democratic Thailand (Tuchinda et al, 2002)61 X
Republic
Malaysia Thailand (Tuchinda et al, 2002)61 X
Marshall Islands Papua New Guinea (Ogle et al, 2001)63 X
Micronesia Papua New Guinea (Ogle et al, 2001)63 X
Mongolia People’s Republic of China (Karvonen X
et al, 2000)36
Myanmar Thailand (Tuchinda et al, 2002)61 X
Nauru Papua New Guinea (Ogle et al, 2001)63 X
New Caledonia Papua New Guinea (Ogle et al, 2001)63 X
New Zealand New Zealand (Karvonen et al, 2000)36 1990-94 Auckland, 213 100% A
Canterbury
Niue Papua New Guinea (Ogle et al, 2001)63 X
Palau Papua New Guinea (Ogle et al, 2001)63 X
Papua New Guinea Papua New Guinea (Ogle et al, 2001)63 1996-2000 Whole country 8 N/A B
Philippines People’s Republic of China (Karvonen X
et al, 2000)36
Samoa Papua New Guinea (Ogle et al, 2001)63 X
Singapore, Republic of Singapore (Lee et al, 1998)a, 65 1992-94 Whole country 40 92% A
Solomon Islands Papua New Guinea (Ogle et al, 2001)63 X
Taiwan Hong Kong (Huen et al, 2000)62 X
Thailand Thailand (Tuchinda et al, 2002)61 1991-95 North, north- 191 N/A B
east, south and
central regions
Tokelau Papua New Guinea (Ogle et al, 2001)63 X
Tonga Papua New Guinea (Ogle et al, 2001)63 X
Tuvalu Papua New Guinea (Ogle et al, 2001)63 X
Vanuatu Papua New Guinea (Ogle et al, 2001)63 X
Vietnam Thailand (Tuchinda et al, 2002)61 X
a. Only to age 12 years
N/A not available
131

Chapter 2
Table 2.14
Estimates of type 1 diabetes in children – Western Pacific Region
Incidence rates
Australia 3,931 17.8 4.4
Brunei Darussalam 105 0.3 0.0
Cambodia 5,979 0.3 0.1
China, Hong Kong 1,093 1.4 0.1
China, Macau 86 1.4 0.0
China, People’s Republic of 299,371 0.6 9.3
Cook Islandsb 8 0.1 0.0
East Timor 298 0.3 0.0
Fiji 273 0.1 0.0
French Polynesia 71 0.1 0.0
Guam 59 0.1 0.0
Indonesia 64,466 0.3 1.2
Japan 18,228 1.7 1.9
Kiribatib 39 0.1 0.0
Korea, Democratic People’s Republic of 5,858 0.7 0.3
Korea, Republic of 9,576 0.7 0.4
Lao People’s Democratic Republic 2,355 0.3 0.0
Malaysia 7,785 0.3 0.1
Marshall Islandsb 36 0.1 0.0
Micronesiab 48 0.1 0.0
Mongolia 840 0.6 0.0
Myanmar 15,782 0.3 0.3
Naurub 5 0.1 0.0
New Caledonia 66 0.1 0.0
New Zealand 864 15.2 0.9
Niueb 1 0.1 0.0
Palaub 5 0.1 0.0
Papua New Guinea 2,049 0.1 0.0
Philippines 29,012 0.6 1.1
Samoa 65 0.1 0.0
Singapore, Republic of 892 2.5 0.2
Solomon Islands 221 0.1 0.0
Taiwanb 4,733 1.4 0.4
Thailand 16,775 0.3 0.3
Tokelaub 1 0.1 0.0
Tongab 42 0.1 0.0
Tuvalub 4 0.1 0.0
Vanuatu 86 0.1 0.0
Vietnam 25,090 0.3 0.5
WP Total 516,194 § 21.6

132

Chapter 2
19. Akerblom HK, Vaarala O, Hyoty H, Ilonen J, Knip M.

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134

Chapter 2
2.2 Type 2 Diabetes in the Young
Introduction type 2 diabetes. However, there are now

At a glance
also reports of type 2 diabetes occurring
It is well recognized that the global amongst Europid (White Caucasoid)
• Type 2 diabetes in
burden of type 2 diabetes is both teenagers (7). In Japan, the prevalence
the young is a global
significant and rising, with most of of type 2 diabetes amongst junior high
phenomenon, which is
the increase registered in the last school children has almost doubled from
on the increase.
two decades. From 2003 to 2025 the 7.3 per 100,000 in 1976-80 to 13.9 per
• The risk of type 2
worldwide prevalence of diabetes in 100,000 in 1991-5, with type 2 diabetes
diabetes is clearly
adults is expected to rise from 5.1% now outnumbering type 1 diabetes in
linked to an increasing
to 6.3% of the adult population, or Japanese children (8).
prevalence of obesity,
194 million to 333 million people.
which is associated
Compared to adults, there is little
with changing dietary
The largest proportional and absolute information on type 2 diabetes incidence
and lifestyle patterns.
increase will occur in developing and prevalence in the young with many
countries, where the prevalence will surveys being clinic based or case series • Studies have shown
rise from 4.2% to 5.6% (see Chapter 1). with a paucity of population-based that youth with type
In India and China the adult diabetic surveys, particularly outside North 2 diabetes will also
population is expected to double by America (4) and Japan (8). Similarly, unlike develop diabetes-
2025 to about 73 million in India and 46 adults, information on the natural history related micro- and
million in China. By 2025, type 2 diabetes and aetiology of type 2 diabetes in the macrovascular
prevalence is expected to reach 2.8% of paediatric age range is also sparse. Other complications,
the adult population in Africa and 7.2% in deficiencies include a lack of uniformity as with adults.
South and Central America. in case definition, data collection and • The increasing
follow-up, with the diagnosis often made prevalence of type 2
In 1990 it was estimated that 0.2% of retrospectively (9). diabetes in the young
the total global diabetic population may be blunted by
of 118 million was under 15 years Despite these weaknesses, it is now encouraging more
of age (1). The prevalence of type 2 becoming recognized that type 2 diabetes physical activity, and
diabetes increases with age and affects in children is becoming a global public changing dietary
some 17% of all 65-74 year olds in the health issue with potentially serious habits.
US, and a similar proportion in other health outcomes (10). In response to this
countries, such as Australia (2-4). the American Diabetes Association (ADA)
Amongst the young, type 2 diabetes is has issued a consensus statement on the
thought to account for 2-3% of all types screening, diagnosis and treatment of
of diabetes. This, however, is likely to children with type 2 diabetes (5).
be an underestimate as, depending on
the study, 8-45% of recently diagnosed The impact of misclassification
diabetes in the young in the US is due There may be underestimation in type 2
to type 2 diabetes (5). Data from the diabetes rates due to a misclassification
third National Health and Nutrition of the type of diabetes at initial
Examination Survey (NHANES III) in the presentation. The presence of diabetic
USA indicates that 16 million Americans ketoacidosis (DKA), or diabetic coma,
have type 2 diabetes (2). is classically a manifestation of type 1
diabetes. However, a number of reports
There are ever increasing reports of type have shown that DKA may occur at
2 diabetes in children worldwide, with initial presentation in patients who are
some as young as eight years of age eventually found to have type 2 diabetes.
being affected (6). These are mostly in That is, they have elevated C-peptide
ethnic groups known to be at high risk of and an absence of islet cell or anti GAD
135

Chapter 2
antibodies (4). This type of presentation reported in Asians, Hispanics, indigenous

has also been termed Flatbush (11,12), or peoples (USA, Canada, Australia) and
atypical diabetes mellitus (ADM) (13). African Americans, with some of
the highest rates in the world being
Unlike type 1 diabetes, most children observed amongst Pima Indians (19,20).
with type 2 diabetes are asymptomatic, For instance from the period 1967-76
however, approximately a third present to 1987-96 the prevalence of type 2
with ketonuria (an excess of ketones in diabetes in Pimas increased four to
the urine) (14). One study found DKA six-fold, reaching a prevalence of
occurred in 4.2% of all patients attending 22.3 per 1,000 for 10-14 year olds and
a paediatric clinic, all of whom were 50.9 per 1,000 for 15-19 year olds by
of Canadian aboriginal descent (15). A 1992-96 (14).
case series examining African American
adolescents found that up to 42% Obesity, diet and inactivity
presented with ketonuria and 25% with On a global basis the rise in type 2
DKA (16). Similarly another report has diabetes rates seems to mirror the
shown that some 30% of Hispanic youth growth in urbanization and economic
with type 2 diabetes can present with development and may be due to
ketosis (17). Why type 2 diabetes can maladaptation to a rapidly changing
present with ketosis and in particular why environment (21,22). Closely associated
this presentation is more likely to occur with this is the increase in overweight
in African Americans or Hispanics is not and obesity.
clear (18).
Obesity has been linked to changing
Possible factors in type 2 patterns in diet and physical activity
levels (23,24). Allied to this are studies
diabetes development
from Japan which have demonstrated a
Ethnicity parallel rise in type 2 diabetes incidence
Ethnicity is an important factor in type 2 in children and levels of obesity from
diabetes development in both adults 1975 to 1995 (8) as shown in Figure
and children with higher rates being 2.2. Of note is that over this time period
there have also been significant increases
in fat and animal protein intake among
Figure 2.2 Japanese youth, now mirroring the
Annual incidence of type 2 diabetes and prevalence kind of westernized diets consumed by
of obesity among Japanese school children Japanese-Americans (25).
(from Kitagawa T et al, 1998 (8))
Dietary changes are not only confined
�� to the home environment. A survey of
��
��
Californian public schools found that 85%
��
sold fast food, which in turn accounted
�� for 70% of all food sales (26). Of concern
is that almost 70% of school districts
��
allowed advertising on campus, with 24%
�� allowing advertising in exchange for cash
or equipment.
��
��
�� The prevalence of obesity among

Japanese children has increased from
�� 5% in 1976 to 8% in 1992 and is similar
to data reported from the United States
��
(27). In the USA, the National Longitudinal
136

Chapter 2
Survey of Youth, which is a prospective well as the adoption of a more sedentary

cohort study conducted from 1986 to life with a westernized diet are thought
1998, showed that over this time period to contribute to rising obesity levels (34).
the overweight prevalence increased Currently some 85% of children with type
annually by 3.2% in non-Hispanic whites, 2 diabetes are either overweight or obese
5.8% in African Americans and 4.3% at diagnosis (5).
in Hispanics. Thus by 1998, 21.5% of
African Americans, 21.8% of Hispanics Inactivity is one of the major contributors
and 12.3% of non-Hispanic whites were to being overweight. In the developed
overweight (28). world, use of computers and increasing
time spent in front of the television
A more recent study of nearly 5,000 are some of the factors impacting on
children in the USA has shown that activity (24, 29).
during 1999-2000, 15% of 6-19 year
olds were overweight, compared to A recent longitudinal study showed a
11% in 1994-98. The biggest rises marked decline in physical activity in
were recorded in African American and adolescent girls with 56% of black and
Mexican American adolescents (29). This 31% of white girls aged 16-17 years
study also showed that the prevalence having no habitual leisure-time physical
of being overweight (BMI ≥25) reached a activity (35). Pregnancy, cigarette
staggering 65% in US adults. Increasing smoking, higher BMI and lower parental
obesity is also a problem elsewhere, with education at baseline were all associated
a recent study from Australia examining with a subsequent decline in physical
children aged 7-15 years, reporting that activity. Another study highlighting racial
the prevalence of obesity has increased differences in physical activity levels
two to four-fold from 1985 to 1997 (30). found that white students in the USA
have generally higher physical activity
The problem of obesity also extends to levels than other ethnic groups, with
developing nations, particularly in the boys usually more active than girls,
more affluent urban areas. In India, a whatever the race (36).
recent study found that the age adjusted
prevalence of being overweight among A lifestyle predisposing to obesity and
13-18 year olds was around 18%. type 2 diabetes seems to characterize
Prevalence rates increased with age and families with adolescents who have
decreasing physical activity and with type 2 diabetes, according to a study by
higher socio-economic status (31). Other Pinhas-Hamiel et al. Specifically the study
factors also thought to be important showed that members of such families
amongst Indian Asians are low birth tend to be overweight, inactive and have
weight and insulin resistance (22). a tendency to high fat intake and even
binge eating (37). Overall in the USA, only
Obesity is also being increasingly 50% of young people aged 12-21 years
observed in indigenous populations, are regularly involved in physical activity,
such as the Objiwa-Cree community in with some 25% admitting to no physical
Canada, where a study found that 48-51% activity at all. Even in schools there is
of children aged 4-19 years have a weight a decline in physical education, with
more than the 90th percentile (32). participation rates down from 41.6% in
Similar reports have come from other 1991 to 24.5% in 1995 (38).
communities such as indigenous
Australians, with obesity rates of up to Insulin resistance
86% (33). Changes in traditional lifestyles The onset of type 2 diabetes is frequently
among indigenous communities such as reported around puberty and is thought
a reduction in hunting and gathering as to coincide with the physiological rise
137

Chapter 2
in insulin resistance (IR) associated with resistance and is reported to occur in

puberty, where insulin sensitivity may be up to 60-90% of young people with
reduced by as much as 30% (9). Healthy type 2 diabetes (19). This seems to be
young adolescents compensate for the especially true for African Americans
peri-pubertal rise in IR by increasing and some Native Americans, but so far
insulin secretion as they have normal not demonstrated in other populations
pancreatic beta cell function. This is not such as in Japan (25). However, despite
the case with adolescents with type 2 its ubiquitous occurrence in some
diabetes, where both insulin action populations with type 2 diabetes, it
and eventually beta cell function are should not exclusively be used as a
impaired (5). reliable marker of hyperinsulinaemia and
insulin resistance.
There appear to be ethnic differences in
insulin resistance, with African American In a study conducted by Nguyen
children being more hyperinsulinaemic et al, only 35% of obese children with
(having high levels of insulin in the hyperinsulinaemia had AN, whether black
blood) and insulin resistant than Europids or white (44). Similarly a recent survey
(39). Similarly, the Bogalusa Heart Study of obese Hispanic children (BMI ≥95th
has shown that compared to Europids, percentile) found that there was no
African Americans (especially girls) had association between AN and markers of
higher insulin levels and insulin:glucose insulin resistance. In contrast, acanthosis
ratios (40). nigricans was associated with BMI but
negatively with birth weight (45).
Further, a recent study has shown
that compared to Europids, African Polycystic ovary syndrome
American children have a combination Polycystic ovary syndrome (PCOS) is
of both lower insulin clearance and associated with menstrual irregularities,
higher insulin secretion (41). Using a infertility and a state of insulin resistance
frequently sampled intravenous glucose (46). It is also said to affect up to 5-10%
tolerance test, both African American of females in their reproductive years (47)
and Hispanic children demonstrated and is thought to predispose to glucose
greater insulin resistance than Europid intolerance, with studies showing up
children (42). Further analysis showed to 30-40% being affected by impaired
no ethnic differences in the first phase glucose tolerance (IGT) and up to 7-10%
insulin secretion. However, second with type 2 diabetes (46, 48, 49).
phase secretion was significantly higher It may explain why there are more
among Hispanics compared to African females with type 2 diabetes amongst
Americans, due to lower hepatic insulin adolescents (9, 46).
clearance among African Americans.
Family history
Insulin resistance may be lowered by Many studies show a strong family
simple means such as increasing activity history among affected youth with
levels. This has been demonstrated in 45-80% having at least one parent with
obese children and more recently in non- diabetes and 74-100% having a first
diabetic, normal weight children (43), or second degree relative with type 2
where the more active children had diabetes (5, 50). Children with diabetes
lower fasting insulin and greater insulin are also more likely to have a family
sensitivity. history of cardiovascular disease (CVD),
with one study showing that up to
Acanthosis nigricans 28% have a positive family history of
Acanthosis nigricans (AN) is thought CVD (51).
to be a physical marker of insulin
138

Chapter 2
The Bogalusa Heart Study (52) has shown size, leading to low birth weight and
that children of individuals with type 2 hence later development of insulin
diabetes were more likely to be obese resistance (61-64).
and have higher blood pressures, fasting
insulin, glucose and triglycerides. In a Two recent studies challenge this. First,
study among Pima Indians, it was shown a study examining 300 five-year old
that the cumulative incidence of type 2 British children found that girls were more
diabetes was highest in offspring if both insulin resistant than boys, and insulin
parents had diabetes (53). resistance was not related to birth weight
(65). The second is a study from Belgium
Intrauterine environment (66), which examined twins aged 18-35
Apart from genes, the intrauterine years and found that among twin pairs
environment may be important as there discordant for birth weight, there was
is evidence of higher rates of type 2 little evidence that the lighter twin had
diabetes in offspring of mothers who abnormal glucose-insulin metabolism in
develop gestational diabetes (GDM) adult life. Low pre-pregnancy maternal BMI
(54). A prospective study by Silverman and older maternal age at delivery were
et al found that the prevalence of IGT in independently associated with insulin
the children of mothers with a diabetic resistance in the offspring. These findings
pregnancy increased with time from 1.2% suggest that maternal factors may be
at less than five years of age to 19.3% at more important than feto-placental factors
10-16 years of age. This was compared to in determining glucose-insulin metabolism
2.5% in control subjects. in the offspring.
In addition, higher levels of amniotic fluid Methods

insulin (AFI) measured at 33-38 weeks
gestation was a strong predictor of later A Medline search was conducted using
IGT (55). AFI is also thought to correlate Ovid (medical information service) of
with later childhood obesity (56), which papers written in the English language
in turn may lead to later type 2 diabetes from 1965-2002.
development.
Key words used were: Diabetes, diabetics,
Birth weight is strongly influenced by non-insulin dependent diabetes, type II
the intrauterine environment, particularly diabetes, impaired glucose tolerance,
in diabetic pregnancies, which can be insulin resistance, child, childhood,
associated with high birth weight (57). young, adolescence, overweight, obesity
Conversely there is also evidence that and polycystic ovary syndrome.
low birth weight can result in later adult
type 2 diabetes development (58). The keywords related to diabetes were
This is most likely due to poor maternal combined with those related to children
nutrition leading to impaired islet cell and then further combined with terms
development (57, 59), but may also related to obesity and then finally with
occur in a number of other conditions polycystic ovary syndrome.
such as pregnancies complicated by
hypertension/pre-eclampsia, which is not All available studies with relevant data
an uncommon condition complicating up have been included and have been
to 3-5% of all pregnancies (60). grouped by study type (population
based, case reports, case series and
There is a hypothesis that insulin clinic based). These have further
resistance is a product of fetal been divided into the IDF regions of
programming and that gestational Africa (AFR), Eastern Mediterranean and
metabolic perturbations affect fetal Middle East (EMME), Europe (EUR), North
139

Chapter 2
America (NA), South and Central America of Africa (79-82), studies found are few
(SACA), South-East Asia (SEA) and Western and in most examples conducted some
Pacific (WP). 15 years ago.
Studies which include subjects 20 years Africa

of age and under have been selected. Five studies were found and included
However, data are presented for studies two from west Africa (79, 81) and three
which have given higher age ranges but from east Africa (80, 82, 83). All but
which include subjects less than 20 years one, which looked only at Indians (83),
of age within those ranges. In these cases showed a zero or low prevalence of
it has not been possible to separate those diabetes. Apart from the study examining
under 20 from the information given. Indians, all the others were conducted
in the 1980s. Therefore taking into
Most papers have been published in account the current information on
peer review journals but a number are in type 2 diabetes rates around the world,
abstract form. These are no more than the results for Africa are probably an
three years old. underestimate and may not represent the
contemporary situation.
Results
Eastern Mediterranean and
Results are reported as presented in Middle East
the original papers, unlike in the adult A large study of some 25,377 individuals
diabetes and childhood type 1 diabetes aged 2-77 years was conducted in Saudi
sections (see Chapters 1.1 and 2.1 Arabia by el-Hazmi et al (78). The figures
respectively) in which figures have been for those less than 29 years of age have
calculated for the national population. been selected. In the under-14 year age
group, IGT prevalence was double that
In some of the studies used, the of type 2 diabetes (0.25% versus 0.12%).
prevalence of type 2 diabetes in the The opposite was true for the 14-29
general population (child and adolescent) year age group, where type 2 diabetes
was determined from a representative outnumbered IGT almost 3:1 (0.79% for
population-based sample (67). However, type 2 diabetes versus 0.21% for IGT).
many studies have simply reported a
series of cases, sometimes supplemented North America
by a calculation of the prevalence in Unlike other regions, data from North
the general population, using estimated America on type 2 diabetes and IGT
figures for the size of the population prevalence are more extensive and
from which the cases were drawn (68), or recent. The ethnicity of the study
examined only a specific sub-population, subjects is diverse with many including
such as from a diabetes registry (69-72) African Americans, Mexican Americans
or an obesity clinic (73-77). and non-Hispanic white Americans in the
same study.
Population-based studies
In general, it is very difficult to compare A study from Texas in 1981 examining
the studies due to wide differences 15-24 year old Mexican Americans found
in study design. Population-based no type 2 diabetes in males and only a
studies were found from all regions low prevalence of 0.4% in females (84).
except Europe, and South and Central By 2002, a study surveying Mexican
America. Apart from studies from Japan American fourth graders found not only
(8) and Saudi Arabia (78), many of the an overall type 2 diabetes prevalence
other papers only examined relatively of 0.3%, but also cases of IGT (0.14%)
small numbers of people. In the case and impaired fasting glucose (IFG)
140

Chapter 2
(0.14%) (85). In contrast another study A study from Chenai in south India (90),
has reported relatively high rates of conducted eight years ago, found a zero
type 2 diabetes (1.5%) and IFG (10.8%) prevalence rate for type 2 diabetes.
in a population of Europids and African This may, however, be an underestimate
Americans (86). This study, however, given the recent worldwide rise in type 2
is ongoing with some 50% of recruited diabetes in children.
subjects still to have an oral glucose
tolerance test (OGTT). The true rates of Western Pacific
IFG and type 2 diabetes may change once Studies from Japan (8) and Taiwan (93)
the full picture is known. were identified in the Western Pacific
area. The largest study reported is from
North America: Japan (8), with some seven million youth
Indigenous/First Nation being studied between 1976 and 1997.
A study, which examined Pima Indians Over this time type 2 diabetes incidence
since 1967, demonstrated rising rates increased 10-fold in primary school
of glucose intolerance over time, as well children: 0.2 per 100,000 per year from
as a female preponderance (87). From 1976 to 1980 versus 2.0 per 100,000 per
1967-76 to 1987-96 the prevalence of year from 1991 to 1995. Similarly over
type 2 diabetes markedly increased from the same time period, type 2 diabetes
2.4% in males and 2.7% in females to incidence doubled among junior high
3.8% in males and 5.3% in females. A school children: 7.3 versus 13.9 per
female preponderance of type 2 diabetes 100,000 per year.
of almost 4:1 among Navajo subjects was
also found in another study (88). A cohort of indigenous Australian
children aged 7-18 years was surveyed
A study of American Indian and Alaskan in 1989 and again in 1994. Over the five
Native adolescents reported that the years, the prevalence of type 2 diabetes
prevalence of type 2 diabetes increased almost doubled to 1.3%, while that
by 68% from 1990 to 1998 among those for IGT increased almost seven-fold to
aged 15-19 years (0.32% to 0.54%) (20). 8.1% (94). At the follow-up, 18% of the
In addition although the prevalence population were overweight or obese.
of type 2 diabetes was higher among In addition one-third of the children had
females, the relative increase over this elevated cholesterol levels, with almost
time period was greater among males half reporting alcohol use and smoking.
(0.23% to 0.41% for males versus 0.42%
to 0.68% for females). Even though the In contrast to the Australian study, the
overall prevalence among under-15 Tongan study (95) examining 15-19 year
year olds remained the same at 0.12%, olds found no glucose intolerance in that
there was regional variation, and Alaska population.
recorded the biggest rise of 114% (0.04%
to 0.09%). Case reports
Although there are case reports of type 2
From Canada, greater rates for IFG (2.6%) diabetes in the young from a number
compared to type 2 diabetes (1.1%) were of countries (96), only two (both from
found among Cree-Objiway subjects, but the UK) have been included. These were
no female preponderance (89). included for two reasons. First, there
has so far been little available data from
South-East Asia the UK and secondly, one of the reports
Studies in the South-East Asian Region includes Europids (7), who until now
were identified from India (90) and have been thought to be at low risk of
Bangladesh (91, 92). developing childhood type 2 diabetes.
141

Chapter 2
In the other report (97), all the subjects These studies have also shown an
were female and of Indian/Pakistani Asian increase in incidence rates. One
or Arab origin. They were all obese and study (69) found that type 2 diabetes
with a strong family history of diabetes. incidence rates rose by 9% per year from
Three out of the eight children had 1985 to 1994, reaching 3.8 per 100,000
polycystic ovary syndrome. The finding per year by 1990-94, while another
of being overweight and having a strong study (101) found a 10-fold increase in
family history is also a feature in the type 2 diabetes incidence rates from 0.7
report by Drake et al (7). However, here per 100,000 per year in 1982 to 7.2 per
the subjects are all Europid, with only one 100,000 per year in 1994. Yet another
having PCOS. study (102) reported that in 1994, 9.4%
of new cases of diabetes were due to
Clinic/register-based studies type 2 diabetes, rising to 20% by 1998.
Clinic and register-based studies make up Similarly, Likitmaskul et al (67) reported
the largest group of studies conducted a rise from 5% to 17% from 1997 to 1999
on youth IGT and type 2 diabetes. They in the proportion with type 2 diabetes
reveal type 2 diabetes occurring in referred to a diabetic clinic.
children as young as under the age of
five years (98). In addition, they have A study from 1989 to 2001 from a clinic
demonstrated a female preponderance in Hungary (103) also reported rising
(33, 70, 71, 99), strong family history incidence rates over time with 57% of
(70, 100, 101), obesity (6,67,70,99-101) all type 2 diabetes and 77% of all IGT
and acanthosis nigricans (6,67,99,101).
Profile: Chul Hee Han
Chul Hee Han, 15, was born in Seoul, South Korea and
moved to Australia in 1994 when he was seven years
old. James, as his friends call him, was diagnosed with
type 2 diabetes at 14 when his mother noticed that he
was gaining weight, especially around his middle.
His only medical problem had been an operation at the

age of five months for a twisted bowel but apart from
this, his childhood had been a healthy one. James’ father
died when he was only four years old and he has little memory of his father. James’ mother
tells of her husband who was a big man and who developed type 2 diabetes at the age of 28.
Little treatment was given and he died of a heart attack at 32 years of age. The family then
moved to Australia to be with relatives, and became Australian citizens.
On noticing his weight gain, James’ mother wanted to have him checked out for diabetes
because of the family history. This led to an oral glucose tolerance test being done and the
two-hour blood glucose level of 17.2mmol/l was diagnostic of diabetes. Other tests ruled
out the possibility of this being type 1 diabetes and James was started on treatment for
142

Chapter 2
diagnosed in the last six years of the IGT prevalence of 23% in subjects
13-year study. pre-selected for obesity. More recently,
Sinha et al (76) selected subjects whose
Incidence rates also rise with age, with weight was more than the 95th percentile
one study (98) demonstrating that 15-19 for age and sex attending an obesity
year olds with rates of 5.9 per 100,000 clinic and found similar rates of IGT: 25%
per year have three times the rate in 4-10 year olds and 21% in 11-18 year
compared to 10-14 year olds with rates olds.
of 1.8 per 100,000 per year.
A study by Ciampalini et al (77) from Italy
Although a population-based study have reported similar rates of 24%, but
from south India eight years ago (90) others have not been able to reproduce
found no cases of diabetes, a very these results from their study population
recent clinic-based study (99), also from of obese youth, with Uwaifo et al (75)
Chenai, diagnosed 18 cases of type 2 from USA and Invitti et al (104) from
diabetes among children aged 9-15 years. Italy reporting much lower rates of 4.1%
Common factors noted in this group were and 4.5% respectively for IGT. Another
female preponderance, family history and study from Western Pacific also found
obesity. lower rates of IGT (4.3%) in young obese
subjects (73).
A number of studies have pre-selected
subjects for obesity, AN or PCOS. The cause for the discrepancy in results
One study (74) in 1965 found an is unknown but has been suggested to
type 2 diabetes. He now does three blood tests a day and takes a tablet to control his blood
glucose levels. He goes to the clinic every three months for a check-up. Says James: “I worry
that my diabetes may get worse and that complications may occur. The blood glucose tests
are not much of a bother and I have learnt to take my tablets every day before breakfast.”
James has continued life as before as far as school and sport is concerned, he does everything
that his friends do. But he has become very careful when it comes to eating. His mother packs
his lunch and he does not buy food from the tuck shop. He only rarely has fast food and
avoids any junk food. “I don’t do any special sports nor do I weigh myself at home but I look
after myself,” says James. “I think about my diabetes almost every time I eat and try not to
eat too much. My teachers don’t know that I have diabetes and I have only told my two best
friends.”
James, who is in year 10 of high school, attends a selective school for high achievers in an
outer suburb of Sydney. He has known that he wants to become a dentist all his life. His
mother and his relatives worry about James. “We are careful with food and stick to a Korean
diet. We only choose the low fat recipes and use olive oil for cooking,” says his mother. “We
pray for the diabetes to go away.”
143

Chapter 2
be due to referral bias in the study by with type 2 and 20.2% of those with
Sinha et al (76) in favour of children who type 1 had nephropathy.
are extremely obese (75). Another reason
could be the contribution of PCOS. Of Yet another study (109) looked at
note is that 40% of the subjects with IGT incidence of retinopathy and nephropathy
in Sinha et al’s (76) study had PCOS. In among Pima Indians diagnosed with
addition Sinha et al reported a type 2 type 2 diabetes at under 20 years of age
diabetes prevalence of 3.6%, all of whom (youth), 20-39 years (young adults) and
were non-Hispanic Black or Hispanic, 40-59 years of age (older). At less than
while Invitti et al noted a much lower five years duration of type 2 diabetes,
prevalence of 0.1%, among Europids. nephropathy was present in all age
groups (incidence/1,000 person years:
Studies pre-selecting for PCOS have 13/1,000 youth, 8/1,000 young adults
demonstrated significant rates of glucose and 7/1,000 older). However, retinopathy
intolerance. One study (47) reported an only appeared among those with youth
IGT prevalence of 26.9% while another onset diabetes after 5 to 10 years
(105) found a rate of 13%. However, both duration (incidence/1,000 person years:
studies report lower prevalences of type 10/1,000 youth, 29/1,000 young adults
2 diabetes of 3.7% and 0.0% respectively. and 35/1,000 older).
Brickman et al (106) have conducted These studies have important

one of the few studies pre-selecting for implications in that they highlight the risk
the presence of AN and report an IGT of complications occurring at a relatively
prevalence of 24% in subjects with AN. young age and as in the case of the Pima
They suggest that children with AN may Indian study, that these complications
benefit from diabetes screening and can occur relatively soon after diagnosis.
early intervention. However, AN is not a This will place a significant burden on
universal phenomenon in children with health budgets as well as society as a
type 2 diabetes, and has so far not been whole. This is particularly so because
noted to any degree among the large these people would be entering their
studies surveying Japanese youth (8). peak working and earning capacity. Early
detection and intervention is therefore
Diabetic complications essential to reduce the risk of future
complications.
As with adults it is expected that
youth with type 2 diabetes will also Discussion
develop diabetes-related micro- and
macrovascular complications. This was Compared to adults there is a paucity of
reported recently in a study from Canada information on both the epidemiology
(107), where subjects who developed and natural history of type 2 diabetes
type 2 diabetes as children were then in the young. This needs to be urgently
surveyed as young adults, aged between addressed given the potential threat of an
18 and 33 years. Of the 51 subjects, 9% explosion in childhood type 2 diabetes.
had died, 6% were on dialysis while one
had a toe amputation and one was blind. There are only a few large scale
population-based studies focusing on
Another follow-up study from Japan (108) youth with type 2 diabetes. Most of the
compared those with type 1 and type 2 information available comes from case
diabetes diagnosed at under 30 years series or clinic-based studies, together
of age for development of nephropathy. with some case reports. On a global
After 30 years of diabetes, 44% of those basis, the majority of data come from
144

Chapter 2
developed countries, particularly North and it is possible that it may partly

America and Japan, with a distinct lack explain the female preponderance
of information from many regions in the in youth onset type 2 diabetes.
world, particularly from Africa and South Future work may need to address the
America. issue of PCOS, especially since it is
amenable to treatment.
Notably, there is also a lack of 6 Studies have shown that youth
standardization in study methods, with with type 2 diabetes will also
many surveys only examining small develop diabetes-related micro- and
numbers of subjects, as well as using macrovascular complications, as with
different diagnostic methods and criteria. adults. These studies have important
In addition some studies have only implications in that they highlight
looked at very high risk subjects, such the risk of complications occurring
as those with PCOS (47), presence of AN at a relatively young age, which will
(106), or obesity (76). This can make place a significant burden on health
comparisons between studies difficult. budgets as well as society as a whole.
7 The increasing prevalence of type 2
Conclusion diabetes in the young may be blunted
by encouraging more physical activity
Despite apparent deficiencies in research, and changing dietary habits.
we can still make some valid conclusions 8 Interventional programmes should
regarding type 2 diabetes in the young: be implemented to address the
underlying cause, with an emphasis
1 It is a global phenomenon, which is on diet, weight, exercise and lifestyle
on the increase. issues.
2 Children are being affected in both
developed and developing nations. It is recognized that in an ideal world
3 Reports are appearing that show its it would be possible to implement the
existence in populations hitherto proposed recommendations. In reality
thought not to be at risk, such as this may be difficult given the poor
British Europids. economic condition that many have
4 The risk of type 2 diabetes is clearly to endure and the already tight health
linked to an increasing prevalence of budgets governments have to deal with.
obesity, which is in turn associated However, many regions of the world are
with changing dietary and lifestyle progressing economically and hence
patterns. In particular an increase in becoming more urbanized.
fatty foods as well as a reduction in
activity levels both at home and in A consequence of urbanization is the
the school. The change in lifestyle is parallel emergence of cardiovascular
a worldwide phenomenon, occurring disease and diabetes, which hitherto,
in both developed and emerging was mainly a problem of the developed
nations, where it is most prevalent in world (see Chapter 3). Governments,
urban areas. In these nations as well therefore, will be forced to deal with the
as among indigenous communities problem of type 2 diabetes in children.
residing in developed nations, there As such, it would be better to address
seems to be a gradual abandonment the problem as a public health issue
of traditional ways of living in favour under the heading of primary care and
of a ‘westernized’ lifestyle. prevention, rather than dealing with the
5 A number of studies have noted an consequences of an entrenched condition
association between type 2 diabetes and its complications in a young
and polycystic ovary syndrome. Not population.
all studies look for this condition
145

Chapter 2
Table 2.15
Type 2 diabetes and impaired glucose tolerance in the young – population-based studies
Region Country Author Year of study Ethnicity Age (yrs)

AFR
Mali Fisch et al, 198781 1984-1985 Mixed tribal 15-24
Tanzania McLarty et al, 198982 1988 African 15-24
Ahren et al, 198480 1982-1983 African ≤19
Ramaiya et al, 199183 Indian 15-24
Togo Teuscher et al, 198779 1987 Mixed tribal <20

EMME
Saudi Arabia el-Hazmi et al, 200078 1998 Arab 2-29
NA
Canada Dean et al, 199889 1996-1997 Cree-Ojibway 4-19
Delisle et al, 1993110 1989 Algonquin 15-20
Harris et al, 1997111 1996 Cree-Ojibway 10-19
USA Harrell et al, 200286 2001-2002 Caucasian 69% 10-15
African American 24%
Hale et al, 200285 2002 Mostly Mexican 4th grade
American
Hanis et al, 199684 1981-2002 Mexican American 15-24
Chavez et al, 2002112 2002 N/A 15-19

Freedman et al, 199788 1991-1992 Navajo 12-19
Dabelea et al, 199887 1987-1996 Pimas 5-19
Acton et al, 200220 1990-1998 American Indian and ≤19

Alaskan native
Kim et al, 1999113 1999 Navajo 13-20

SEA
Bangladesh Sayeed et al, 199592 1995 South Asian rural 15-29
Sayeed et al, 199791 1997 South Asian urban 15-19
India Bai et al, 199590 1994 South Asian 5-19
WP
Australia Braun et al, 199694 1989 Indigenous 7-18
Australia Daniel et al, 1999114 1987-1995 Indigenous 15-24
Japan Kitagawa et al, 19988 1991-1995 Japanese <15
Taiwan Chuang et al, 200293 1993-1999 South-East Asian 6-18
Tonga Colagiuri et al, 200295 1998-2000 Polynesian 15-19
DM type 2 diabetes
FBG fasting blood glucose
FCG fasting capillary glucose
FPG fasting plasma glucose
IGT impaired glucose tolerance
N/A not available
OGTT oral glucose tolerance test
RBG random blood glucose
146

Chapter 2
Prevalence (%) DM incidence

Diagnostic method Sample size DM IGT per 100,000 per year
FCG 2,558 0.39

OGTT 1,178 0.4 6.7
OGTT 1,327 0.15
OGTT 156 Male 0.0 Male 2.3
Female 0.0 Female 4.2
OGTT 864 0.0
OGTT 9,917 (<14) <14 = 0.12 <14 = 0.25

14-29 = 0.79 14-29 = 0.21
FBG 717 1.1 2.6

OGTT 106 1.9
OGTT 244 3.0 10.0
FPG 668 1.5 10.8
OGTT 1,417 0.3 0.14
OGTT 729 Male 0.0

Female 0.4
RBG 778 0.13
OGTT 160 Male 3.0 Male 3.0
Female 13.0 Female 13.0
OGTT 3,098 5-9 years: Male 0.0
Female 0.0
10-14 years: Male 1.5
Female 2.9
15-19 years: Male 3.8
Female 5.3
Chart review <15 years: 0.12
15-19 years: 0.54
Male: 0.41
Female: 0.68
OGTT 234 0.42 3.4
OGTT 371 0.5 5.7

OGTT 271 0.06 0.04
OGTT 3,515 0.0
OGTT 74 1.3 8.1

OGTT 1,070
Annual urinalysis. 386,000 Primary school 2
If glycosuria x2, then OGTT Junior high school +13.9
Semi-annual urinalysis. 3x106 Male 0.009
If glycosuria, then OGTT Female 0.01
OGTT 59 0.0
147

Chapter 2
Table 2.16
Type 2 diabetes in the young – case reports
Year of Diagnostic Type 2 cases

Region Country Author study Ethnicity Age (yrs) method (No.)
EUR
United Kingdom Ehtisham et al, 200097 2000 South Asian/Arab 9-16 Chart review Female 8.0
United Kingdom Drake et al, 20027 2002 Caucasian 13-15 Chart review Male 3.0
Female 1.0
Table 2.17
Type 2 diabetes in the young – case series

EMME
Libya Kadiki et al, 199698 1981-1990 Arab ≤19
United Arab Emirates Punnose et al, 2002115 1990-1998 Arab ≤18
EUR
United Kingdom Ehtisham et al, 200171 1993 Mixed <18
Ehtisham et al, 200171 1999-2000 Mixed <18

NA
Canada Harris et al, 199670 1978-1994 Cree-Ojibway <16
Dean, 1998116 1996 First Nation 5-14

USA Jones, 1998117 1993-1998 Mexican American 67% 5-17
Lipton et al, 200269 1985-1994 African American ≤17
Latino
Pihoker et al, 19986 1998-1995 African American 8-21
Caucasian
Hispanic
Macaluso et al, 2002102 1994-1998 Hispanic 5-19
African American
WP
Australia Davis et al, 200233 1990-2002 Mixed <15
Sinha et al, 200050 1999-2000 Indigenous 6-16
* Calculated using an estimate of the total at-risk population.
DM type 2 diabetes
N/A not available
148

Chapter 2
Type 2 cases Prevalence * DM incidence *

Diagnostic method Source of cases (No.) (%) per 100,000 per year
Chart review Diabetes register and hospital 0-4 years: 0 N/A 5-9 years: 0.1
clinic 5-9 years: 1 10-14 years: 1.8
10-14 years: 11 15-19 years: 5.9
15-19 years: 30
Chart review Hospital clinic Male 1 N/A
Female 4
Chart review Paediatric clinics Male 2 0.004 N/A

Female 15
Chart review Paediatric clinics 4 N/A DM 1.52
Chart review Diabetes register Male 1 Male 0.07 N/A

Female 14 Female 0.42
Total 0.25
Chart review Diabetes register 15 0.77 N/A
OGTT or Sustacal challenge test Medical centre and clinics 18 N/A N/A
Chart review Diabetes register N/A N/A DM 3.8
Chart review Diabetes clinic 37 N/A N/A

12
1
Chart review Diabetes clinic 92 14 N/A
Chart review Paediatric centre Male 12 N/A N/A

Female 25
Chart review/OGTT Diabetes clinic 20 N/A N/A
149

Chapter 2
Table 2.18
Type 2 diabetes and impaired glucose tolerance in the young – clinic-based studies

EUR
Hungary Korner, 2002103 1989-2001 Caucasian ≤19
Italy Invitti et al, 2003104 1994-2001 Caucasian 6-18
Ciampalini et al, 200277 N/A Caucasian 3-19
United Kingdom Barrett et al, 2002118 2000 Mixed <16
NA
USA Paulsen et al, 196874 1965 Mixed 4-16
Legro et al, 1999105 1983-1991 Mixed 14-20
Pinhas-Hamiel et al, 1996101 1984-1994 African American 68% ≤19
White 32%
Neufeld et al, 199817 1990-1994 Mexican American <17
Uwaifo et al, 200275 1996-2002 Caucasian 6-11
African American
Sinha et al, 200276 1999-2001 Caucasian 58% 4-18
Hispanic 19%
African American 23%
Brickman et al, 2002106 1999-2002 Mixed Mean 11.9
Palmert et al, 200247 2001 Mixed 13-19
SEA
India Ramachandran et al, 200399 2002-2003 Indian Asian 9-15
WP
Singapore, Republic of Lee et al, 199973 1999 Malay 42% ≤15
Indian 28%
Chinese 33%
Thailand Likitmaskul et al, in press67 1997-1999 South-East Asian <15
New Zealand McGrath et al, 199972 1978-1998 Maori DM onset before 30
AN acanthosis nigricans
BMI body mass index (kg/m²)
DM type 2 diabetes
IGT impaired glucose tolerance
N/A not available
PCOS polycystic ovary syndrome
150

Chapter 2
Prevalence (%) DM incidence

Population Diagnostic method Sample size DM IGT per 100,000 per year
Diabetic clinic Chart review 524 10.7 N/A

Obese OGTT 710 0.1 4.5 N/A
Paediatric diabetes centres Questionnaire of 15,255 0.2 N/A
paediatric centres in UK

PCOS – all female OGTT 16 0.0 13.0 N/A
N/A N/A N/A 7.2

Overweight BMI at ≤95th OGTT Overweight 121 0.0 4.1 N/A
percentile Not overweight 104 0.0 0.0
Obesity clinic OGTT 4-10 years: 55 0.0 24.0 N/A
11-18 years: 112 3.6 23.0
Presence of AN OGTT 33 3.0 24.0 N/A

PCOS – all female OGTT 27 3.7 26.9 N/A
Diabetes clinic Chart review 18 0.0
Obese children in a OGTT 23 17.0 4.3 N/A

paediatric clinic

Diabetes register Chart review 51 55.0 N/A
151

Chapter 2
18. Pinhas-Hamiel O. Type 2 diabetes: not just for grownups

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111. Harris SB, Gittelsohn J, Hanley A, Barnie A, Wolever TM,

Gao J, Logan A, Zinman B. The prevalence of NIDDM and
associated risk factors in native Canadians. Diabetes Care
1997; 20:185-187.
112. Chavez RA, Strazdas LA, Lebowitz MD, Arriaga YE, Caruso Y,
Dixit NM. Prevalence of type 2 diabetes in adolescents in
Douglas, Arizona: is it significant. Diabetes 2002; 51:A429.
113. Kim C, McHugh C, Kwok Y, Smith A. Type 2 diabetes
mellitus in Navajo adolescents. West J Med 1999;
170:210-213.
114. Daniel M, Rowley KG, McDermott R, Mylvaganam A,
O’Dea K. Diabetes incidence in an Australian aboriginal
population. An 8-year follow-up study. Diabetes Care 1999;
22:1993-1998.
115. Punnose J, Agarwal MM, El Khadir A, Devadas K,
Mugamer IT. Childhood and adolescent diabetes mellitus in
Arabs residing in the United Arab Emirates. Diabetes Res
Clin Pract 2002; 55:29-33.
116. Dean H. NIDDM-Y in First Nation children in Canada.
Clin Pediatr (Phila) 1998; 37:89-96.
117. Jones KL. Non-insulin dependent diabetes in children and
adolescents: the therapeutic challenge. Clin Pediatr (Phila)
1998; 37:103-110.
118. Barrett TG, Ehtisham S, Smith A, Hattersley AT. UK Diabetes
Survey shows type 2 diabetes present in 0.4% of newly
diagnosed children, associated with overweight, female and
ethnic minorities. Diabetes 2002; 51:A25.
155

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Chapter 3
The Widening Circle Chapter 3
A very disturbing feature of diabetes

has been the clustering of diabetes
with other well-known cardiovascular risk
factors, in particular central (abdominal)
obesity. It is for this reason that a chapter
on obesity and cardiovascular disease
(CVD) appears in this edition of the
Diabetes Atlas.
With globalization, there have been

dramatic changes in the human
environment, behaviour and way-of-
life which have resulted in escalating
rates of both diabetes and obesity. This
explains the recent popularity of the
term ‘diabesity’. The frequency of central
obesity, hypertension and elevated
3.1 Obesity
blood lipids are dramatically increased in
3.2 Cardiovascular Disease and persons with diabetes and this has been
Diabetes: Double Jeopardy called the ‘Deadly Quartet’.
The concern regarding the associated

increase in cardiovascular risk becomes
even greater when one considers
that people with impaired glucose
tolerance (IGT) and impaired fasting
glucose (IFG) also have a substantial
increase in cardiovascular risk factors
and, like persons with diabetes, higher
cardiovascular risk. Coronary artery
disease and cerebrovascular disease
are two to three times more common
in people with diabetes than in people
without diabetes.
Cardiovascular disease is the major cause

of death in people with type 2 diabetes.
A key strategy in reducing macro-vascular
disease lies in the better understanding
of the metabolic syndrome: glucose
157

The Widening Circle
Chapter 3
intolerance (type 2 diabetes, IGT or

IFG), hyperinsulinaemia, hypertension,
dyslipidaemia and central obesity. This
clustering of CVD risk factors represents
a time bomb for both individuals with
diabetes and the nations faced with the
public health burden as it provides the
driving force for a cardiovascular disease
epidemic.
It is now very clear that management

of diabetes should focus not only on
tight blood glucose control but also
on strategies for reducing the other
important cardiovascular risk factors
such as central obesity, hypertension,
and dyslipidaemia in order to reduce
cardiovascular disease complications.
It is also clear from a number of

epidemiological studies that the clock
starts ticking for cardiovascular disease
many years before the clinical diagnosis
of diabetes. This highlights the rationale
for early intervention in the IGT phase.
The potential for IGT and, indeed, the
metabolic syndrome to be prevented
is now well documented with lifestyle
interventions and pharmacotherapy.
Reducing obesity through healthy

nutrition along with exercise provides
the logical means of prevention of both
diabetes and associated cardiovascular
morbidity and mortality. This is
supported by three major type 2 diabetes
intervention studies – the DaQing
Study in China, the Diabetes Prevention
Study (DPS) in Finland and the Diabetes
Prevention Program (DPP) in USA. An
integrated approach to preventing both
diabetes and obesity can hopefully
reduce the global burden.
The report on obesity was compiled

by the International Obesity Task Force
while the data on CVD mortality rates
were compiled by the WHO Collaborating
Centre at the Menzies Centre, University
of Tasmania, Australia.
158

The Widening Circle
Chapter 3
3.1 Obesity
Introduction be obese. The International Obesity A new generation is

Task Force (IOTF) estimates that up to entering adulthood with
Obesity is the principal risk factor for 1.7 billion people may be exposed to unprecedented levels
type 2 diabetes. An excess of body fat, weight-related health risks, taking into of obesity. This, in
especially when concentrated within account varied Asian populations with a addition to the existing
the abdomen, has a range of potentially BMI of 23 or more. burden of adult obesity,
harmful consequences. Classified as a reinforces the concern
disease, obesity diminishes both quality Average BMI levels across Africa and Asia that weight-related
of life and life expectancy, but it is also a have been estimated at between 20-23 chronic diseases will
common risk factor for a number of other kg/m2, but in Europe and North America be the most significant
diseases from osteo-arthritis to heart mean levels are much higher at 25-27 public health concern
disease and some types of cancer (see kg/m2, indicating that a substantial part throughout the
Box 3.1). of the population may be exposed to 21st century.
the health risks of higher BMIs (3). More
The World Health Organization (WHO) than 2.5 million deaths each year are
defines overweight as a body mass attributed to higher BMI, a figure that is
index (BMI) of at least 25 kg/m2 and expected to double by 2030.
obesity as a BMI of at least 30 kg/m2
(see Box 3.2). However, the health risks Regional trends
rise progressively above BMI levels of
20-22 kg/m2 in all populations (1). The Across the world the epidemic of
conclusions of a WHO expert group, obesity has been gathering momentum
which considered the evidence for lower affecting both developed and developing
BMI action points around BMI 23 in countries.
different Asian populations, are at present
under review.
Box 3.1
WHO recommends a general limit for
waist circumference of 102 cm and 88
Obesity – a risk factor
cm in men and women respectively, but
more appropriate waist circumference
action levels are now being sought to
specify risk levels relating to diabetes and
O verweight and obesity lead to adverse metabolic
effects on blood pressure, cholesterol, triglycerides
and insulin resistance. Risks of coronary heart disease,
other co-morbidities in Asian countries to
ischaemic stroke and type 2 diabetes mellitus increase
help alert those with lower BMIs to their steadily with increasing body mass index (BMI).
increased risks (2).
Type 2 diabetes mellitus - confined to older adults for
Over recent years rates of overweight most of the 20th century - now affects obese children even
and obesity have escalated rapidly in before puberty. Modest weight reduction reduces blood
many parts of the world to epidemic pressure and abnormal blood cholesterol and substantially
lowers risk of type 2 diabetes.
proportions, reflecting increased
consumption of energy dense diets high Raised BMI also increases the risks of cancer of the breast,
in fats and sugars, compounded by colon, prostate, endometrium, kidney and gallbladder.
declining levels of physical activity. Although the mechanisms that trigger these increased
cancer risks are not fully understood, they may relate to
Using the standard classification, more obesity-induced hormonal changes. Chronic overweight
than 1.1 billion people are estimated and obesity contribute significantly to osteo-arthritis, a
to be overweight, of whom around major cause of disability in adults.
320 million are now calculated to
159

The Widening Circle
Chapter 3
rates of 50.9% in Tunisia and 51.3% in

Box 3.2
Morocco, and obesity rates (BMI≥30)
in women of 23% in Tunisia and 18%
Defining body mass index (1)
in Morocco, representing a three-fold
Body mass index (BMI) is calculated by dividing weight in increase over 20 years (6).
kilogrammes (kg) by the square of height in metres (m).
Europe
BMI ≥25 = overweight Few countries in the European Region
BMI 25-29.9 = pre-obesity report obesity rates below 10%.
BMI ≥30 = obesity Prevalence rates, particularly among
women, rise to more than 20% in
The sub-categories of obesity: countries such as the United Kingdom,
Obesity class I 30.0-34.9 = moderate Germany, Finland and Greece. The most
Obesity class II 35.0-39.9 = severe rapid increase is noted in England where
Obesity class III 40+ = very severe obesity rates have risen three-fold from
1980 to 2001, with levels of morbid
obesity (BMI≥40) also increasing three-
fold among men and almost doubling
among women during the 1990s (7).
Africa North America

Wide disparities in levels of obesity are In the United States obesity affects
found in this region with the highest one in three adults overall, more than
rates in South Africa, where mean BMI double the rate of 20 years ago. Ethnic
values for men and women are 22.9 minorities, particularly women, are even
kg/m2 and 27.1 kg/m2 respectively, but more adversely affected with 40% of
levels of central obesity among women Mexican American women and 50% of
have been assessed at 42% (4). The South black American women having a body
Africa Health Review 2000 indicated mass index above 30 kg/m2 compared
obesity rates from 8% among black men to 30.6% of white women. Extreme
to 20% among white men, but among obesity rates, classified as morbid or
women the rates range from 20% for very severe obesity of BMI≥40, are as
Indian/Asians to 30.5% for black women. high as 15% among black American
In parts of sub-Saharan Africa obesity women (8). Neighbouring Canada
often exists alongside under-nutrition (5). experienced an increase of 150% in its
overall adult obesity rate from 1985 to
Eastern Mediterranean 1998 reaching 14.8%, but 40% of men
and Middle East and 25% of women fell into the pre-obese
High levels of overweight and obesity category (9).
exist particularly among women, in
countries as diverse as Egypt and the In the Caribbean, obesity is a significant
Gulf states including Saudi Arabia. problem, particularly among women,
Obesity rates of 25-30% and even higher with correspondingly high rates of type 2
are not untypical in Kuwait, the United diabetes. Abdominal obesity, using WHO
Arab Emirates and Bahrain. In Iran, waist circumference limits, ranged from
obesity rates vary from rural to urban 3% of men in St Lucia to 8% in Barbados,
populations rising to 30% among women but among women was found to be as
in Tehran. high as 34% in Jamaica, 41% in St Lucia
and 45% in Barbados (10). Diabetes
In northern Africa the prevalence of studies in Jamaica have demonstrated
obesity among women is high. Half of markedly high risks associated with
all women are overweight (BMI≥25) with overweight and central obesity (11).
160

The Widening Circle
Chapter 3
South and Central America this apply in the Asian region. Using this
Evidence of the impact of the ‘nutrition standard, adult obesity in Japan would
transition’ is clear in the growing levels of average 20%, rising to 30% in men over
obesity throughout this region. Obesity 30 years old and women over 40 years
rates are reported to vary for men from old, representing a three to four-fold
7% in Peru and Brazil to more than 20% in increase over the last 40 years (15,16).
Paraguay, where the rates in women rise
to as high as 36% (12). China has adopted its own standards
defining overweight at a BMI of 24 or
Western Pacific more, and obesity at a BMI of 28 or more.
Various Asian populations may be However abdominal obesity is defined by
particularly susceptible to the health risks a waist circumference of 85 cm in men
of central obesity, regardless of BMI (13). and 80 cm in women (17). Figure 3.1
Consequently there is an increasing focus shows the prevalence of obesity, using
on measuring waist circumferences, BMI ≥25 as a criterion, in selected
which can predict individual risk more countries in the Western Pacific.
accurately than body mass index (14).
However, Japanese experts have agreed The link between obesity and type 2
independently to redefine the criteria diabetes is most manifest in the Pacific
for obesity as a disease, with a cut-off at area which has some of the highest levels
BMI≥25. It has also been suggested that of adult obesity. Obesity prevalence rates
Figure 3.1
Prevalence of obesity using BMI ≥25 as criterion in selected countries – Western Pacific Region
��
��
��
��
��
��
��
��
��
��
��
��
� ��
��
��
��
161

The Widening Circle
Chapter 3
(BMI ≥30) of between 60% and 80% can as fat cells expand, particularly in the
be found among men and women in abdomen. Physical inactivity, both a
some islands including Samoa and Nauru. cause and consequence of weight gain,
In Tonga, 60% of the adult population also contributes to insulin resistance.
is obese and recently 12% of men and
nearly 18% of women were identified with The IOTF analyses, undertaken for the
type 2 diabetes, a doubling of the rate World Health Report 2002 and associated
over 25 years. A further 20% were found WHO Global Burden of Disease research,
to be at risk due to elevated blood sugar indicate that approximately 58% of
levels (18). diabetes mellitus globally (as well as 21%
of ischaemic heart disease and 8-42% of
Obesity and diabetes certain cancers) can be attributed to BMI
above 21 kg/m2. However in western
Obesity and type 2 diabetes are causally countries, around 90% of type 2 diabetes
linked. Weight gain leads to insulin cases are attributable to weight gain (see
resistance through several mechanisms. Figure 3.2), and childhood overweight
Insulin resistance places a greater and obesity are now leading to an
demand on the pancreatic capacity to unusual pattern of premature type 2
produce insulin, which also declines diabetes, which is particularly difficult to
with age, leading to the development of manage once established (19).
clinical diabetes.
Among adults, clear evidence exists that
Fat accumulation induces insulin surprisingly modest weight reductions
resistance through changes in its can markedly reduce the development
hormonal and other secretions. Protective of type 2 diabetes, if not prevent it
hormones such as adiponectin decline completely, in susceptible individuals,
Figure 3.2
Proportion of diabetes (%) attributable to weight gain by region (30+ years)
��
��
��
��
��
��
��
��
��
��
� ��
��

��
��
Source: © IOTF (19)
162

The Widening Circle
Chapter 3
and that weight loss can reverse the Figure 3.3

type 2 diabetic state. The remarkable Overweight and obesity among school-age children
effect of weight loss through diet and (5-17 years)
increased activity has been demonstrated
��
in the National Institute of Diabetes and
Digestive and Kidney Diseases (NIDDK)
��
Diabetes Prevention Program in the USA
to benefit particularly the over-60s, in
whom nearly three-quarters of new cases ��
of diabetes were prevented.
��
��
This and other studies provide hope to

those with impaired glucose tolerance ��
and a susceptibility to diabetes. Dietary

and activity changes to produce a 5-7% ��
weight loss can successfully reduce the
incidence of type 2 diabetes; reductions �
in fat and calorie intake accompanied
by half an hour’s extra walking or �
��
other exercise each day have been
��
demonstrated to lower the incidence by ��
58%. Great success has been achieved �� Source: © IOTF (25)
among people over 60 years, reducing
the development of diabetes in that high-
risk age group by 71% (20). Similar data
have emerged from China, Scandinavia reduce the quality of life as well as
and other European studies. lowering life expectancy. Higher body
mass index has been shown to account
Costs of obesity for up to 16% of the global burden of
disease, expressed as a percentage of
The cost of obesity in economic terms disability-adjusted life years (DALYs)
has been estimated to account for 2-7% (see Map 3.1) (24).
of total healthcare costs (1). Recently
the combined direct and indirect costs Childhood obesity
to the USA have been re-assessed
at US$123 billion in 2001 (21). This Childhood obesity is a relatively recent
expenditure may overshadow the costs phenomenon, which poses a critical
in smaller countries such as England threat to health. Significant prevalences
where the Parliamentary National Audit exist in developing countries as well as
Office assessed the cost at around £2.5 in industrially developed economies. An
billion (£3 billion when adjusted to IOTF analysis (see Figure 3.3) has shown
2003 figures) (22). In the Pacific islands, that overweight and obesity affects one
the economic consequences of non- in 10 children worldwide, but the rate
communicable diseases, chiefly obesity is double in Europe and three times as
and type 2 diabetes, have been dramatic, great across the entire Americas (25).
consuming US$1.95 million, almost 60% The emergence of type 2 diabetes in
of the health budget of Tonga, and in Fiji childhood is a serious development. In
absorbing US$13.6 million, 39% of the the USA it has been noted that up to
health budget (23). 45% of children with newly diagnosed
diabetes have type 2 diabetes and
The human cost can be measured in most are overweight or obese at
terms of years of disability, which can diagnosis (26).
163

The Widening Circle
Chapter 3
Conclusion weight-related chronic diseases will be

the most significant public health concern
The most recent WHO recommendations throughout the 21st century.
for dietary improvements and increased
levels of exercise across entire The provision of effective obesity
populations provide the basis for the treatment, which can prevent or delay
development of global strategies to the onset of type 2 diabetes, and the
challenge the rise in obesity along development of coherent strategies
with other diet and activity related to halt the progressive weight gain
chronic diseases, including type 2 in evidence in most populations, is
diabetes (27). However even if the WHO lacking. Weighing the clear benefit of
recommendations, including those to interventions against the significant costs
reduce fat, sugar and salt consumption, in both human and financial terms of
were to be implemented, it would be inaction, it is surprising, if not alarming,
some considerable time before the that so little has been done worldwide
benefits were reflected in a reduction of to attack the root causes of the twin
obesity and co-morbidity rates. epidemics of obesity and type 2 diabetes.
A new generation is entering adulthood

with unprecedented levels of obesity.
This, in addition to the existing burden of
adult obesity, reinforces the concern that
Map 3.1
Proportion of DALYs attributable to overweight (high body mass index)
� ��
��
��
��
��
��
� �� Source: World Health Report 2002, WHO
164

The Widening Circle
Chapter 3
Map 3.2
Global prevalence of obesity (BMI ≥30) in males
��
� ��
��
��
��
��
� ��
Source: © IOTF, 2003
Map 3.3
Global prevalence of obesity (BMI ≥30) in females
��
� ��
��
��
��
��
� ��
Source: © IOTF, 2003
165

The Widening Circle
Chapter 3
20. Knowler WC, Barrett-Connor E, Fowler SE, Hamman

References RF, Lachin JM, Walker EA, Nathan DM. Reduction in the
incidence of type 2 diabetes with lifestyle intervention or
1. World Health Organization. Obesity: Preventing and metformin. N Engl J Med 2002; 346:393-403.
Managing the Global Epidemic. Technical Report Series no. 21. Wolf AM, Manson JE, Colditz GA. The Economic Impact of
894. WHO, Geneva, 2000. Overweight, Obesity and Weight Loss. Ed Eckel R in Obesity.
2. Choo V. WHO reassesses appropriate body mass index for Lippincott, Williams and Wilkins, 2002.
Asian populations. Lancet 2002; 360:234. 22. National Audit Office. Tackling Obesity. National Audit
3. IOTF analysis of data gathered for the WHO Global Burden Office, London 2001.
of Disease 2003. 23. Dalton A and Crowley S. Economic Impact of NCD in the
4. Puoane T, Steyn K, Bradshaw D, Laubscher R, Fourie J, Pacific Islands in Obesity in the Pacific: Too Big to Ignore.
Lambert V, Mbananga N. Obesity in South Africa: the South Secretariat of the Pacific Community 2002.
African demographic and health survey. Obesity Research 24. World Health Organization. The World Health Report
2002; 10:1038-1048. 2002. Reducing Risks, Promoting Healthy Life. IOTF
5. Maire B, Delpeuch F, Cornu A, Tchibindat F, Simondon F, research for the WHO Global Burden of Disease programme.
Massamba JP, Salem G, Chevassus-Agnes S. Urbanization 25. IOTF. Childhood Obesity – The New Crisis in Public Health.
and nutritional transition in sub-saharan Africa: exemplified International Obesity Task Force, London, 2003; in press.
by Congo and Senegal. Rev Epidemiol Santé Publique 1992; 26. American Diabetes Association. Type 2 diabetes in children
40:252-258 (article in French). and adolescents. Diabetes Care 2000; 3:381-389.
6. Mokhtar N, Elati J, Chabir R, Bour A, Elkari K, Schlossman 27. WHO/FAO. Diet, Nutrition and the Prevention of Chronic
NP, Caballero B, Aguenaou H. Diet culture and obesity in Diseases. Technical Report Series no. 916. WHO, Geneva,
northern Africa. J Nutrition 2001; 131:887S-892S. 2003. (www.who.int/hpr/NPH/docs/who_fao_expert_
7. Department of Health 2001. Health Survey for England. report.pdf)
www.doh.gov.uk/.
8. NHANES 1999-2000. www.cdc.gov/.
9. Katzmarzky PT. The Canadian obesity epidemic, 1985-1998.
CMAJ 2002; 166(8):1039-1040.
10. Okosun IS, Forrester TE, Rotimi CN, Osotimehin BO,
Muna WF, Cooper RS. Abdominal adiposity in six
populations of West African descent: prevalence and
population attributable fraction of hypertension. Obes Res
1999; 7:453-462.
11. Wilks R, Rotimi C, Bennett F, McFarlane-Anderson N,
Kaufman JS, Anderson SG, Cooper RS, Cruickshank JK,
Forrester T. Diabetes in the Caribbean: results of a
population survey from Spanish Town, Jamaica. Diabetic
Medicine 1999; 16:875-883.
12. Filozof C, Gonzales C, Sereday M, Mazza C, Braguinsky J.
Obesity prevalence and trends in Latin American countries.
Obesity Reviews 2001; 2:99-196.
13. James WPT, Chunming C, Inoue S. Appropriate Asian body
mass indices? Obesity Reviews 2002; 3:139.
14. Lean ME, Han TS, Deurenberg P. Body composition by
densitometry from simple anthropometric measurements.
Am J Clinical Nutrition 1996; 63:4-14.
15. The Examination Committee of Criteria for ‘Obesity Disease’
in Japan, Japan Society for the Study of Obesity. New
Criteria for ‘Obesity Disease’ in Japan. Circulation Journal
2002; 66(11):987-992.
16. Kanazawa M, Yoshiike N, Osaka T, Numba Y, Zimmet P,
Inoue S. Criteria and classification of obesity in Japan and
Asia-Oceania. Asia Pac J Clin Nutr 2002 Dec; 11 Suppl
8:S732-S737.
17. Zhou BF, Cooperative Meta-Analysis Group of the Working
group on Obesity in China. Predictive values of body mass
index and waist circumference for risk factors of certain
related diseases in Chinese adults - study on optimal cut-
off points of body mass index and waist circumference in
Chinese adults. Biomed Environ Sci 2002; 15:83-95.
18. Colagiuri S, Colagiuri R, Na’ati S, Muimuiheata S, Hussain Z,
Palu T. The prevalence of diabetes in the kingdom of Tonga.
Diabetes Care 2002; 25:1378-1383.
19. James WPT, Jackson-Leach R, Mhurdu CN, Kalamara E,
Shayeghi M, Rigby N, Nishida C and Rodgers A. Overweight
and Obesity. In Comparative Quantification of Health
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to Selected Major Risk Factors, eds. Ezzati M, Lopez AD,
Rodgers A, Murray CJL. WHO, Geneva, 2003; in press.
166

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Chapter 3
3.2 Cardiovascular Disease and Diabetes:

Double Jeopardy
Introduction Major cardiovascular

complications
Cardiovascular disease (CVD) is a major
worldwide health problem and the The most important cardiovascular
leading cause of death in industrialized complications of diabetes are:
countries. Cardiovascular disease is also
the major complication of type 2 diabetes • coronary heart disease (CHD);
and is responsible for more than 50% • cerebrovascular disease (CBVD); and
and up to 80% of deaths in people with • peripheral vascular disease (PVD).
diabetes as well as for very substantial
morbidity and loss of quality of life (see Given the global epidemic of diabetes,
Chapter 1.2). the double threat of diabetes and CVD is
set to explode unless preventative action
Diabetes can lead to cardiovascular is taken. It is noteworthy for example
damage in a number of ways. The that, in some Western populations,
processes do not develop independently, CHD rates have declined in the overall
and each may accelerate or worsen the population but no consistent decline is
others. Thus, as diabetes progresses, the seen in people with diabetes (1).
heart and blood vessels are exposed to
multiple attacks.
The cardiovascular disease triad
Cardiovascular death rates are either high
or appear to be climbing in countries ��
��
where diabetes is prevalent. The outlook
for cardiovascular diseases is alarming
when one considers the number of
people with diabetes worldwide and that
��
this is set to more than double by 2025. ��
The recent decline in cardiovascular

disease in the USA, Australasia and
western Europe may be compromised
significantly by this upsurge in diabetes.
In other parts of the world where CVD
has been proliferating in recent years, the
additional impact of diabetes threatens to
have devastating consequences.
Many cardiovascular deaths are

potentially preventable in both people
with and without diabetes if action is ��
��
taken to systematically address the
known risk factors. While some risk
factors are fixed, such as age, gender
and genetic background, many others are
modifiable, such as high blood pressure,
lipid abnormalities, obesity and smoking.
167

The Widening Circle
Chapter 3
Figure 3.7 Diabetes as a risk factor

Heart attacks in people with and without diabetes over a
period of seven years (adapted from Haffner SM et al (2)) The impact of cardiovascular disease in
diabetes is exacerbated even further by
��
the earlier age of onset of type 2 diabetes
�� which is now reaching down even to
children and adolescents, and carries
��
the threat of early onset of CVD. In
�� addition advances in insulin therapy have
improved the life expectancy of people
��
��
with type 1 diabetes and each year of
�� prolonged life increases the likelihood of
�� cardiovascular complications.
��
Diabetes leads to cardiovascular damage
�� by a number of mechanisms, each of
which in turn may accelerate or worsen
�
the others. It belongs to a special risk
� category as it has so marked an effect
��
on cardiovascular risk. As well as being
�� a risk factor in its own right, diabetes
��
is associated with a higher prevalence
of other common risk factors such
Source: Diabetes and Cardiovascular Disease: Time to Act, IDF 2001 (3) as hypertension and dyslipidaemia,
and, these risk factors, in turn, have a
more harmful effect in the presence of
Figure 3.8 diabetes. For each risk factor present, the
Deaths in people with and without diabetes in the year risk of cardiovascular death is about three
following a first heart attack (adapted from Miettinen et al (4)) times greater in people with diabetes
compared to those without diabetes.
��
�� The end result is that people with

diabetes are two to four times more
��
likely to develop CVD than the general
�� population (see Figure 3.7). In the case
of CVD, silent myocardial infarction is
��
��
common and the risks of sudden death
�� and heart failure are also increased. In
�� the case of stroke, transient ischaemic
attacks are two to six times more
��
common in the diabetic population and
�� vascular dementia is also more common.
In the case of PVD people with diabetes
�
have a 15-40 times increase in the risk of
� lower limb amputation compared to the
��
general population.
��
��
These figures also conceal additional
problems. For a given major vascular
Source: Diabetes and Cardiovascular Disease: Time to Act, IDF 2001 (3) event such as myocardial infarction
or stroke, the outcome is worse in
people with diabetes compared to the
168

The Widening Circle
Chapter 3
general population (see Figure 3.8). The use of mortality data, obtained
This results from both the severity and principally from the Global Cardiovascular
widespread nature of atherosclerosis in Infobase, does however serve to indicate
diabetes, combined with other causes the magnitude of the problem and to
of vascular disease in diabetes apart highlight regional differences and trends.
from atherosclerosis, such as arterial
stiffness, microangiopathy and autonomic It should be noted that considerable The link between
neuropathy*. differences exist in the degree of diabetes and CVD is
completeness of the vital registration so strong that the
It is important to note also that even at data submitted by countries. In some prevention agenda for
the stage of impaired glucose tolerance countries, the vital registration data both diseases can be
(IGT), before full-blown diabetes has system covers only a part of the country linked and integrated
developed, the risk of cardiovascular (for example urban areas, or some at many levels of
disease is already increased by about two provinces only). In some other countries, the system. The high
times compared to people with normal although the vital registration data CVD risk in people
glucose tolerance. system covers the whole country, not all with IGT and newly-
deaths are registered. Further details on diagnosed diabetes
A costly combination data sources and methodology can be also emphasizes both
found in Appendix 1.4. the importance of
About half of all the money spent on primary prevention of
diabetes care goes towards the costs It should be emphasized also that these diabetes in the context
of managing diabetic complications. data provide the overall picture of total of overall prevention
Cardiovascular complications frequently CVD mortality and are not limited to CVD of CVD and the
account for the bulk of the costs as in the context of diabetes. significance of diabetes
reflected in the patterns of hospital as an ‘entry point’ for
admissions for the treatment of Regional and national trends overall, comprehensive
complications (see Figure 3.9). The As well as differences in total trends cardiovascular risk
trend of escalating diabetes prevalence in different parts of the world, there management.
with its impact on CVD will no doubt may also be differences in disease
lead to an immense financial burden patterns which are not revealed by these
in many countries unless action is figures. For example, in the case of
taken to prevent both diabetes and its cerebrovascular disease, the proportion
complications. of deaths resulting from haemorrhagic
stroke compared to thrombotic stroke is
The global burden of higher in Japan, China and many African
countries, compared to Europe or North
cardiovascular disease
America. This may reflect differences in
The data which follow summarize the the relative importance of individual risk
global burden of cardiovascular disease factors, such as hypertension.
by using mortality data for coronary heart
disease and cerebrovascular disease Africa
from individual countries. It needs to Available data from Africa are very
be emphasized that these are mortality limited but show marked contrasts
data and do not therefore indicate levels between countries. Botswana reports
of morbidity in survivors. They also do zero deaths from CHD and a low
not include information about peripheral mortality from cerebrovascular disease
vascular disease. whereas Zimbabwe occupies an
intermediate position. In South Africa the
mortality from cerebrovascular disease
in females stands out as being equal to
* For further details readers are referred to
Diabetes and Cardiovascular Disease: Time to Act, that of males and double that of CHD in
International Diabetes Federation, 2001 (3). females.
169

The Widening Circle
Chapter 3
Figure 3.9
Proportion of hospital bed days used for the treatment of diabetic complications
United Kingdom Argentina
��
��
��
��
��
��
��
��
��
��
��
��
��
��
��
��
��
��
��
��
��
Source: International Diabetes Federation, 1999 (5)
Eastern Mediterranean North America

and Middle East CHD mortality rates have shown recent
Limited reports from the Middle East falls in both Canada and USA and are
indicate cerebrovascular disease mortality broadly similar to western European
rates similar to those of western countries such as Germany, Sweden and
European countries with the lowest rates, Austria although still much higher than
for example France. Rates in Egypt are other European countries such as France
however higher and appear to be rising and Portugal. Rates of cerebrovascular
quite rapidly. By contrast CHD rates disease in USA and Canada are broadly
are relatively low in Egypt compared to similar to those in lower prevalence
Bahrain, and, particularly, Kuwait. western European countries such as
France, Netherlands and Spain.
Europe
In many western European countries South and Central America
CHD mortality rates have dropped and the Caribbean
appreciably in the last two decades. CHD mortality rates vary greatly from
However the eastern European countries country to country but are generally
from the previous Soviet bloc have some similar to or below those for North
of the highest rates in the world for America, with the exception of Trinidad
both CHD and cerebrovascular disease. and Cuba and a few other countries
Thus Estonia has double the rate of which have a relatively high mortality
Finland, and Georgia makes interesting rate in females. Mortality rates from
comparison with France, with a five cerebrovascular disease are relatively
times higher rate in males and ten times much higher and approach or exceed
higher rate in females. The Russian those from CHD, a notable example
Federation and Ukraine also have very being Brazil.
high rates. Similar trends are seen with
cerebrovascular disease.
170

The Widening Circle
Chapter 3
South-East Asia be linked and integrated at many levels of

Data are available only from Sri Lanka the system. The high CVD risk in people
and Mauritius. The absence of data from with IGT and newly-diagnosed diabetes
India, Pakistan and Bangladesh makes also emphasizes both the importance
detailed analysis difficult. This lack of primary prevention of diabetes in the
of data also causes concern given the context of overall prevention of CVD
numbers of people with diabetes in India and the significance of diabetes as an
and relatively high reported rates for CHD ‘entry point’ for overall, comprehensive
in migrant Indian populations. cardiovascular risk management. An
effective prevention strategy should
The reported rates from Sri Lanka indicate therefore include each of the following
that both CHD and cerebrovascular components:
disease mortality rates are approximately
similar to those of France, a western • Primary prevention of diabetes,
European country with relatively low preferably integrated with other non-
rates. Mauritius has very high rates for communicable disease prevention
both CHD and cerebrovascular disease, programmes. A carefully balanced
and is also well known for high diabetes combination of population-wide and
prevalence rates. targeted high-risk strategies should be
employed.
Western Pacific • Secondary prevention of diabetes
This is a huge and diverse region and complications by optimal diabetes
this diversity is reflected in the ranges care.
of reported mortality rates. The reported • Overall risk factor management in
mortality rates for CHD in males range people with diabetes. This requires
from 7.9 in China to 235 in Singapore and intensive treatment of the whole
in females range from 5.5 in China to 116 range of involved risk factors and
in New Zealand and 109 in Singapore. metabolic abnormalities and not just
hyperglycaemia.
In several countries cerebrovascular • Provision of targeted medical and
mortality is higher than CHD mortality revascularisation treatments to reduce
with China and Japan providing the death and disability in people who
clearest examples of this. This is likely have already developed CVD.
to reflect the importance of hypertension • Careful design of healthcare systems
as a risk factor in these countries to overcome barriers, ensure flexibility
and, as commented upon above, also and provide adequate facilities for the
coincides with a relatively high ratio of overall management of CVD risk.
haemorrhagic stroke to ischaemic stroke
in these two countries.
Prevention
As stated earlier CVD is the cause of
most of the deaths and much of the
disability seen in people with diabetes.
Good evidence now exists that much of
this disease burden can be prevented or,
at the very least, delayed by appropriate
preventative measures. The link between
diabetes and CVD is so strong that the
prevention agenda for both diseases can
171

The Widening Circle
Chapter 3
Map 3.4
Coronary heart disease in males (35-74 years): mortality rates per 100,000 population per year
��
� � ��
��
��
��
��
��
��
��
� ��
Map 3.5
Coronary heart disease in females (35-74 years): mortality rates per 100,000 population per year
��
� � ��
��
��
��
��
��
��
��
� ��
172

The Widening Circle
Chapter 3
Map 3.6
Cerebrovascular disease in males (35-74 years): mortality rates per 100,000 population per year
��
� � ��
��
��
��
��
��
��
��
� ��
Map 3.7
Cerebrovascular disease in females (35-74 years): mortality rates per 100,000 population per year
��
� � ��
��
��
��
��
��
��
��
� ��
173

The Widening Circle
Chapter 3
References
1. Gu K, Cowie CC, Harris MI. Diabetes and decline in heart

disease mortality in US adults. J Am Med Assoc 1999;
281:1291-1297.
2. Haffner SM, Lehto S, Rönnemaa T, Pyörälä K, Laakso M.
Mortality from coronary heart disease in subjects with
type 2 diabetes and in nondiabetic subjects with and
without previous myocardial infarction. N Engl J Med 1998;
339:229-234.
3. International Diabetes Federation. Diabetes and
Cardiovascular Disease: Time to Act. International Diabetes
Federation, Brussels, 2001.
4. Miettinen H, Lehto S, Salomaa VV, et al. Impact of diabetes
on mortality after the first myocardial infarction. Diabetes
Care 1998; 21:69-75.
5. International Diabetes Federation. Diabetes Health
Economics: Facts, Figures and Forecasts. International
Diabetes Federation, Brussels, 1999.
174

The Economic Impact of Diabetes
Chapter 4
The Economic Impact of Diabetes Chapter 4
T he economic impact of diabetes is

considerable. Its costs affect health
services, national productivity as well
as individuals and families. Hospital
in-patient costs for the treatment of
complications are the largest single
contributor to direct healthcare costs.
Many of these complications and,
therefore, their costs are preventable.
Intensive therapy, directed at the control
of blood glucose, blood pressure etc, has
been shown to be cost-effective in that,
although initial costs are increased, it
decreases longer term costs as a result of
delayed or prevented complications.
The annual direct healthcare costs of

diabetes worldwide, for people in the 20-
79 age bracket, is estimated to be at least
153 billion international dollars* and may
be as much as 286 billion, or even more.
If predictions of diabetes prevalence

are fulfilled, total direct healthcare
expenditure on diabetes worldwide will
be between 213 billion and 396 billion
international dollars in 2025. This would
mean that the proportion of the world’s
healthcare budget being spent, in 2025,
on diabetes care will be between 7% and
13% with high prevalence countries, such
as Nauru, spending up to 40% of their
budget.
In many countries a substantial

proportion of healthcare costs are
borne by the individual and the family.
Estimates of the indirect cost of diabetes
ie the cost of lost production are as high
as direct costs or even higher than those
for direct costs. * see footnote a, page 183.
175

Chapter 4
Calculated costs for by increasing the effectiveness of

all countries surveillance and treatment for those who
already have diabetes, by implementing
The future predictions The first edition of Diabetes Atlas primary prevention measures for those
of cost are as looked at published empirical estimates who are at high risk of developing type 2
alarming as the of the current direct healthcare costs diabetes and reducing the risk profile for
future predictions of of diabetes (1). While continuing to type 2 diabetes in the population as a
diabetes prevalence. emphasize the importance of such whole.
They suggest that, estimates, this chapter in the second
unless effective edition is wider in scope. Economic information is an important
prevention measures component in making decisions about
are introduced, It puts forward, for the first time, diabetes and diabetes healthcare.
expenditure devoted calculated estimates of the current Decision makers are asking, or should be
to diabetes and its direct cost of diabetes care worldwide. asking, such questions as:
complications will It also uses the same method, together
dominate the health with predictions of the future burden of • What is the economic impact of
economies of many diabetes in these countries, to estimate diabetes?
countries by the end of the likely future direct cost burden of the • How does this impact compare with
the first quarter of the disease in 2025. This widening of scope that of other current health problems?
current century. reflects the inclusion, in this edition of • What information is available on the
the Atlas, of diabetes prevalence data for cost-effectiveness of different methods
all countries. for the prevention of diabetes?
• What do we know about the cost-
These future predictions of cost are effectiveness of delivering diabetes
as alarming as the future predictions care in different ways?
of prevalence. They suggest that,
unless effective prevention measures IDF’s Task Force on Diabetes Health
are introduced, expenditure devoted Economics has recently completed
to diabetes and its complications will a review of currently available
dominate the health economies of many information on the cost-effectiveness
countries by the end of the first quarter of interventions relevant to diabetes
of the current century. prevention and care (2). A large number
of interventions – intensive blood glucose
Importance of economics and blood pressure control, the use of
lipid lowering agents, screening for and
Economic aspects of diabetes and treatment of diabetic retinopathy and
diabetes care continue to attract active care of the feet, for example – are
attention as the world diabetes epidemic known to be effective. Evidence is
progresses and the healthcare sectors accumulating that many of these are
of countries remain under pressure also cost-effective, or even cost-saving.
to accomplish more and more within Many of the costs of diabetes and its
constrained resources. complications are, therefore, potentially
preventable.
Governments, diabetes associations,
health professionals and people with Availability of up-to-date
diabetes themselves need to be aware of
information
the current and future economic impact
of the disease on the healthcare sector, Most of the estimates in the following
the individual and family, and society. sections are those that have appeared in
the literature since the previous edition of
They also need to be aware of the Diabetes Atlas.
potential for reducing this cost burden
176

Chapter 4
Considerable caution is required Total cost of care for

when considering these estimates and people with diabetes
comparisons between them can only The second cost estimate includes all
validly be made when they have been episodes of care for people with diabetes
assembled using the same methods and – diabetes-related healthcare and also
the same assumptions. As with all cost those of care in which the main reason
of illness studies, the methods used are for the encounter is apparently unrelated
either ‘top down’ or ‘bottom up’. to diabetes. The latter would include,
for example, surgery for appendicitis
In the ‘top down’ approach, aggregate or hip replacement or treatment for
data at national or local level of breast cancer in people with co-existing
treatments, healthcare utilization etc diabetes.
are used together with unit costs for the
appropriate item. This second estimate has at least two
advantages. First, it sidesteps the need
In the ‘bottom up’ approach, affected to decide whether, or to what extent, a
individuals are identified, their treatments condition is or is not related to diabetes
and healthcare utilization events recorded and, second, it incorporates the impact
and unit costs used to calculate the totals which diabetes may have on the costs
required. of care even for such conditions as
Each method has its own advantages appendicitis, hip replacement or breast
and disadvantages. A third method – the cancer in people with co-existing
calculation of direct costs by means of diabetes.
formulae – has been suggested and is
described here with empirically derived Lengths of hospital stay may be longer
estimates in sections which follow. if diabetes co-exists. Drug bills are likely
to be larger, care in general will be more
Direct costs intense and rehabilitation more complex
and thus more costly. If such overall cost
It is important to distinguish between two estimates are used then the incremental
estimates of direct healthcare costs: (or ‘extra’) cost of diabetes is calculated
by subtracting the average costs of care
1 Cost of diabetes healthcare for a person without diabetes from those
2 Total cost of care for people with of a person with diabetes, preferably
diabetes. using age, sex and ethnicity matched
estimates.
Cost of diabetes healthcare
This is the cost element that is Costs may be calculated from the point
attributable to diabetes itself or to the of view of the state or the individual and
complications of diabetes. It clearly family. These latter costs are sometimes
includes the costs of hospital admissions termed ‘out-of-pocket’ expenditures.
and other healthcare episodes for diabetic More and more studies are focusing on
ketoacidosis, hypoglycaemia and other these personal costs of care and on the
direct results of diabetes or its therapy. potential for economic issues to influence
the quality of care which people receive.
The healthcare costs of diabetic
neuropathy, retinopathy and nephropathy Direct costs:
are also usually included. It is less clear,
calculations using formulae
however, how much of the costs of care
for such things as a myocardial infarction Formulae have been proposed by
or stroke in a person with diabetes Jönsson (3) which can enable countries
should be attributed to diabetes per se. or regions to estimate direct healthcare
177

Chapter 4
prevalence estimates for the 20-79 year

Box 4.1
age group for 2003, and data on per
capita health expenditure (in international
Formulae for calculating direct healthcare costs
dollars) as presented in the World Health
of diabetes (3)
Report 2002 (5). By multiplying the 20-79
year population figures by the per capita
1. Cost of diabetes care: health expenditures, the total healthcare
P(R – 1) budget for that age group is derived.
× THCB
P(R – 1) + 1 Calculations are then presented for values
of R of 2 and 3. Figure 4.1 shows the
2. Cost of care for people with diabetes: values of R of 2 and 3 by region.
P×R
× THCB
P(R – 1) + 1 All countries are represented except for
22 countries or areas for which no value
P = prevalence of diabetes of per capita health expenditure is given
R = ratio of the cost of care for people with diabetes/ in the WHO Report*. These represent 1%
cost of care for people without diabetes of the world’s population.
THCB = total healthcare budget
The calculated estimates for some
countries can be validated against the
empirically derived estimates listed
below. For example, the American
costs of diabetes, or any other disease, Diabetes Association’s latest estimate
without the need for costly and time for the direct cost of diabetes over all
consuming empirical studies (see age groups in the USA is US$91.8 billion
Box 4.1). in 2002 (6). This is within the range of
calculated costs, by formula, using the
Of the three variables needed to make diabetes prevalence and total healthcare
these calculations, estimates of the budget figures for the USA which is 66.7
prevalence of diabetes (P) are now billion international dollars for R = 2 to
available for every country and the 124.2 billion international dollars for
total healthcare budget (THCB) for most R = 3 (Table 4.5). The empirically derived
countries is available from published figure of US$91.8 billion corresponds to a
sources. However, R, the ratio of the value of R lying between 2.5 and 2.6.
cost of care for people with diabetes
compared with the cost of care of Empirically derived
people without diabetes, is not widely
cost estimates
available in various countries and some
assumptions need to be made in order to Africa
use these formulae. There is a growing interest in the
economics of diabetes in Africa. However,
The data to hand suggest that, at least no recent country specific estimates
for countries with high or moderate have been published since the work of
incomes, the value of R lies between 2 Chale and her colleagues in Tanzania in
and 3, eg Rubin et al’s (4) estimate of 2.6 1992 (7). Cost of illness data from African
for the United States. countries is badly needed.
Tables 4.1-4.8 give estimates of the cost * Anguilla, Antigua and Barbuda, Aruba, Bermuda,
of diabetes care for persons aged 20-79 British Virgin Islands, Cayman Islands, China Hong
Kong, China Macau, East Timor, French Guiana, French
using the first formula in Box 4.1. The
Polynesia, Guadeloupe, Guam, Martinique, Occupied
tables use, from the data in Chapter 1, Palestinian Territories, Puerto Rico, Reunion, Saint
population estimates and diabetes Lucia, Taiwan, Tanzania, Tokelau and Western Sahara.
178

Chapter 4
Eastern Mediterranean Figure 4.1

and Middle East Estimates of the costs of diabetes care by region
Data are also extremely sparse for the
��
countries in the Eastern Mediterranean
and Middle East Region. There appears to
��
be nothing published since the study by
��

Arab (8) in Egypt and by Rekik et al (9)
��
in Tunisia. It is worth noting that, in the
Tunisian study, the total annual cost of
medication and outpatient care for people ��
with diabetes was 2.6 times that for

people without diabetes (US$179 versus ��
US$68) and that a clear relationship was

found between higher costs and the ��
presence of ‘degenerative complications’.

��
Europe
Diabetes healthcare costs in Sweden �
��
have been extensively studied since
the early estimates by Jönsson and ��
others. Recently, Norlund et al (10) have ��
estimated that 28% of the extra cost of
diabetes is attributable to the costs of
healthcare (the remainder are indirect From France (13) comes the observation
costs). This amounts to an estimated that medical care costs for people with
SEK9,548 (US$1,118) per person per year. diabetes are around 3,048 (US$3,265)
per person per year (twice the average
Björk (11) has estimated that three times medical care consumption in the French
the healthcare resources are being spent population) while in the Netherlands,
on diabetes complications compared van Os et al (14) have estimated diabetes
with that spent on diabetes control healthcare costs to be a modest 2.5% of
while Jönsson et al (12) have made the the total healthcare budget.
important observation that excess costs
in the first year after the diagnosis of Using a number of complementary
diabetes in young adults (15-34 years data sources, Currie and colleagues
at diagnosis) are considerably greater have published several cost estimates
than those incurred seven years later for diabetes and its complications in
ie eight years after diagnosis. Annual the same defined United Kingdom (UK)
excess costs at these two time points population. In 1997 they published one
for men were US$4,743 and US$2,010 of the few estimates of future costs of
respectively while, for women, the diabetes (15). More recently, they have
equivalent figures were US$4,976 and been involved with others in developing
US$2,734. The cost profile during a computer-based model for testing the
the natural history of the condition in effects of demographic, epidemiological
any one person with diabetes seems, and therapeutic changes on these future
therefore, to be ‘U’ or ‘J’ shaped, with, costs (16), thus linking descriptive
immediately after diagnosis, relatively estimates of the cost of diabetes with
high costs which subsequently fall cost-effectiveness information from
and then rise again with the onset of studies such as the UK Prospective
complications. Diabetes Study (UKPDS).
179

Chapter 4
The findings of the CODE-2 (Cost of End-stage renal failure had the effect of
Diabetes in Europe – Type 2) and T2ARDIS increasing costs by 771%.
(Type 2 Diabetes Accounting for a Major
Resource Demand In Society) studies Recent work in Canada suggests that the
agree that the financial burden of type 2 total direct healthcare cost of diabetes
diabetes in the United Kingdom is just is US$3.5 billion in 1998 prices (21).
under 5% of the nation’s healthcare Comparison with the estimates in Table
budget in 1998, that there is a strong 4.5 of 4.7 billion international dollars
relationship between hospital costs and (R=2) and 8.7 billion international dollars
the presence of complications, and that (R=3) suggests that this may be an
the economic and psychosocial burden underestimate (or the calculated figures
of diabetes extends not only to affected an overestimate).
individuals but also to their carers (17).
The empirical Canadian work
North America emphasized the dominant contribution
The most recent peer-reviewed of cardiovascular disease in people with
estimate of the annual direct cost of diabetes (35% of direct and indirect costs)
diabetes in the USA is the American and declared that “the cost of preventive
Diabetes Association’s 2002 estimate treatment is insignificant compared
of US$91.8 billion (6). This compares with the downstream costs of failure to
with the previous estimate for 1997 of adequately treat the disease”.
US$44 billion (18). This is a total figure
covering all aspects of diabetes and its South and Central America
complications. Of considerable interest, given the range
of countries studied, is the work of
The US literature also has a number of Barceló et al (22). The direct healthcare
estimates which break down the total costs were estimated as US$10.69 billion
cost figure into estimates for specific, for 25 countries in 2000 (Table 4.9). The
individual complications. For example, contributions of the various items to the
O’Brien et al (19) estimated the ‘event direct cost total are shown in Figure 4.2,
cost’ of a single myocardial infarction in while the specific contributors to the
a person with diabetes to be US$27,630 cost of diabetic complications are shown
(1996 prices). This leads on to a ‘state in Figure 4.3. Indirect costs were also
cost’ (ie the annual additional cost of care calculated and were around five times the
following such an event) of US$2,185 per direct cost total.
annum. They point out that some early
complications, such as the presence of The method employed by Barceló et al
microalbuminuria (the presence of small is the ‘top down method’ (22). They
traces of protein in the urine), are low used population prevalence estimates
cost, estimated as a US$14 per annum for diabetes, treatment and healthcare
‘state cost’, but, if left undetected and utilization figures taken both from
untreated, lead to extremely high later individual studies and routinely collected
costs, in this case the US$53,660 per data (see Table 4.9). These were then
annum ‘state cost’ of end-stage renal multiplied by unit costs for insulin, oral
failure. hypoglycaemics and other items. Like
all top-down studies, the accuracy of the
In a similar fashion, for people with results is dependent on the validity of the
diabetes receiving their healthcare from assumptions made. Nevertheless, this
one health maintenance organization, a work represents a considerable advance
major cardiovascular disease event eg in pulling together comparable data from
myocardial infarction was estimated to Latin American and Caribbean countries
increase the cost of care by 360% (20). not previously studied (see Map 4.1).
180

Chapter 4
South-East Asia Figure 4.2

In India, estimates have been made of the Contributions to total direct healthcare cost in 25 Latin
out-of-pocket expenses resulting from American and Caribbean countries, 2000 (adapted from
diabetes. This is the direct healthcare Barceló et al (22))
impact on the person with diabetes
who may need to spend a considerable
��
proportion of the family income in order
to receive treatment at a chosen location
eg outside the public sector. In a diabetes ��
centre in Chenai, families in the poorest
section of the population may have to
spend as much as 25% of their income
in order to obtain the care of their
��
choice (23).
Western Pacific
A similar theme, of the personal direct ��
costs, is developed by Simmons et al
(24) for patients resident in an inner
OHA oral hypoglycaemic agents
suburb of Auckland, New Zealand. Not
only were these patients spending a
significant proportion of their income on
diabetes care but between a fifth and a Figure 4.3
half (depending on income and ethnic Specific contributors to the cost of diabetic complications,
origin) of those taking part reported that 2000 (adapted from Barceló et al (22))
personal costs had an inhibitory effect
on self-monitoring of blood glucose,
��
self-medication and even on insulin
��
therapy amongst those who needed it.
��
��
Taiwan has been estimated to spend
11.5% of its healthcare budget on the
treatment of people with diabetes. This
comes from a national extrapolation
of Bureau of National Health Insurance
claims between July 1997 and July
1998 (25). The average cost of care for
someone with diabetes in this system
was 4.3 times higher than that for a
��
person without diabetes.
Indirect costs and

intangible costs
There is much less information on the
indirect costs of diabetes, ie cost of American Diabetes Association 2002
lost production, partly because of the study mentioned above, indirect costs
methodological difficulties involved in its were estimated to be US$39.8 billion
collection. When indirect costs have been compared with direct costs of US$91.8
calculated, they have been estimated billion and compared with a previous
as around the same, sometimes more estimate of indirect costs of US$54
than direct costs. For example, in the billion (6).
181

Chapter 4
In a study of 30,000 people in Manitoba, been no predictions of the likely future

Canada, the 600 individuals who had costs of diabetes. As the prevalence
diabetes were twice as likely not to be in of diabetes increases, the likelihood is
the work force as those without diabetes that costs will also rise although the
(26). Predicted increases in the prevalence magnitude will depend on a number of
of diabetes worldwide emphasize the things, particularly, the extent to which
fact that the economically productive age complications will be prevented or
groups within society will be particularly delayed.
affected. Given these predictions, the
effects on lost production are likely to be The ratio of the cost of care of people
considerable and need to be quantified with diabetes to the cost of care of
more extensively. those without (R in Jönsson’s formulae
– Box 4.1) may well rise initially, as
Considerable interest is currently being the increased costs of more intensive
shown in information of intangible costs treatment assert themselves. However,
(quality of life) and standardized methods this ratio of costs is likely then to fall
to obtain this are becoming available. as the preventive effect of this more
Again, however, the data available are intensive therapy becomes manifest.
sparse and none are shown in this edition
of the Diabetes Atlas. Using, again, the first formula listed in
Box 4.1 together with the predictions
Predictions of the future costs of prevalence in 2025 in Chapter 1,
the future costs of diabetes can be
of diabetes
calculated given certain assumptions.
Apart from the Bagust et al study (16) If it is assumed that per capita health
and the predictions, for Australia, expenditure of the countries listed in
included in McCarty et al (27), there have Tables 4.2 to 4.8 will not increase in real
terms, then each country’s total health
expenditure in 2025 for people aged
Figure 4.4 20–79 years can be calculated using
Predictions of the future costs of diabetes (as % of total this per capita figure and the predicted
healthcare expenditure) by region, 2025 population for that year.
��
Table 4.10 lists the overall predictions
�� by region (see Figure 4.4) and, for each
region, the predicted costs for the
��
country with the highest diabetes care
�� expenditure expressed as a percentage
��
of total health expenditure. The predicted

��
diabetes costs for all other countries
�� are available from the author or can be
�
calculated using the first formula given in
Box 4.1 and the appropriate data for that
� country given in Chapter 1.
�
�
��
��
��
182

Chapter 4
Map 4.1
Estimated total direct healthcare costs of diabetes per person (USD) in 25
Latin American and Caribbean countries (adapted from Barceló et al (22))
��
��
��
��
Table 4.1
Calculated estimates of the costs of diabetes care by region
Cost of diabetes care per year

(’000 international dollarsa) given values for Rb of:
Region R=2 R=3
AFR 784,539 1,522,237
EMME 3,594,864 6,677,924
EUR 42,768,723 80,520,020
NA 73,526,777 136,815,507
SACA 7,086,861 13,465,503
SEA 2,602,742 4,937,200
WP 22,635,907 42,906,055
Worldwide Total 153,000,412 286,844,446
a. The international dollar is a common currency unit that takes into account differences in the relative
purchasing power of various currencies. Figures expressed in international dollars are calculated using
purchasing power parities (PPP), which are rates of currency conversion constructed to account for
differences in price level between countries.
b. R = Ratio of cost of care for people with diabetes/cost of care for people without diabetes
183

Chapter 4
Table 4.2
Calculated estimates of the costs of diabetes care – African Region
Per capita health Cost of diabetes care per year

expenditure (’000 international dollarsa)
(international dollarsa) given values for Rb of:
Country R=2 R=3
Angola 52 7,940.6 15,477.0
Benin 27 1,652.0 3,236.0
Botswana 358 8,815.1 17,044.0
Burkina Faso 37 4,873.4 9,495.1
Burundi 16 600.0 1,184.5
Cameroon 55 3,186.4 6,322.5
Cape Verde 92 476.5 932.0
Central African Republic 37 1,493.4 2,920.6
Chad 19 1,860.5 3,624.3
Comoros 35 303.9 593.3
Congo, Democratic Republic of 21 11,313.6 22,096.7
Congo, Republic of 25 875.1 1,707.6
Côte d’Ivoire 45 8,170.3 15,976.1
Djibouti 63 888.6 1,697.4
Equatorial Guinea 103 562.8 1,099.1
Eritrea 25 888.1 1,743.8
Ethiopia 17 9,182.5 18,035.5
Gabon 171 3,140.2 6,107.1
Gambia 46 693.2 1,357.4
Ghana 51 16,482.7 31,932.0
Guinea 56 4,329.8 8,489.3
Guinea-Bissau 28 323.9 635.3
Kenya 115 40,360.2 78,826.2
Lesotho 100 3,113.9 6,046.6
Liberia 3 93.5 183.4
Madagascar 33 6,180.3 12,070.1
Malawi 38 3,258.2 6,409.4
Mali 32 3,352.3 6,573.0
Mauritania 52 2,310.8 4,469.9
Mozambique 30 7,756.9 15,065.0
Namibia 366 9,055.1 17,586.6
Niger 22 3,130.3 6,077.7
Nigeria 20 23,838.5 46,651.9
Reunion N/A
Rwanda 40 1,637.4 3,238.4
Sao Tome and Principe 23 64.9 126.5
Senegal 56 5,679.4 11,114.1
Seychelles 758 4,049.6 7,299.4
Sierra Leone 28 1,340.3 2,625.2
Somalia 7 629.8 1,232.5
South Africa 663 539,377.0 1,044,412.1
Swaziland 210 2,732.7 5,311.9
Tanzania N/A
Togo 36 1,590.9 3,119.1
Uganda 36 5,491.5 10,818.3
Western Sahara N/A
Zambia 49 6,663.1 12,945.5
Zimbabwe 171 24,779.6 48,327.5
AFR Total 784,539 1,522,237
N/A not available

184

Chapter 4
Table 4.3
Calculated estimates of the costs of diabetes care – Eastern Mediterranean
and Middle East Region

Country R=2 R=3
Afghanistan 9 7,627.1 14,174.9
Algeria 142 99,274.1 191,019.1
Armenia 192 37,478.6 69,735.7
Bahrain 641 36,532.9 64,667.7
Egypt 138 486,102.3 892,230.6
Iran 336 450,956.0 871,535.0
Iraq 573 487,336.9 909,974.6
Jordan 325 56,198.5 105,506.7
Kuwait 542 76,044.3 136,631.8
Lebanon 696 91,739.2 173,117.5
Libya 392 43,299.1 83,644.5
Morocco 166 116,582.9 224,217.7
Occupied Palestinian Territories N/A
Oman 448 58,322.1 105,830.0
Pakistan 76 432,936.1 803,003.8
Qatar 849 46,040.1 80,924.1
Saudi Arabia 684 620,292.9 1,142,333.8
Sudan 51 25,824.0 50,117.8
Syria 51 25,364.9 47,930.4
Tunisia 472 123,476.7 236,579.9
United Arab Emirates 761 232,769.2 398,837.1
Yemen 70 40,665.5 75,911.4
EMME Total 3,594,864 6,677,924
N/A not available
185

Chapter 4
Table 4.4
Calculated estimates of the costs of diabetes care – European Region

Country R=2 R=3
Albania 129 9,319.4 17,978.1
Andorra 1,639 5,929.6 11,059.0
Austria 2,171 498,962.5 961,054.0
Azerbaijan Republic 57 19,055.6 35,789.7
Belarus 430 268,819.5 495,419.9
Belgium 2,269 686,248.6 1,319,504.9
Bosnia and Herzegovina 319 85,970.0 158,079.0
Bulgaria 198 106,386.3 194,996.3
Croatia 638 120,022.6 227,502.4
Cyprus 1,415 37,285.6 71,106.4
Czech Republic 1,031 691,931.6 1,273,362.9
Denmark 2,428 601,903.8 1,131,216.2
Estonia 556 48,799.6 89,656.9
Finland 1,667 425,125.2 796,447.7
France 2,335 5,832,389.7 11,017,934.3
Georgia, Republic of 199 60,669.1 112,057.3
Germany 2,754 7,030,622.9 13,504,262.2
Greece 1,390 645,813.0 1,221,304.7
Hungary 846 548,733.3 1,008,471.7
Iceland 2,626 9,532.1 18,709.6
Ireland, Republic of 1,944 168,899.1 327,168.1
Israel 2,338 614,662.6 1,152,777.9
Italy 2,040 5,513,866.1 10,388,485.7
Kazakhstan 211 111,821.8 212,633.6
Kyrgyzstan 145 17,348.4 33,320.2
Latvia 398 62,882.1 115,391.7
Lithuania 420 95,557.6 175,996.3
Luxembourg 2,740 32,989.4 63,636.6
Macedonia 300 19,991.7 38,201.2
Malta 803 18,969.8 34,988.4
Moldova, Republic of 64 14,290.0 26,547.0
Monaco 1,877 2,477.0 4,685.2
Netherlands 2,255 939,828.2 1,814,885.1
Norway 2,373 470,761.4 885,799.1
a. The international dollar Poland 578 1,329,141.0 2,455,541.3
is a common currency Portugal 1,469 796,331.3 1,484,921.8
unit that takes into Romania 190 264,165.7 487,023.5
account differences Russian Federation 405 3,594,804.5 6,630,412.9
in the relative San Marino 2,805 3,175.5 6,010.7
purchasing power of
Serbia and Montenegro 237 94,735.9 179,935.4
various currencies.
Slovakia 690 215,042.2 398,282.1
Figures expressed in
Slovenia 1,462 193,676.0 356,136.8
international dollars
are calculated using Spain 1,539 4,206,901.2 7,718,179.9
purchasing power Sweden 2,097 893,237.9 1,673,172.8
parities (PPP), which Switzerland 3,229 1,054,290.7 1,986,431.5
are rates of currency Tajikistan 29 3,264.3 6,305.0
conversion constructed Turkmenistan 286 68,422.3 125,505.5
to account for Turkey 323 893,338.1 1,677,294.1
differences in price level Ukraine 152 478,529.5 879,350.3
between countries.
United Kingdom 1,774 2,852,838.2 5,497,291.5
b. R = Ratio of cost of
Uzbekistan 86 8,963.5 17,795.8
care for people with
diabetes/cost of care for
people without diabetes EUR Total 42,768,723 80,520,020
186

Chapter 4
Table 4.5
Calculated estimates of the costs of diabetes care – North American Region

Country R=2 R=3
Anguilla N/A
Antigua and Barbuda N/A
Aruba N/A
Bahamas 1,137 18,049.9 33,352.5
Barbados 915 13,577.7 25,183.0
Belize 273 1,833.1 3,477.4
Bermuda N/A
British Virgin Islands N/A
Canada 2,534 4,729,909.0 8,739,290.2
Cayman Islands N/A
Dominica, Commonwealth of 340 1,098.8 2,041.1
Grenada 351 1,215.5 2,284.7
Guadeloupe N/A
Guyana 197 5,127.5 9,702.4
Haiti 54 12,066.9 22,890.1
Jamaica 208 21,452.3 40,192.1
Martinique N/A
Mexico 483 1,982,045.4 3,707,672.7
St Kitts and Nevis 658 927.7 1,750.3
St Lucia 272 1,599.0 2,997.5
St Vincent and the Grenadines 374 1,876.9 3,505.9
Trinidad and Tobago 468 29,455.4 54,899.6
USA 4,499 66,706,541.4 124,166,267.2
NA Total 73,526,777 136,815,507
N/A not available
187

Chapter 4
Table 4.6
Calculated estimates of the costs of diabetes care – South and Central
American Region

Country R=2 R=3
Argentina 1,091 1,349,719.3 2,566,892.2
Bolivia 158 32,687.7 62,489.7
Brazil 631 3,409,088.8 6,498,705.1
Chile 697 367,540.7 697,779.1
Colombia 616 648,755.2 1,246,094.6
Costa Rica 481 77,392.0 145,399.1
Cuba 186 173,025.7 309,922.1
Dominican Republic 357 162,156.2 297,257.2
Ecuador 78 26,851.5 51,360.5
El Salvador 388 82,225.6 155,356.1
French Guiana N/A
Guatemala 192 56,149.8 106,745.2
Honduras 165 29,275.4 55,565.5
Netherlands Antilles 2,255 36,541.6 65,862.6
Nicaragua 108 16,017.2 30,285.0
Panama 464 55,970.5 104,833.0
Paraguay 323 35,824.2 69,076.4
Peru 238 179,381.8 342,020.8
Puerto Rico N/A
Suriname 424 8,468.3 15,687.7
Uruguay 1,005 141,283.2 265,714.1
Venezuela 280 198,506.0 378,457.2
SACA Total 7,086,861 13,465,503
N/A not available
Table 4.7
Calculated estimates of the costs of diabetes care – South-East Asian Region

Country R=2 R=3
Bangladesh 47 131,898.0 254,283.8
Bhutan 64 2,389.1 4,614.7
India 71 2,380,739.0 4,510,916.9
Maldives 254 648.7 1,274.8
Mauritius 330 25,178.2 45,900.8
Nepal 66 30,974.2 59,617.5
Sri Lanka 120 30,915.1 60,591.9
SEA Total 2,602,742 4,937,200
188

Chapter 4
Table 4.8
Calculated estimates of the costs of diabetes care – Western Pacific Region

Country R=2 R=3
Australia 2,213 1,780,583.1 3,365,036.0
Brunei Darussalam 618 12,402.2 22,631.4
Cambodia 111 13,627.7 26,737.0
China, Hong Kong N/A
China, Macau N/A
China, People’s Republic of 205 4,751,974.7 9,259,469.2
Cook Islands 426 321.0 606.9
East Timor N/A
Fiji 194 6,746.8 12,535.9
French Polynesia N/A
Guam N/A
Indonesia 84 209,963.7 412,172.4
Japan 2,009 12,642,179.4 23,745,326.3
Kiribati 140 487.9 922.3
Korea, Democratic People’s Republic of 33 24,287.4 46,278.8
Korea, Republic of 909 1,867,440.5 3,522,931.2
Lao People’s Democratic Republic of 52 1,435.7 2,841.9
Malaysia 234 267,650.0 492,852.2
Marshall Islands 312 1,148.2 2,126.2
Micronesia 343 1,767.9 3,326.7
Mongolia 120 2,390.7 4,716.7
Myanmar 24 7,397.4 14,636.5
Nauru 525 937.9 1,533.3
New Caledonia N/A
New Zealand 1,623 296,672.6 554,408.9
Niue 1,111 101.0 185.2
Palau 482 444.9 826.3
Papua New Guinea 147 7,081.4 13,900.4
Philippines 167 164,753.2 321,967.4
Samoa 221 918.0 1,738.8
Singapore, Republic of 913 303,674.6 547,303.8
Solomon Islands 97 427.8 838.8
Taiwan N/A
Thailand 237 204,644.4 401,088.9
Tokelau N/A
Tonga 312 2,274.3 4,093.9
Tuvalu 860 475.3 881.0
Vanuatu 119 256.2 501.7
Vietnam 129 61,440.6 121,638.6
WP Total 22,635,907 42,906,055
N/A not available
189

Chapter 4
Table 4.9
Estimated number of people with diabetes1 and estimated total direct healthcare costs of diabetes
in 25 Latin American and Caribbean countries, 2000
Direct cost per Average healthcare

No. of people Direct cost person with diabetes expenditure
Population with diabetes (population) per year per person per year
Country (000’s) (000’s) (USD million) (USD) (USD)
Argentina 34,768 1,250.3 747.0 597 320
Bahamas 279 12.8 10.7 836
Barbados 260 23.3 12.8 549
Bolivia 7,414 153.9 85.5 556 12
Brazil 159,014 4,532.6 3,952.3 872 159
Chile 14,210 496.5 295.0 594 120
Colombia 35,814 937.7 414.9 442 128
Costa Rica 3,424 154.9 96.6 624 197
Cuba 10,964 592.4 722.2 1,219
Dominican Republic 7,823 254.1 225.7 888 33
Ecuador 11,460 267.3 233.4 873 35
El Salvador 5,662 219.4 137.4 626 54
Guatemala 10,621 368.7 291.2 790 26
Guyana 856 28.4 20.4 718
Haiti 7,124 79.5 48.0 604 7
Honduras 5,654 193.0 113.8 590 23
Jamaica 2,468 181.4 136.1 750 56
Mexico 91,145 3,738.0 1,974.2 528 132
Nicaragua 4,123 136.1 85.0 625 22
Panama 2,631 120.5 104.4 866 196
Paraguay 4,828 92.5 72.0 778 46
Peru 23,532 606.8 502.4 828 56
Trinidad and Tobago 1,287 71.3 38.0 533
Uruguay 3,186 119.0 94.6 795 116
Venezuela 21,844 610.8 307.5 503 119
Total 470,391 15,241 10,691
1. Prevalence estimates taken from Amos et al, 199728.
Source: Barceló et al22
190

Chapter 4
Table 4.10
Predictions of the future costs of diabetes by region (20-79 age group), 2025
Cost of diabetes per year Cost of diabetes per year

(’000 international dollarsa) (as % of total healthcare expenditure)
for two values of ratiob: for two values of ratiob:
Region Country R=2 R=3 R=2 R=3
AFR 1,192,556.3 2,305,837.2 3.3 6.3
Seychellesc 6,595.2 11,673.8 13 23
EMME 7,335,249.7 13,511,171.7 8.0 14.7
United Arab Emiratesc 371,147.6 620,376.7 19.7 32.8
EUR 50,539,601.5 94,318,016.1 6.7 12.5
Tajikistanc 8,378.1 15,142.0 10.7 19.3
NA 106,030,745.8 195,147,133.0 8.7 15.9
Barbadosc 22,547.0 40,493.4 11.4 20.4
SACA 12,509,955.8 23,469,465.1 6.4 12.0
Cubac 239,831.9 418,051.8 14.7 25.7
SEA 5,278,860.5 9,842,467.0 7.7 14.4
Mauritiusc 41,665.2 73,871.2 12.8 22.7
WP 30,696,300.4 57,700,700.3 5.7 10.8
Nauruc 1,316.1 2,104.7 25.1 40.1
Total 213,583,269.9 396,294,790.4 7.3 13.5
c. Costs for countries within each region that have the highest value of diabetes costs as percentage of total
national health expenditure.
191

Chapter 4
20. Brown JB, Pedula KL, Bakst AW. The Progressive Cost of
References Complications in Type 2 Diabetes Mellitus. Arch Intern Med
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to diabetes care and prevention. IDF Task Force on Diabetes diabetes in Latin America and the Caribbean. Bulletin of the
Health Economics. International Diabetes Federation, World Health Organization 2002; in press.
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3. Jönsson B. The economic impact of diabetes. Diabetes Care Ramachandran A. Expenditure on healthcare incurred by
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Metab 1994; 78: 809A-809F. of diabetes: a significant barrier to care in South Auckland.
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192

Access to Insulin and Diabetes Supplies
Chapter 5
Access to Insulin Chapter 5

and Diabetes Supplies
One of the major breakthroughs in

medical sciences of the last century
was the discovery of insulin in 1921.
This discovery meant that people with
diabetes who were insulin-treated
survived the acute effects of the disease.
The fact of the matter is that some eighty
years later so many people in the world
are still dying because of lack of access
to insulin. Unfortunately, international
economics still determines who should
live or die, while we all watch on. This
lack of access to insulin may be chronic
or acute depending on the circumstances. The fact of the
matter is that some
Acute lack of access to insulin occurs eighty years after the
due to natural disaster, for example the discovery of insulin
earthquake in the Democratic Republic so many people in
of Congo, civil unrest including war, the world are still
for example the recent Balkan war, dying because of
or financial crisis as was the case in lack of access to
Argentina. Nevertheless, the major insulin. Unfortunately,
problem lies in the widespread chronic international
lack of access to insulin that poses a economics still
serious threat to the developing countries determines who should
of the world. live or die, while we all
watch on.
For proper delivery of diabetes care,
insulin, insulin syringes and needles
should be available, accessible and at
an affordable cost to all people with
diabetes who require them. Continuous
accessibility to insulin is still a major
problem in many developing countries
especially those in sub-Saharan Africa
such that there are reports of premature
deaths due to the chronic lack of access
to insulin in some of these countries.
193

Chapter 5
This chapter focuses on the chronic syringes and needles 100% of the time
lack of access to insulin because the was greater in urban than in rural areas
International Diabetes Federation (IDF) (48 vs 32 for insulin and 41 vs 29 for
Task Force on Insulin and major insulin syringes and needles) whereas the
manufacturers have put in place a reverse was true for lack of access ie
mechanism to alleviate the acute lack of less than 25% of the time (21 vs 5 for
access to insulin whenever a situation insulin and 20 vs 7 for syringes and
arises. needles). The chronic lack of access to
insulin, syringes and needles was more
Magnitude of the problem common in Africa than elsewhere. South
and Central America also suffered from
The IDF Task Force on Insulin conducted the chronic lack of access to syringes and
a survey on the global access to insulin needles. Both these problems were least
in 1997. In that survey, 48 of the 73 common in Europe.
responding countries reported continual
and uninterrupted availability of insulin A similar survey, the Global Access to
in urban areas, whereas 20 reported Insulin and Diabetes Supplies Survey,
that insulin was available 25-99% of the was conducted by the IDF Task Force
time and 5 reported availability of less on Insulin in 2003. The results of this
than 25%. survey are summarized in this chapter.
Eighty-five participants from 74 countries
The 1997 survey showed that in the completed the questionnaire on insulin
seven IDF regions access to insulin, accessibility.
It is regrettable that many developing

countries did not participate in this
Box 5.1
survey despite several reminders. There
are several shortcomings in drawing
What is Insulin?
absolute conclusions from such a survey;
however, it is the only reliable document
I nsulin is the internal secretion of the pancreas formed

by groups of cells called the islets of Langerhans in this
organ. It is the hormone needed to enable glucose to enter
which we have to assess global access to
insulin, syringes and needles.
the cells and provide energy. Insulin is also important in

keeping blood glucose levels within the acceptable limits. Global access to insulin
Forty-four and 40 of the 74 countries
Insulin is injected into the body by people with type 1
reported continual and uninterrupted
diabetes in whom the cells that produce insulin have been
access to insulin for people with type 1
destroyed. This is the most common form of diabetes in
and type 2 diabetes respectively.
children and young adults, and they depend on insulin for
However, it is significant to note that
survival. Insulin may also be used by people with type 2
people with type 1 diabetes in 30
diabetes. In type 2 diabetes, the body needs more insulin
countries did not have access to insulin
than it can produce.
100% of the time (see Table 5.1), while
people with type 2 diabetes in 34
Since the landmark discovery of insulin by Frederick
countries did not have 100% access (see
Banting and Charles Best in 1921, huge steps forward
Table 5.2).
have been made in research and development in creating
genetically engineered human insulin. Until recently insulin
The distribution of access to insulin
was derived from a limited resource of the pancreas of
was different in the various regions
cattle and pigs.
for both people with type 1 and type 2
diabetes (see Figures 5.1 and 5.2).
Only Africa had no country with 100%
194

Chapter 5
accessibility to insulin. The countries Figure 5.1

with the lowest accessibility were the Access to insulin for people with type 1 diabetes by region
Democratic Republic of Congo where
��
people with type 1 diabetes had access
to insulin for less than 25% of the time ��
and Zambia where those with type 2
��
diabetes had access only 26-49% of the
��

time. In Europe, Ukraine had the lowest ��
accessibility to insulin (less than 25%); in ��

South and Central America, El Salvador
and Peru (26-49%) and in North America, ��
Guyana (50-74 %). ��
��
Causes of lack of access
to insulin ��
The most important causes of the lack
��
of access to insulin in both people with
type 1 and type 2 diabetes were (see �
��
Figure 5.3):
��
• insulin is too expensive; ��
• lack of availability in all regional areas; ��
• transportation problems; ��
• lack of adequate supply to meet
��
demand; and
��
• very poor quality of insulin.
High cost was the most important cause Figure 5.2

for the lack of access to insulin in people Access to insulin for people with type 2 diabetes by region
with type 1 diabetes in most countries
��
in Africa (7 out of 9), but less so in
South and Central America (3 out of 8) ��
and North America (2 out of 10) (see
��
Table 5.3). Two countries, Zambia and
Sri Lanka, reported poor quality of insulin
��
��
as a cause of lack of access to insulin
��
in people with type 2 diabetes (see
Table 5.4). ��
��
Cost of insulin
��
At present, human insulin is the most ��

available form of insulin in the world,
��
according to the results of the survey.
This is followed by pork, beef and �
��
pork/beef mixture, as shown in
Figure 5.4. ��
��
Animal insulin is considerably cheaper ��
in those countries where both human ��
and animal insulin are available,
��
except in some countries in the North
��
195

Chapter 5
Figure 5.3
Causes of lack of access to insulin
��
��
��
��
��
��
� � ��
��
��
��
Figure 5.4 Bangladesh (SEA), and Japan and

Types of insulin available around the world Hong Kong (WP).
��
��
In many countries, insulin in vial form
is significantly cheaper than the same
�� type of insulin in pen-fill cartridge form.
Insulin in vial form should continue to
be available in economically developing
countries to people who otherwise would
�� have to pay a higher price for the same
insulin in pen-fill form.
Taxes are still a significant factor

affecting the price of insulin (and other
diabetes supplies) in a great number of
countries even though WHO essential
American and Western Pacific Regions, drugs guidelines state there should be
as shown in Figure 5.5 and Table 5.5. no taxes on insulin. Taxes were added on
In Africa, for example, the average cost the price of insulin in 7 out of 8 countries
of human insulin is twice as expensive in SACA; 5 out of 9 in Africa; 4 out of 8
as animal insulin. A box of 10 ml U-100 in WP; 12 out of 31 in Europe; 1 out of 3
human insulin was cheapest and most in SEA; and 2 out of 10 in NA (see Figure
expensive respectively in Senegal and 5.6). No taxes were levied in the four
Kenya (AFR), Qatar and Libya (EMME), responding countries in EMME. Taxes
Romania and Italy (EUR), Commonwealth varied from 1% of cost in Kazakhstan to
of Dominica and USA (NA), Cuba and 80% in Poland. Specifically in Africa, it
El Salvador (SACA), Sri Lanka and was 14% in South Africa and 48% in Togo.
196

Chapter 5
Cost implications Figure 5.5

Table 5.6 shows that when the price of Average cost of 10 ml vial of U-100 insulin by region
insulin is compared to the gross national
��
product (GNP) of the countries, insulin
is 3 to 26 times less affordable in Africa
��
than in all other regions. Human insulin
is most affordable in Western Pacific and ��
Europe, and least affordable in Africa
��

while animal insulin is most affordable in ��
South and Central America and Europe,
and least affordable in Africa. ��
��
The main reason for the expansion
of diabetes services in the developed
��
countries was the discovery and
introduction of insulin. Developing �
countries face major scourges including
AIDS, TB and malaria, which compete for �
��
health priority with diabetes. Although
insulin is a life-saving drug, in a situation ��
of grossly restricted medical resources, ��
the ‘opportunity cost’ of keeping alive
a resource-consuming person with
diabetes is a valid if chilling question.
This explains why four African countries Figure 5.6
reported an awareness of death due to Average percentage of taxes on imported and locally
lack of access to insulin in people with produced insulin in four regions
type 1 diabetes.
��
Access to diabetes supplies

��
It would appear from the Global Access
to Insulin and Diabetes Supplies Survey,
��
2003 that blood glucose testing strips
are even less accessible than insulin.
��
Urine testing strips are significantly more ��
accessible because they are much more

affordable. They provide a viable testing ��
method in the absence of affordable
glucose testing. There seems to be
�
evidence that the use of urine strips may
be decreasing without a commensurate
increase in the use of blood glucose �
��
testing strips.
��
Only 40 countries had access to insulin ��
syringes and needles 100% of the time.
Among the regions, Africa had the lowest
access to insulin syringes and needles.
Europe had the highest access followed
by North America (see Table 5.7). The
average cost of 100 insulin syringes was
197

Chapter 5
Figure 5.7 highest in North America, followed by

Average cost of 100 insulin syringes by region South and Central America and Africa,
and cheapest in South-East Asia and
��
Western Pacific (see Figure 5.7).
Self-monitoring of diabetes
��
Urine testing seems to be the method of
��
choice of self-monitoring of diabetes (see

Figure 5.8).
��
In fact, in 71 countries there are

��
individuals who do not monitor their
diabetes either by blood glucose or urine
testing.
�
According to the survey, the main reasons
for not practising self-monitoring were
� (see Figure 5.9):
��
• high cost of testing supplies;

• lack of diabetes education;
• lack of interest by patients; and
• lack of testing supplies.
Figure 5.8
Self-monitoring of glucose and methods used High cost of supplies was the major
reason given by all responding countries
��
in Africa, 75% of the countries in EMME,
71% in Europe, 90% in North America,
��
88% in SACA and 86% in Western Pacific
�� (see Figure 5.10).
��
�� Cost of diabetes supplies

�� There was a great disparity in the cost
of diabetes supplies among the different
��
regions, for instance blood glucose
meters cost, on average, US$105 per
��
glucose meter in the Western Pacific and
�� US$61 in South and Central America (see
Table 5.8). Similarly, a box of 50 blood
� glucose strips costs US$50 in North
� ��
America and US$20 in South-East Asia
�� while a box of 100 urine glucose strips
�� costs US$20 in North America and US$5
�� in South-East Asia (see Figure 5.11). In
some countries, however, these diabetes
supplies are subsidized or supplied free
of charge to particular groups of people
with diabetes.
198

Chapter 5
Figure 5.9
Reasons why people with diabetes do not practise self-monitoring of blood glucose
��
��
��
��
� ��
��
��
��
Figure 5.10
Main reasons for not practising self-monitoring by region
��
��
��
��
��
��
��
��
��
��
��
�
��
��
��
199

Chapter 5
Figure 5.11
Average cost of diabetes supplies by region
a. Blood glucose meter b. 100 urine test strips c. 50 blood glucose strips
��
��

��
��
��

��
��
��
��
��
��
�
��
� � �
��
Conclusion
The chronic lack of access to insulin

and diabetes supplies in most regions
especially the developing countries pose
serious challenges to the international
diabetes community. IDF has positioned
itself to look for long-term solutions
to these problems. Our individual and
collective responsibilities are important
to alleviate these problems. At the
national level IDF can serve as a catalyst
to massive price reductions as it has
been the case in India. The Task Force
on Insulin will continue to work with
other groups within and outside IDF to
establish national collaborative projects.
It still appears that Derek Wall, an

ecologist, was right when he said, “At
present cats have more power and
influence than the poor of this planet.
Accidents of geography and colonial
history should no longer determine who
gets the fish.” The international diabetes
family can defend the rights of those
who will die because they lack insulin,
and work towards a world where insulin
and other diabetes supplies are freely
available to all those with diabetes.
200

Chapter 5
Profile: Hamisi Rashidi
T wice a day Hamisi Rashidi removes a vial of insulin from a mud pot filled with water for
his daily injections. The mud pot is the only way Hamisi, 12, can store his supply of insulin
without it being destroyed. Sometimes, he says, “the water seeps
into the insulin bottles diluting the insulin, and due to that I get
high blood glucose even if I have injected insulin.”
Storage is a major problem for Hamisi, who has had type 1

diabetes since he was three. His parents cannot afford to buy a
refrigerator; they live in a one-room house without electricity or
running water in Dar es Salaam, Tanzania.
His parents also cannot afford to buy syringes although Hamisi

obtains his insulin free of charge from the District Hospital. He
uses a disposable syringe for about two and a half weeks before
buying a new one. His parents worry greatly about sustaining
his insulin treatment with their meagre earnings. Hamisi’s father
does odd jobs while his mother is a housewife.
An added expense has now arisen with his weakened eyesight,

which was discovered during a recent screening programme
conducted by the Tanzanian Diabetes Association on World Diabetes Day. He has been advised
to wear spectacles.
Hamisi has learnt to cope with the ups and downs and to find the right balance in order to
avoid hypoglycaemia and hyperglycaemia. His parents have taught him to keep to a strict
schedule for his meals and insulin injections. Says his mother, “Whenever he is not well we ask
him to tell us if the sugar levels are high or low. He knows and understands more than we do
and is the best judge during such a time.”
Optimistic and cheerful by nature, Hamisi welcomes his insulin injections rather than dreads
them: “I’m not afraid; I like to inject insulin as it makes me hungry and I feel better. Otherwise
I don’t feel hungry and I don’t like to eat anything.”
Hamisi, the second child in a family of six children, is the only one to have diabetes. His
parents had never heard about the disease and were heartbroken on hearing the diagnosis.
They were not sure what they would do and how they would treat Hamisi. “I was so worried
about my child that I stopped eating and sleeping and would watch him all the time,” recalls
his mother.
Although Hamisi wonders at times why he is the only one in the family to have diabetes, he
does not see much difference between himself and his friends who do not have the disease,
“I can do what they can do. I will be a doctor when I grow up and help people with diabetes.”
201

Chapter 5
Table 5.1
Access to insulin for people with type 1 diabetes
AFR EMME EUR NA SACA SEA WP Total

No. of countries 9 4 32 10 8 3 8 74
<25% 2 0 0 0 0 0 0 2
26-49% 1 0 0 0 0 0 0 1
50-74% 3 0 0 1 3 0 0 7
75-99% 3 1 4 5 2 2 3 20
100% 0 3 28 4 3 1 5 44
Table 5.2
Access to insulin for people with type 2 diabetes

No. of countries 9 4 32 10 8 3 8 74
<25% 1 0 1 0 0 0 0 2
26-49% 2 0 0 0 3 0 0 5
50-74% 2 0 1 1 0 0 1 5
75-99% 4 1 5 5 3 2 2 22
100% 0 3 25 4 2 1 5 40
Table 5.3
Causes of lack of access to insulin for people with type 1 diabetes

No. of countries 9 4 32 10 8 3 8 74
Insulin is too expensive 7 0 2 2 3 1 0 15
Not available in regional areas 5 1 1 2 4 1 0 14
Transportation problems 3 0 0 0 2 1 1 7
Supply is less than required 2 0 1 1 2 0 0 6
Insulin is of very poor quality 0 0 1 0 1 1 0 3
Table 5.4
Causes of lack of access to insulin for people with type 2 diabetes

No. of countries 9 4 32 10 8 3 8 74
Insulin is too expensive 6 0 1 0 1 1 0 9
Not available in regional areas 4 1 1 1 2 1 1 11
Transportation problems 3 0 0 0 1 1 0 5
Supply is less than required 2 0 2 1 2 0 0 7
Insulin is of very poor quality 1 0 0 0 0 1 0 2
Preference is given to type 1 0 0 1 1 3 1 0 6
AFR African Region

EMME Eastern Mediterranean and Middle East Region
EUR European Region
NA North American Region
SACA South and Central American Region
SEA South-East Asian Region
WP Western Pacific Region
202

Chapter 5
Table 5.5
Number of countries where 10 ml vial of U-100 insulin is available and cost
(median and minimum-maximum) (USD) of human and animal insulin by region

No. of countries 9 4 32 10 8 3 8 74
Human insulin
No. of countries 7 4 22 9 7 3 6 58
Cost per box of 10 ml vial 18 (2-21) 4.6 (1-8) 14 (6-26) 14 (5.6-45) 19 (0.04-32) 10 (3-12.5) 9 (3-15) 13 (0.04-45)
Pork insulin
No. of countries 4 0 5 3 4 2 1 19
Cost per box of 10 ml vial 8 (2.5-11) 7 (5-25) 25 (10-45) 11 (0.04-20) 7 (6-8) 11 9 (0.04-45)
Beef insulin
No. of countries 2 1 3 0 2 1 0 9
Cost per box of 10 ml vial 9 (7-11) 3.4 28 (8.5-43) 6 (0.04-12) 3 8.5 (0.04-43)
Mixture of beef/pork insulin

Cost per box of 10 ml vial 9 (7-11) N/A 0.04 7 (0.04-11)
N/A not available
Table 5.6
Number of countries where 10 ml vial of U-100 insulin is available and cost reported to GNP
(median and minimum-maximum) (USD) of human and animal insulin by region

No. of countries 9 4 32 10 8 3 8 74
Human insulin
No. of countries 7 4 22 9 7 3 6 58
Cost (x1000/GNP) per box of
10 ml vial 13 (1-37) 2 (0.3-5) 1 (0.3-4) 2 (1-3) 2 (0.01-8) 4 (0.4-7) 0.5 (0.1-4) 1.3 (0.01-37)
Pork insulin
No. of countries 4 0 5 3 4 2 1 19
10 ml vial 11 (5-13) 1 (0.4-2) 1.5 (1-2) 2 (0.01- 2) 4 (2-6) 5 1.6 (0.01-13)
Beef insulin
10 ml vial 10.6 (9.5-12) 2 1.4 (1-2) 0.5 (0.01-1) 1 1.4 (0.01-12)
Mixture of beef/pork insulin

10 ml vial 11 (9-12) N/A 0.01 10 (0.01-12)
GNP gross national product

N/A not available
203

Chapter 5
Table 5.7
Access to insulin syringes and needles for people with diabetes

No. of countries 9 4 32 10 8 3 8 74
<25% 2 0 0 0 0 0 1 3
26-49% 2 0 2 0 1 0 0 5
50-74% 0 0 0 1 3 0 2 6
75-99% 5 2 5 5 1 2 0 20
100% 0 2 25 4 3 1 5 40
Table 5.8
Cost of other diabetes supplies (median and minimum-maximum) (USD)
AFR EMME EUR* NA* SACA SEA WP Total*

No. of countries 9 4 32 10 8 3 8 74
Cost of 100 syringes 14 (5-30) 11 (4-30) 12 (0-300) 23 (19-30) 15 (0.5-25) 10 (10-12.5) 10 (7-32) 13 (0-300)
Cost of one insulin pen 40 (30-50) 36 (21-97) 39 (0-103) 0 (0-30) 12.5 (0-30) 10 (3-20) 25 (0-44) 25 (0-103)
Cost of one blood glucose meter 96 (35-207) 65 (60-80) 65 (0-150) 65 (0-105) 61 (30-110) 90 (50-110) 105 (10-130) 70 (0-207)
Cost of 50 blood glucose
test strips 36 (15-45) 22 (15-35) 31 (0-50) 50 (20-55) 30 (20-48) 20 (20-21) 29 (3-45) 30 (0-55)
Cost of 100 urine test strips 12 (5-30) 9 (7-30) 10 (0-100) 20 (0-30) 15 (8-30) 5 (2-10) 8 (5-25) 10 (0-100)
* The minimum cost is zero when the diabetes supply was given free to the patient.
204

Chapter 5
List of countries which participated in Bibliography

the Global Access to Insulin and Diabetes
Supplies Survey, 2003 1. Chale SS, Swai AB, Mujinja PG, McLarty DG. Must diabetes
be a fatal disease in Africa? Study of costs of treatment.
Africa (AFR) BMJ 1992; 304:1215-1218.
Cameroon, Democratic Republic of Congo, Côte d’Ivoire, Kenya, 2. Jervell J. Variations in the utilization and cost of insulin. IDF
Senegal, South Africa, Tanzania, Togo and Zambia. Bulletin 1996; 41:1-2.
3. IDF Task Force on Insulin. Access to insulin. A report of the
Eastern Mediterranean and Middle East (EMME) IDF Task Force on Insulin 1994-97. International Diabetes
Egypt, Libya, Pakistan and Qatar. Federation, Brussels, 1997.
4. King H. Insulin: availability, affordability, and
Europe (EUR) harmonization. World Health Organization, Drug, Geneva,
Albania, Austria, Belgium, Croatia, Cyprus, Czech Republic, 1998. 4:219-223.
Denmark, Estonia, Finland, Georgia, Germany, Greece, Hungary, 5. Shobhana R, Rao PR , Lavanya A, Williams R, Vijay V,
Ireland, Israel, Italy, Kazakhstan, Lithuania, Luxembourg, Malta, Ramachandran A. Expenditure on healthcare incurred by
Netherlands, Norway, Poland, Portugal, Romania, Serbia and diabetic subjects in a developing country – a study from
Montenegro, Slovenia, Spain, Sweden, Turkey, UK and Ukraine. southern India. Diabetes Res Clin Pract 2000; 48:37-42.
6. Lin T, Chou P, Lai M, Tsai S, Tai T. Direct cost-of-illness of
North America (NA) patients with diabetes mellitus in Taiwan. Diabetes Res Clin
Anguilla, Belize, Bermuda, British Virgin Islands, Canada, Pract 2001; 54 Suppl 1:43-46.
Commonwealth of Dominica, Guyana, Jamaica, Mexico and USA.
South and Central America (SACA)

Argentina, Bolivia, Brazil, Chile, Cuba, El Salvador, Peru and
Uruguay.
South-East Asia (SEA)

Bangladesh, Mauritius and Sri Lanka.
Western Pacific (WP)

Australia, China Hong Kong, Japan, New Zealand, Philippines,
Singapore, Taiwan and Thailand.
205

Diabetes Education
Chapter 6
Diabetes Education Chapter 6
D iabetes education has been shown to

be effective and is now considered
an integral part of diabetes care. In
acknowledging the critical importance
of education, the International Diabetes
Federation (IDF) established the Diabetes
Education Consultative Section (DECS)
to address the education needs of IDF
member associations.
In continued recognition and support of

education, this chapter of the Diabetes
Atlas is devoted specifically to diabetes
education and is divided into three
sections: the first summarizes the
evidence-based studies supporting the
effectiveness of diabetes education, the
6.1 Effectiveness of Self-
second is a report of education practices
management Education
in the seven IDF regions based on a
6.2 Educational Practices: comprehensive survey, and the final
a Global View section provides projected cost savings
associated when people with diabetes
6.3 Cost-effectiveness of
receive education.
Diabetes Education
207

Diabetes Education
Chapter 6
6.1 Effectiveness of Self-management Education
Introduction 3 adhere to self-care practices; and

4 make needed changes in their health
Although the medical dimensions of habits.
diabetes care such as eye exams and
blood glucose monitoring have improved More broadly, diabetes self-management
in recent years, outcomes for many education assists people in coping with
people with diabetes remain poor (1,2). the mental and physical demands of their
While many factors contribute to poor illness, given their unique economic,
outcome, this apparent contradiction also cultural and social circumstances.
Diabetes self- reflects the central role that people with
management education diabetes themselves play in determining Why is self-management
is a multi-faceted their health status, and the challenges
important?
process involving much associated with supporting their efforts
more than helping to manage their self-care (3). Improving outcomes
people with diabetes Glucose self-monitoring is essential for
monitor their blood Diabetes self-management is among the identifying episodes of extremely high
glucose, or take most difficult of all chronic illness self- and low blood glucose (hyperglycaemia
their medication as management regimens. To effectively and hypoglycaemia), especially among
prescribed. Diabetes self-manage diabetes, those with the people with type 1 diabetes. This was
education must be an disease must identify symptoms of the conclusion of a review of scientific
ongoing process rather emerging health crises, adhere to often evidence by Piette and Glasgow
than a one-time event complex medication schedules, and supporting various diabetes self-care
because a person’s modify long-standing lifestyle behaviours practices and their promotion through
health status and need such as their diet and physical activity self-management supports (see Box
for support changes levels. Not surprisingly, many people 6.1) (9). There is no evidence, however,
over time. have difficulty meeting the demands that glucose self-monitoring improves
of their illness and experience poorer outcomes among people with type 2
outcomes as a result. diabetes (12, 13), although this could
change if effective systems are put
This section reviews the findings in place to address the cause of their
from recent research on diabetes self- problems.
management supports for adults. More
detailed reviews have been published Foot self-care is essential for people with
previously, and readers are encouraged to diabetes in order to avoid infections
seek these out for additional information and ulcers leading to amputation. Foot
about specific topics such as foot self-care education is an effective means
care education, medication adherence of improving foot care practices and
enhancement, or promotion of smoking outcomes (14, 15). Assisting people with
cessation within primary care clinics (4-11). diabetes in taking their medication as
prescribed is also important, and a variety
Goal of diabetes education of low-cost and simple interventions
such as day-specific pill containers and
The goal of diabetes self-management simplified dosing schedules are effective
education is to support the efforts of in doing this (16-19).
people with diabetes to:
1 understand the nature of their illness Changing lifestyle
and its treatment; With regard to lifestyle behaviours,
2 identify emerging health problems in smoking cessation is an essential aspect
early, reversible stages; of diabetes self-care, and interventions
208

Diabetes Education
Chapter 6
to help people quit smoking increase

Box 6.1
cessation rates (20, 21). Brief advice
to quit smoking produces important
Issues to be addressed by diabetes
effects, although behavioural counselling
self-management education
accompanied by medication and ongoing
support has the greatest impact (22, 23).
• Glucose self-monitoring (for some)
• Foot care
Many people with type 2 diabetes are
• Medication adherence
sedentary, and increasing their physical
• Smoking cessation
activity levels can be important. Effective
• Increasing physical activity
physical activity counselling strategies
• Reducing dietary fat and caloric intake
have been identified that can improve
glucose control (24) of people with type
2 diabetes as well as other cardiovascular
risk factors, such as blood pressure (25)
and cholesterol levels (26). Counselling
and support to decrease the amount of
dietary fat and overall caloric intake have
shown some success (11, 27, 28). Two confidence or ‘self-efficacy’ regarding
important studies recently demonstrated self-management.
that lifestyle interventions promoting
physical activity plus dietary changes can A successful programme for achieving
delay the onset of type 2 diabetes among these goals has been developed by
high-risk individuals (29, 30). Kate Lorig and colleagues at Stanford
University (37) in the USA. The
Where should education programme can be delivered in multiple
languages, and recent evaluations
take place?
indicate that it produces lasting
Group visits in medical settings reductions in symptoms, physician visits
People with diabetes often learn as and costs relative to others receiving
much or more within a group context usual care (38). Ongoing research is
than they do on their own or through evaluating the impact of this intervention
one-to-one visits with clinicians. In one on diabetes treatment outcomes among
study, participants in group visits had low-income Spanish-speakers in northern
fewer emergency department visits, California.
visits to sub-specialists and repeat
hospitalizations (31). Similar effects of In another community-based study,
group visits, including improvements in elderly people with diabetes received
glycaemia control, satisfaction, healthcare disability prevention and disease self-
utilization and costs of care, have been management education in a senior
reported in a wide range of populations centre (39). Individuals receiving the
and health systems, including large health intervention had substantially less decline
maintenance organizations (32, 33), in physical function, greater levels of
under-served populations (34) and health physical activity and less reliance on
systems in different countries (35, 36). medications. Those participating in
the groups also used less hospital care
Community-based than those in a comparison group.
peer-support groups Community-based groups such as
People with diabetes also can improve these may be particularly important in
their self-care through classes led by non- settings where people with diabetes have
clinician peers and structured to improve difficulty accessing care within traditional
their understanding of their illness and healthcare settings.
209

Diabetes Education
Chapter 6
Ongoing home support Female physicians often engage in more

via telephone patient-centred communication than their
Self-management support provided male counterparts (54), and patients are
through regular telephone follow-up more satisfied with female providers
improves outcomes of people with (55-58). Continuity of care has been
diabetes. In one study (40) among elderly associated with better communication
men with type 2 diabetes, monthly calls among asthma patients (59) and greater
by a nurse-educator improved glycaemic patient satisfaction and quality in general
control, and a more recent study had (60, 61).
similar results (41). These studies are
consistent with the broader literature on A training programme developed by
telephone care, showing that telephone Robert Anderson and colleagues (62)
calls can improve the health of those who for diabetes educators to help them
are chronically ill and may even serve as learn how to teach people with diabetes
an effective alternative to face-to-face more effective communication strategies
office visits (28, 42, 43). and become more actively involved in
their own treatment. Following training,
Effective communication educators show significant improvement
in their counselling skills and in their
When people with diabetes play attitudes toward supporting patient
central roles in setting their own self- autonomy (62).
care goals, they are more likely to
adhere to treatment plans (44-46). The empowerment approach has been
Diabetes educators can contribute to demonstrated to produce better patient
this process by providing them with outcomes than usual care (63), and
the information they need for priority- another approach to empowering patients
setting and problem-solving, assisting at the time of clinic visits has also been
them in identifying realistic targets for shown to improve glucose levels (64).
behavioural changes, and providing
ongoing emotional support and Role of emerging
encouragement.
health technologies
Through these efforts, educators can A variety of novel technologies has been
improve the long-term ability of people developed to support self-care efforts
with diabetes to maintain an effective self- of people with diabetes and provide
management regimen and help them avoid an alternative to traditional education
emotional burnout (47, 48). More effective occurring within outpatient clinics (65).
communication between the individual
and educator can lead to better self-care Interactive software
behaviour as well as improvements in Interactive software accessed on a
health outcomes (49-53). personal computer using CD-ROMs
or other hardware represents one
Characteristics of patients, providers and strategy for delivering behaviour change
health systems may influence the quality interventions efficiently and effectively
of patient-provider interactions. Race in the context of busy primary care
and ethnicity may constitute barriers to practices. These systems can be placed in
communication with potentially negative clinic waiting rooms where they can reach
effects on patients’ willingness to receive large numbers of people, require minimal
necessary services and follow self-care staffing, and provide self-paced and
plans. tailored educational messages (66).
210

Diabetes Education
Chapter 6
A clinic-based touch-screen computer

Box 6.2
system was developed by Glasgow and
colleagues to assist diabetes patients
Components of effective self-management
assess their health behaviours, self-
programmes
management goals and barriers to goal
attainment (67). Compared to similar
• Ongoing support rather than one-time counselling
patients, those using the CD-ROM system
• Group visits and peer-to-peer counselling
had improvements in their diet and lower
• Telephone care including the use of automated
cholesterol levels (68, 69).
telephone calls
• Effective communication with providers to set self-
Automated telephone systems
management goals and overcome barriers
Automated telephone systems can allow
• Use of interactive technologies
for frequent follow-up with individuals
• A coordinated systems approach
who have difficulty accessing clinic-
based services or who lack the computer
supports necessary for more ‘high-tech’
interventions. Those who are chronically
ill can provide valid and reliable
information using their touch-tone
telephone during automated monitoring experience by using audio and video,
calls (70, 71). and are potentially available 24 hours
per day. Internet-based diabetes supports
A study, by Piette and colleagues, found also allow people with diabetes to
that a group of low-income English- and communicate with their clinicians,
Spanish-speaking people with diabetes experts in self-care, or one another.
receiving bi-weekly automated calls with
telephone nurse follow-up responded to One of the most definitive studies of
the calls consistently over the 12-month internet-based diabetes supports (81)
study period (72). These individuals used evaluated a web-based self-management
the calls to access self-care education programme in which participants were
(73), and reported information that encouraged to log on to a specially-
identified those at greatest risk for designed website, review their progress
developing problems (74). toward self-management goals, and
access other services such as an online
The intervention improved their blood log of their progress and personal
glucose self-monitoring, foot care, counselling and support. At follow-up,
weight self-monitoring and medication those using the website and those in the
adherence (75). The study also found comparison group improved in their self-
improvements in their glucose control, reported physical activity, however there
diabetes-related symptoms and were no significant differences between
symptoms of depression (76). These the two groups. Individuals who used the
same investigators replicated this study system more frequently reported greater
in another US health system and had change in physical activity than those
similar findings (77). who used it less often.
Internet-based support Summary

Internet-based diabetes self-care support
has the potential to reach large numbers Diabetes self-management education is
of people, and even computer novices a multi-faceted process involving much
are willing to use internet-based diabetes more than helping people with diabetes
education programmes (78-80). Such monitor their blood glucose, or take
systems can enhance the educational their medication as prescribed. Diabetes
211

Diabetes Education
Chapter 6
education must be an ongoing process

rather than a one-time event because
a person’s health status and need for
support changes over time (Box 6.2) (11).
One-on-one counselling may be helpful

to improving self-care, although group
sessions led either by clinicians or others
with diabetes also can be effective.
Telephone care can be a vital link
between people with diabetes and their
healthcare providers for ongoing self-
management support, especially when
there is difficulty accessing face-to-face
services. Automated telephone calls can
extend the reach of self-management
education when staffing is limited or an
individual needs frequent monitoring and
behaviour change supports.
Effective communication with healthcare

providers is strongly linked to
improvements in self-care and outcomes,
and self-management educators can
play an important role in empowering
people with diabetes to become active
participants in identifying self-care
goals and overcoming barriers to their
achievement. Overall, self-management
education is most likely to be successful
when it is part of a comprehensive
and coordinated approach to diabetes
care (82).
212

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patient compliance: a meta-analysis. Medical Care 1998;

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outcomes of diabetes care (a randomized controlled trial);

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Chapter 6
6.2 Educational Practices: a Global View
Introduction Survey response
The efforts of the IDF Diabetes Education The survey questionnaire was sent to
Consultative Section (DECS) are targeted all IDF members associations by mail
to address the needs of three audiences: and electronically. At every opportunity
the person with diabetes and those DECS members, regional chairs and
affected by the disease, the healthcare managers distributed and encouraged
professional responsible for providing survey responses. Some 122 survey
diabetes care, and the public. In an questionnaires were returned and
attempt to capture educational practices analysed. The vast majority of the
that apply to each of these audiences, respondents completing the survey for
DECS members representing all diabetes each country identified themselves as
disciplines from each of the IDF regions physicians and in some cases educators.
designed a survey that was sent to The surveys responses represented:
member associations.
• 57 countries
The survey was designed to gain an • 7 regions
understanding of diabetes educational – Africa (AFR) (n=7)
practice as it applies to all three of the – Eastern Mediterranean and
audiences: the person with diabetes, Middle East (EMME) (n=5)
health professionals and the public. – Europe (EUR) (n=35)
Members of the consultative section – North America (NA) (n=6)
recognize that this survey serves as a – South and Central America
crude methodology in capturing data (SACA) (n=18)
and information; however it does offer – South-East Asia (SEA) (n=8)
the first opportunity to gain a baseline – Western Pacific (WP) (n=36)
understanding of practices and concerns.
It is hoped that this attempt and its Summary of results
findings will pique continued interest
in diabetes education efforts and the The following summarizes survey
development of future tracking, reporting findings according to regions since
and intervention efforts. efforts of the consultative section are
often targeted with far-reaching regional
approaches. More detailed information
for each member country is available in
Figure 6.1 addressing country-specific needs.
Providers of diabetes education
Educational resources
Physicians were identified as the main
��
provider of diabetes education in most
regions, as shown in Figure 6.1, when
�� respondents were asked who provides
education in their country. The exception
was in the Eastern Mediterranean and
Middle East Region, where pharmacists
were most likely to provide education.
��
Short training courses of 40-120 hours

were most often the mechanism for
216

Diabetes Education
Chapter 6
Figure 6.2
Type of training available to diabetes educators
��
��
��
��
��
� ��
� ��
��
� ��
� � ��
��
training, as shown in Figure 6.2, when Figure 6.3

respondents were asked how people Availability of teaching tools
were trained to be educators. However,
��
the African and South-East Asian Regions
��
reported that there was very limited or no
educator training available.
��
Teaching tools are reported to be

available in all regions, but every region
supported the need for computerized ��
resources and networking opportunities.
The media proved to be the tool most
available in all the regions, as indicated in
Figure 6.3.
ADA American Diabetes Association
Respondents expressed interest in having

an international summit addressing the Figure 6.4
global needs and problems related to Understanding and appreciating the role of diabetes educators
diabetes education, and identified IDF as
��
a resource for support in training and the ��
development of standards for practice
(see Box 6.3).
Role of diabetes educators

All regions reported that people with ��
diabetes understood and appreciated
the role of diabetes educators, as shown
in Figure 6.4. This was in contrast to
health authorities, and to some extent, ��
physicians, not many of whom were
217

Diabetes Education
Chapter 6
Box 6.3
Diabetes education training course: the Caribbean example
T he Diabetes Education Consultative Section (DECS) has successfully organized training courses in
collaboration with IDF regions and local diabetes associations. The Caribbean Diabetes Education
Course, organized by the IDF North American Region in collaboration with the Diabetes Association of
Barbados, is a good example of such training courses.
The course, which was based on models developed by DECS and the Declaration of the Americas on
Diabetes (DOTA), was run in two parts. Part one was held in the Barbados and part two, held in the
Bahamas, was a follow-up a year later.
Nurses, dietitians, pharmacists and educators from 13 Caribbean island countries attended the five-day
course in Barbados. Participants came away with updated knowledge in the management of diabetes
and its complications as well as developing their skills in diabetes education and organization. An
important objective was to facilitate the establishment of a programme plan for diabetes education in
each participant’s country.
Mentors were assigned to participants and worked with them throughout the week. This proved to
be an invaluable tool as the evaluation at the end of the course showed: “Excellent guidance for the
programme and ongoing projects – the mentoring concept keeps the group focused.”
Course content included both theory and practical application. Participants were also asked to work on
projects such as foot care education programmes for patients and healthcare professionals, educating
healthcare professionals on diabetes management and healthy lifestyle education which was aimed
at prevention. Projects were to be developed in the next year with strict deadlines. Participants who
completed the project were invited to the follow-up meeting in the Bahamas the following year.
The course was geared towards motivating the participants to apply their training on returning to their
countries. Each participant was asked to propose changes they would make to their practice.
The follow-up course, which took place a year later in the Bahamas, was organized this time in
association with the Bahamas Diabetic Association.
The follow-up course programme was developed based on the IDF International Curriculum for Diabetes
Health Professional Education (1). The course also included a poster presentation of the projects that the
participants from the Barbados course had worked on in collaboration with their mentors.
reported to show understanding of the Access to education

role of diabetes educators in some of Although all countries reported that
the regions. Nonetheless, respondents people with diabetes have access to
reported that the majority of physicians diabetes education, they nonetheless
in all regions, except Africa, did promote identified barriers to access. Barriers were
and refer patients for diabetes education. analysed according to four categories
In addition, all of the respondents were outlined in the ‘Barriers to Diabetes
aware of published studies validating the Care’ instrument (2) used to measure
importance of education.
218

Diabetes Education
Chapter 6
Figure 6.5
Barriers to education
��
��
��
��
� � ��
��
the healthcare provider’s perceptions of Discussion

barriers.
Limitations
Each of the four categories refers to There are several limitations to the
specific problems: interpretation of the summary report
based on challenges inherent in the
1 Psychological: addresses health information gathered through the survey.
beliefs/self-efficacy; Although all IDF member associations
2 Educational: refers to lack of received the survey forms, response
knowledge or education services; rates varied. Some regions, such as
3 Internal physical: refers to other Europe and Western Pacific, had a high
diabetes-related problems such as number of responses while other regions
heart or kidney disease and the had a lower participation. This could be
effects of treatment; and reflective of the make-up of a particular
4 External physical: refers to problems region. For example, the Western Pacific
that are financial or limitations to represents 19 member associations with
proper access. many smaller islands, while South-East
Asia with a large population affected
The categories most frequently reported by diabetes has only five member
as being significant barriers were the associations.
external physical and educational, as
shown in Figure 6.5. In other words, Each of the regions has a diverse group
financial resources, limited access, lack of of member countries that vary in size,
knowledge and educational resources are populations, culture, healthcare practices
perceived to be the biggest challenges. and socio-economics. For example, the
North American Region includes large
Training and advocacy efforts directed developed countries such as Canada
toward health ministers and public and the United States, and developing
awareness were some of the mechanisms countries such as Mexico and the small
most often identified as means to address Caribbean islands.
these barriers, as seen in Figure 6.6.
The regional descriptions in the survey
provide summary information and do not
provide the detail needed to appreciate
219

Diabetes Education
Chapter 6
Figure 6.6
Means to overcome barriers to diabetes education
��
��
��
��
��
��
� � ��
��
the practices and needs of specific References

countries. Descriptions according to
1. IDF Consultative Section on Diabetes
countries and regions will vary in their Education. International Curriculum for
level of detail in accordance with the Diabetes Health Professional Education.
information that was received. International Diabetes Federation, Brussels,
2002.
2. Simmons D, Weblemoe T, Voyle J, Prichard A,
Common themes Leakehe L, Gatland B. Personal barriers
Despite the apparent limitations to diabetes care: Lessons from a multi-
ethnic community in New Zealand. Diabetic
consistent themes were reported that
Medicine 1998; 15(11):958-964.
need to be addressed as the world
incidence and prevalence of diabetes
grow. From the survey it appears that
although some countries do have national
health programmes that include attention
to diabetes education others do not. All
the regions reported poor funding for
education.
Recurrent themes for potential solutions

occurred and should be considered. For
prevention and treatment of diabetes
to be successful through education
initiatives, governments, and local,
national and international health
associations need to organize efforts to
promote the training, financial support,
access and public awareness of diabetes
education.
220

Diabetes Education
Chapter 6
6.3 Cost-Effectiveness of Diabetes Education
Introduction Three independent reviews note that

the economic costs and benefits of
Economic issues in diabetes care are diabetes education have not been fully
garnering great attention throughout addressed (1-3). Several studies provide
the world today. This attention has been either a poor accounting of costs (such as
particularly pronounced in recent years. neglecting to account for the programme
Cost issues in diabetes self-management costs inherent in providing education),
training are of interest because of three or an inadequate comparison group to
current and significant influences; first, assess the impact on diabetes-related
the recognition that diabetes is increasing outcomes. A multi-centre
throughout the world, second, the intervention in
recognition that self-management training Despite the recognized limitations 10 countries in
is effective in improving the health of in economic methodology, Klonoff Latin America has
persons with diabetes, and third, the and Schwartz (1) conclude that self- demonstrated that an
desire of many healthcare payers to limit management training in diabetes is educational programme
healthcare costs. probably cost-effective. This judgment is can reduce the cost
based on a large number of studies that of drugs by 62%.
In this light, cost-effectiveness suggest an economic benefit to self- Another programme
analyses are often used to evaluate management training programmes. in Argentina found a
the economic arguments surrounding reduction in diabetes-
diabetes treatments and interventions. For example, reduced future related costs of 38%.
A cost-effectiveness analysis generally hospitalizations associated with self-
summarizes the impact of an management interventions have been
intervention by characterizing the cost noted in several (1), though, not all
of the intervention relative to the health reports (4, 5). Hospital costs represent
outcomes obtained. These studies are the largest expenditure for diabetes care
used to advocate for the adoption of in several countries and reducing hospital
a healthcare intervention. Typically, costs thereby generally saves money. A
the policy decision is whether a new multi-centre intervention in 10 countries
intervention is better able to meet in Latin America has also demonstrated
a healthcare goal than the existing that an educational programme can
standard of care at a reasonable cost. reduce the cost of drugs by 62% (6).
Another programme in Argentina found
Current understanding a reduction in diabetes-related costs of
38% (7).
Economic arguments for the adoption
of self-management training can be Diabetes education is also an integral part
a powerful tool for advocates and of several interventions that have been
others seeking to improve the health shown to save money. These include
of the diabetes population. Does the interventions that address diabetes and
implementation of diabetes education pregnancy (8, 9) and those that shift the
represent value for money? The answer initiation of insulin therapy from inpatient
is not clearly understood at this time. to outpatient settings (10-13).
Both the multi-faceted nature of diabetes
self-management and the dynamic way in More recently, self-management and
which it is used in diabetes care make it diabetes education have been a vital
difficult to decipher the economic benefit component in landmark intensive
related to diabetes education alone. treatment and lifestyle modification
221

Diabetes Education
Chapter 6
clinical trials. Intensive treatment, as

practised in the Diabetes Control and
Complications Trial (DCCT) and United
Kingdom Prospective Diabetes Study
(UKPDS), is now generally regarded
as being cost effective, where health
benefits can be obtained at a reasonable
additional cost (14, 15). Emerging work
from the Diabetes Prevention Program
gives promise to the economic benefit
of preventing diabetes through lifestyle
changes.
Future needs
In the current healthcare environment,
questions arise over the cost of self-care
and diabetes education programmes and
who will pay for it. While most evidence
is encouraging regarding the economic
benefits of diabetes education, the
multi-faceted nature of self-management
training and the team approach to
diabetes care limits our ability to
conclusively demonstrate its economic
effect. As economic data provide effect to
advocacy arguments, future evaluations
of education interventions should seek
to fully describe the associated economic
costs and benefits.
222

Diabetes Education
Chapter 6
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7. Gagliardino JJ, Etchegoyen G. A model educational program
for people with type 2 diabetes: a cooperative Latin
American implementation study (PEDNID-LA). Diabetes Care
2001; 24(6):1001-1007.
8. Scheffler RM, Feuchtbaum LB, Phibbs CS. Prevention: the
cost-effectiveness of the California diabetes and pregnancy
program. Am J Public Health 1992; 82:168-175.
9. Elixhauser A, Weschler JM, Kitzmiller JL, Marks JS,
Bennert Jr HW, Coustan DR, Gabbe SG, Herman WH,
Kaufmann RC, Ogata ES, Sepe SJ. Cost-benefit analysis of
preconception care for women with established diabetes
mellitus. Diabetes Care 1993; 16(8):1146-1157.
10. Simell T, Moren R, Keltikangas-Jarvinen L, Hakalax J,
Simell O. Short-term and long-term initial stay in hospital
of children with insulin-dependent diabetes: adjustment of
families after two years. Acta Paediatr 1995; 84:41-50.
11. Penfornis A, Millot L. Initiating insulin treatment in insulin-
requiring type 2 diabetic patients: comparative efficiency
and cost of outpatient and inpatient management. INNOV
Study Group. Diabetes Metab 1998; 24(2):137-142.
12. Mengistu M, Lungi Y, Mamo F. Inpatient or outpatient
initiation of insulin therapy. Experience and cost effective
analysis in a suboptimal clinical setting. Trop Geogr Med
1991; 43(1-2):180-183.
13. Dougherty G, Schiffrin A, White D, Soderstrom L,
Sufrategui M. Home-based management can achieve
intensification cost-effectively in Type 1 diabetes. Pediatrics
1999; 103(1):122-128.
14. The DCCT Research Group. Lifetime benefits and costs of
intensive therapy as practiced in the DCCT. JAMA 1996;
276:1409-1415.
15. Gray A, Raikou M, McGuire A, Fenn P, Stevens R, Cull C,
et al. Cost effectiveness of an intensive blood glucose
control policy in patients with type 2 diabetes: Economic
analysis alongside randomised controlled trial (UKPDS 41).
BMJ 2000; 320:1373-1378.
223

Meeting the Challenges
Chapter 7
Meeting the Challenges Chapter 7
W hile other chapters discuss diabetes

from a global perspective, this
chapter looks at it from a regional
viewpoint. This close-up of the seven
regions, reflecting the IDF regional
structure, will provide readers with an
overview of diabetes prevalence, care and
management as well as the challenges
posed by the diabetes epidemic.
The seven regions are:
• Africa (AFR)
• Eastern Mediterranean and Middle East
(EMME)
• Europe (EUR)
• North America (NA)
7.1 Africa
• South and Central America (SACA)
7.2 Eastern Mediterranean • South-East Asia (SEA)
and Middle East • Western Pacific (WP)
7.3 Europe
Although diabetes is the common enemy,
7.4 North America evidence shows that the challenges
differ from region to region as a result of
7.5 South and Central America
several complex and interrelated factors.
7.6 South-East Asia Actions carried out at regional levels
also indicate that culturally appropriate
7.7 Western Pacific
strategies must be identified in order to
improve the lives of people with diabetes
as well as prevent those at risk from
developing the disease.
225

Chapter 7
7.1 Africa
The landscape of sub-Saharan Africa

At a glance
is dominated by the twin disasters of
poverty and HIV infection. All of the
All diabetes and IGT 2003 2025 countries, except South Africa, Gabon
and Zimbabwe, currently have per
Total population (millions) 666.6 1,107.4 capita gross domestic products (GDPs)
Adult population (millions) of less than US$2,000, and for half of
(20-79 years) 295.1 541.1 these countries the figure is less than
Diabetes prevalence (%) US$1,000. The greatest life expectancy
(20-79 years) 2.4 2.8 is in Senegal (63 years), and in over half
Diabetes numbers (millions) the countries life expectancy at birth
(20-79 years) 7.1 15.0 is less than 50 years. Two of the three
IGT prevalence (%) countries with higher GDPs, South Africa
(20-79 years) 7.3 7.3 and Zimbabwe, have HIV infection rates
IGT numbers (millions) currently estimated at 20% and 25%
(20-79 years) 21.4 39.4 respectively (1).
While HIV infection and AIDS so dominate

the health needs for sub-Saharan Africa,
there is only a small proportion of the
population reaching ages at which type
2 diabetes becomes a major health
Introduction concern. For all sub-Saharan Africa, only
9.7% of the population is currently 50
Diabetes exerts a considerable toll on years of age or older, and this is expected
health resources of the developing to increase to only 10.5% by 2025.
countries of sub-Saharan Africa. The Thus the effects of HIV and malnutrition
chronicity of the disease and diabetic combine to greatly reduce the size of the
complications also place a heavy burden groups most at risk for type 2 diabetes.
on people with diabetes and their
families. Diabetes and IGT prevalence
Of the 49 least developed countries There are marked discrepancies between
in the world, as defined by the United the prevalences of diabetes among
Nations Economic and Social Council, 33 different communities in sub-Saharan
are in sub-Saharan Africa. The economic Africa (see Chapter 1). The highest
cost of diabetes and its complications prevalences are among the ethnic Indian
cannot be met by most of the individuals population of Tanzania (2) and South
and families in these countries whose Africa (3). The studies from Tanzania
incomes are insufficient to purchase (4, 5) (urban:rural ratio of 5:1) and
insulin, oral hypoglycaemic agents and Cameroon (6) (ratio of 2:1) both confirm
other supplies for diabetes management. the marked urban/rural discrepancy in
diabetes prevalence, with the consequent
The rate at which new cases of diabetes likely increases as more people move to
are emerging poses an additional burden urban areas.
on countries already stretched to the limit
by common life-threatening infections The availability of prevalence data for
such as malaria, tuberculosis and sub-Saharan Africa is very limited, and
HIV/AIDS. nearly all the data in Chapter 1 were
226

Chapter 7
derived from studies from South Africa (7, kilometres from where the study was
8), Tanzania (4, 5), Ghana (9), Cameroon undertaken.
(6) and Sudan (10). This meant that
data from these studies were applied to It should be noted that the Cameroon
populations living up to several thousand and Ghana studies indicated markedly
Figure 7.1
Prevalence estimates of diabetes in selected countries – African Region
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Figure 7.2
Prevalence estimates of impaired glucose tolerance in selected countries – African Region
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227

Chapter 7
rising prevalence of impaired glucose

At a glance
tolerance (IGT), which now varies
between 2.2% and 16.2%.
Type 1 diabetes 2003
Incidence of type 1 diabetes
Child population (millions) The need for extrapolation of rates of
(0-14 years) 295.0 childhood type 1 diabetes was also
particularly evident in the sub-Saharan
Type 1 diabetes prevalence (%) African region. Published rates were
(0-14 years) 0.01 found for only three of the countries
in this region, and some of the studies
Type 1 diabetes numbers (thousands) were of poor quality and based on
(0-14 years) 35.1 small numbers. Consequently imperfect
estimates of rates from Nigeria, Zambia
and Tanzania have had to be used for
widespread extrapolations because of
the dearth of published studies (see
Chapter 2).
different prevalences of diabetes and IGT Diabetes care

among the urban participants surveyed,
and these differences are too pronounced Most of the diabetes care services in the
to be a consequence of the changed developing countries of sub-Saharan
WHO diagnostic criteria since 1999 (11). Africa have been established through
Notwithstanding that Cameroon and unsystematic, needs-based efforts. This
Ghana are about 1,000 kilometres apart, is due to the limited resources of these
and classified by the United Nations countries which have to be divided
(12) as being in different parts of Africa between fighting poverty, implementing
(central and western, respectively), it was education strategies, providing housing
decided to use the average of the results and appropriate sanitation, as well as
of the two studies to apply to the other the social, economic and health burden
African countries not otherwise applying of fighting the increasing prevalence and
the Tanzanian, South African or Sudanese incidence of HIV and AIDS.
data.
As the burden of diabetes and
That the data should need to be its complications increases with
extrapolated to such distant and probably modernization, economic wellbeing and
dissimilar countries and populations westernized lifestyle, these resource-
indicates the great need for further limited countries are unable to provide
epidemiological investigation in the even minimum care in some instances, let
region. Such a need can also be linked alone secondary and tertiary care.
with the high rate of diabetes that
had not been previously detected, but There is an urgent need for a multi-
found only at the time of surveying. sectoral approach in which governments,
Undiagnosed diabetes accounted for 60% the pharmaceutical industry, national
of those with the disease in Cameroon diabetes associations, healthcare
(6), 70% in Ghana (9) and over 80% of the providers and people with diabetes can
recent Tanzania survey (5). play a role in providing at least minimum
standards of care that would help those
The impact of type 2 diabetes is bound affected maintain the best possible
to continue if nothing is done to curb the quality of life.
228

Chapter 7
Regional initiatives References
1. CIA. World Factbook 2002. Central

The IDF African Region has addressed Intelligence Agency, 2002.
two critical issues by forming task forces 2. Ramaiya KL, Denver E, Yudkin JS.
on diabetes clinical care guidelines and Diabetes, impaired glucose tolerance and
cardiovascular disease risk factors in the
diabetes education.
Asian Indian Bhatia community living in
Tanzania and in the United Kingdom. Diabet
The objective of the Task Force on Med 1995; 12(10):904-910.
3. Omar MA, Seedat MA, Dyer RB, Motala AA,
Diabetes Clinical Care Guidelines is to
et al. South African Indians show a high
provide standardized clinical guidelines prevalence of NIDDM and bimodality in
for diabetes care and to promote its plasma glucose distribution patterns.
implementation and use in order to Diabetes Care 1994; 17(1):70-73.
4. McLarty DG, Swai AB, Kitange AM, Masuki G,
improve the quality of care provided to et al. Prevalence of diabetes and impaired
people with diabetes. glucose tolerance in rural Tanzania. Lancet
1989; 1(8643):871-875.
5. Aspray TJ, Mugusi F, Rashid S, Whiting D,
The aim of the Task Force on Diabetes
et al. Rural and urban differences in diabetes
Education is to provide high quality prevalence in Tanzania: the role of obesity,
information by adequately trained physical inactivity and urban living. Trans R
Soc Trop Med Hyg 2000; 94(6):637-644.
individuals to people with diabetes so
6. Mbanya JC, Ngogang J, Salah JN,
as to improve their standard of care. Minkoulou E, et al. Prevalence of NIDDM and
impaired glucose tolerance in a rural and an
A standardized curriculum taking into urban population in Cameroon. Diabetologia
1997; 40(7):824-829.
consideration socio-economic variations 7. Omar MA, Seedat MA, Motala AA, Dyer RB,
within the region will be developed et al. The prevalence of diabetes mellitus
using existing resources such as the IDF and impaired glucose tolerance in a group
of urban South African blacks. S Afr Med J
Diabetes Education Consultative Section
1993; 83(9):641-643.
(DECS) and the Pan African Diabetes 8. Levitt NS, Katzenellenbogen JM, Bradshaw D,
Education Study Group (PADEG). Hoffman MN, et al. The prevalence and
identification of risk factors for NIDDM in
urban Africans in Cape Town, South Africa.
Diabetes Care 1993; 16(4):601-607.
9. Amoah AG, Owusu SK, Adjei S. Diabetes in
Ghana: a community based prevalence study
in Greater Accra. Diabetes Res Clin Pract
2002; 56(3):197-205.
10. Elbagir MN, Eltom MA, Elmahadi EM,
Kadam IM, Berne C. A population-based
study of the prevalence of diabetes and
impaired glucose tolerance in adults in
northern Sudan. Diabetes Care 1996;
19:1126-1128.
11. World Health Organization. Definition,
Diagnosis and Classification of Diabetes
Mellitus and its Complications; Part 1:
Diagnosis and Classification of Diabetes
Mellitus. World Health Organization,
Department of Noncommunicable Disease
Surveillance, Geneva, 1999.
12. United Nations Population Division. World
Population Prospects: The 2000 Revision.
United Nations, Geneva, 2001.
230

Chapter 7
7.2 Eastern Mediterranean and Middle East
Diabetes prevalence in some countries of

the Eastern Mediterranean and Middle East All diabetes and IGT 2003 2025
Region (EMME) are among the highest in
the world. This vast region extends from Total population (millions) 544.6 839.2
Pakistan in the east to Morocco in the Adult population (millions)
west, and the population is a mosaic of (20-79 years) 276.0 493.6
several ethnic groups. The age distribution Diabetes prevalence (%)
(20-79 years) 7.0 8.0
pattern of the population is pyramidal
Diabetes numbers (millions)
with about 50% of the population below
(20-79 years) 19.2 39.4
the age of 20 years.
IGT prevalence (%)
(20-79 years) 6.8 7.4
Over the past three decades major social IGT numbers (millions)
and economic changes have occurred (20-79 years) 18.7 36.5
in the majority of these nations. These
include progressive urbanization,
decreasing infant mortality and increasing
life expectancy. Current life expectancy
exceeds 65 years in most member
countries, while per capita GDP varies
markedly, from US$800 in Afghanistan to with IGT is expected to also double from
US$21,200 in Qatar. 18.7 million today to 36.5 million in
2025, increasing the likelihood of further
Rapid economic development, especially increases in the prevalence of diabetes as
among the more wealthy oil-producing the century proceeds.
countries, has been associated with
tremendous changes in lifestyle towards The ageing of populations, together with
the westernized pattern reflected by socio-economic changes and
changes in nutrition, less physical activity, westernization, has resulted in the
tendency to increased obesity and more dramatic increase in the diabetes
smoking (1-5). prevalence. Studies conducted in different
populations have reported prevalences as
Diabetes and IGT prevalence high as 20% in the United Arab Emirates
(6), 16% in Qatar and 15% in Bahrain (7),
The last two decades have witnessed a but even in much less affluent Pakistan the
change in diabetes epidemiology. It is prevalence is 8.5% (8-10).
now recognized that it is the developing
countries, and the migrant population Four of the countries of the region –
from the Indian subcontinent living in the United Arab Emirates, Bahrain, Kuwait and
developed countries, which presently face Oman (6, 7, 11, 12) – have had studies
the greatest burden of diabetes. performed showing their current diabetes
prevalence to be among the world’s 10
The explosion of diabetes in the EMME highest, and a similar situation applies for
Region is mainly due to type 2 diabetes. the IGT prevalence of these countries (see
An estimated 19.2 million people, or 7% Chapter 1). As with many other countries
of the adult population, have diabetes. with high diabetes prevalence, the onset
This is anticipated to more than double of type 2 diabetes tends to occur at a
by 2025. Similarly the number of persons relatively young age.
231

Chapter 7
In contrast to Africa, there are a large areas with the changes in lifestyle leading
number of studies ascertaining diabetes to increased prevalence of diabetes and
prevalence, so that of the 22 countries all related metabolic dysfunctions. A good
of the region, 13 have data from which example is the migration of Nubians from
national prevalence estimates could be southern Egypt to the northern cities
derived. (13) and of Indo-Pakistanis to western
countries (14,15).
Differences in prevalence rates in
different geographic areas and among Whereas in some countries gestational
various ethnic groups are quite marked. diabetes mellitus (GDM) is reported to be
In general, prevalences of both diabetes about 3.5%, GDM was detected in 10.2%
and impaired glucose tolerance (IGT) are of pregnant women in the high risk group
higher in urban areas compared to rural and 0.6% in cases with no risk factor in a
communities. Certain rural communities, study from Pakistan (16).
furthermore, seem to be protected and
have appreciably lower prevalence rates, Incidence of type 1 diabetes
such as the Bedouins in the Egyptian In the EMME Region about half of the
deserts (3). countries have published incidence rates
for type 1 diabetes. By far the largest
Recent studies confirm the tremendous contribution to the total number of
effect of migration from rural to urban estimated childhood type 1 cases for this
Figure 7.3
Prevalence estimates of diabetes in selected countries – Eastern Mediterranean and
Middle East Region
��
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232

Chapter 7
region comes from Egypt whose estimate as life expectancy, infant mortality,
accounts for about a quarter of the availability of hospital beds, number
region’s total (see Chapter 2). of physician and nurse per capita, are
improving. Furthermore, some of these
Diabetic complications parameters are satisfactory, even in
countries with lower incomes, such as
In some recent unpublished studies on the Egypt (1, 19).
epidemiology of diabetic complications in
Pakistan and Egypt, there are indications Although government and household
that nephropathy occurs in 14-20% of expenditures on health vary in the
people with diabetes, neuropathy 40%, region, the general pattern of these
retinopathy 32-43%, foot ulcers 4-7%, two parameters is nearer to that typical
associated obesity 80% and hypertension in developing countries. So, in contrast
64% (17, 18). Lack of proper glycaemic to the developed European countries,
control was present in 50-80% of those expenditure on health constitutes
studied. a smaller fraction of the total national
production compared to expenditures
Costs of diabetes on food, defence and education (1, 4, 5).
With progressive economic development In general, the economic burden of

in the region, health parameters, such diabetes in the EMME countries is great
Figure 7.4
Prevalence estimates of impaired glucose tolerance in selected countries – Eastern Mediterranean
��
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233

Chapter 7
These programmes were more easily

At a glance
implemented by countries with smaller
population and high income than in
Type 1 diabetes 2003 countries with larger populations.
Child population (millions) In general higher standards of diabetes

(0-14 years) 205.8 care are provided in urban than rural
areas. Primary care for diabetes is
Type 1 diabetes prevalence (%) generally carried out by general
(0-14 years) 0.02 practitioners or physicians and less
commonly by diabetologists in diabetes
Type 1 diabetes numbers (thousands) clinics at university hospitals and diabetes
(0-14 years) 46.5 institutes. Diabetes clinics with elaborate
facilities and organized referral systems
provide services at secondary and tertiary
levels in the capitals and major cities of
all countries. However, certain aspects
of diabetes care are evidently lacking,
such as services of dietitians and more
because of the high prevalence rate seriously, foot care specialists.
coupled with the high cost of diabetes and
limited resources. This is more evident Diabetes camps and day school
in the lower income countries with big programmes for children and adolescents
populations such as Egypt, Morocco and are organized by several EMME countries
Pakistan (1, 4, 5, 19). eg Tunisia, Qatar, Bahrain, Iran, Syria and
Egypt.
Some earlier studies have indicated that
the direct cost of diabetes, ie ambulatory Diabetes associations
and hospital care, may make up more than
one-third of total available government Most of the countries in this area have
resources for health expenditure. diabetes associations. The diabetes
Moreover, the progressively increasing associations vary markedly in their
prices of recently introduced medications membership size from less than 200 to
place a further burden on people with more than 14,000, and in their capacities
diabetes, especially in the lower income to carry full diabetes programmes for care,
countries. Therefore, programmes for advocacy and education.
government subsidies, whether partial or
whole, are available in different forms in Some national diabetes associations eg
some countries. in Pakistan, Egypt and Iran have regular
diabetes magazines published in local
Diabetes care languages while others also have regular
scientific diabetes journals such as the
Standards for diabetes care provision Egyptian Diabetes Journal.
differ between different countries
according to available resources, although Educational courses for people with
not exactly corresponding to their diabetes and for physicians are organized
absolute levels of per capita income (4). by almost all of the national associations,
and frequently also by health authorities.
National diabetes programmes based Recently, educational programmes for
on IDF and WHO recommendations were nurses and pharmacists are gaining
adopted by several countries in the region. interest (19).
234

Chapter 7
Public awareness about self-care and References

prevention of complications has increased
1. Arab M. The Economics of Diabetes Care in the Middle East.
over the years through programmes In International Text Book of Diabetes Mellitus, Eds Alberti
carried out by the national associations, KGMM, et al. J Wiley & Sons second edition, 1997.
especially during World Diabetes Day 2. Arab M. Epidemiology of Diabetes Mellitus in Egypt. Egypt
J of Diab 1997; 2:1-14.
events.
3. Arab M, El Sewi F. Diabetes in the Egyptian Deserts: a very
low prevalence. Diabetes Care 1996; 19:90.
Sociological considerations 4. Arab M. Socioeconomic background of Diabetes in
Mediterranean countries. Proceedings of MGSD, Madrid.
Medicographia 1993;16 suppl 1.
Although misconceptions about diabetes 5. The World Bank. World Bank Data, WHO parameters,
may still exist widely in some areas, they 1999-2000.
are being actively corrected through 6. Malik M, Bakir A, Abi Saab B, Roglic G, et al. Prevalence
of Diabetes Impaired Fasting Glucose, Impaired Glucose
educational efforts. The high rate of Tolerance, Hypertension and Obesity in the Multi-ethnic
illiteracy in some countries indicates the Population of the United Arab Emirates. Unpublished.
use of specific tools for public and patient Abu Dhabi, 2002.
7. Al-Mahroos, McKeigue FPM. High prevalence of diabetes in
education. Television programmes play an
Bahrainis. Associations with ethnicity and raised plasma
important role to achieve this objective. cholesterol. Diabetes Care 1998; 21(6):936-942.
8. Shera AS, Rafique G, Khawaja IA, Baqai S, et al. Pakistan
National Diabetes Survey: prevalence of glucose intolerance
Since Moslems constitute the majority
and associated factors in Baluchistan province. Diabetes
of the population, certain aspects of Res Clin Pract 1999; 44(1):49-58.
the Moslem faith have close interaction 9. Shera AS, Rafique G, Khwaja IA, Ara J, et al. Pakistan
with diabetes management, through its national diabetes survey: prevalence of glucose intolerance
and associated factors in Shikarpur, Sindh Province. Diabet
doctrines of encouragement of exercise, Med 1995; 12(12):1116-1121.
moderation of food intake, cleanliness 10. Shera AS, Rafique G, Khwaja IA, Baqai S, et al. Pakistan
and self preservation of health. Fasting, National Diabetes Survey prevalence of glucose intolerance
and associated factors in North West at Frontier Province
during the holy month of Ramadan,
(NWFP) of Pakistan. J Pak Med Assoc 1999; 49(9):206-211.
requires some modification of diabetes 11. Abdella N, Al Arouj M, Al Nakhi A, Al Assoussi A, et al. Non-
management, in order to avoid the insulin-dependent diabetes in Kuwait: prevalence rates and
associated risk factors. Diabetes Res Clin Pract 1998; 42(3):
hazards of hypoglycaemia or of disturbing
187-196.
the metabolic control. Exemption from 12. Al-Lawati JA, Al Riyami AM, Mohammed AJ, Jousilahti P.
fasting is allowed during sickness, while Increasing prevalence of diabetes mellitus in Oman. Diabet
travelling, for the elderly and whenever Med 2002; 19(11):954-957.
13. Arab M, Abdel–Rehim A, Khalifa KMA, Kafrawy N,
there is risk of endangering health and El-Guisery D. Prevalence of diabetes and related metabolic
safety (4). changes among the Egyptian Nubians and the effect
of changes in their lifestyle as a result of migration to
urbanized communities. The Egyptian Diabetes Journal July
Diabetes research 1997; 2:59-64.
14. Mather HM, Keen H. The Southall Diabetes Survey:
Scientific research in the EMME Region is prevalence of diabetes in Asians and Europeans. BMJ 1985;
291:1081-1084.
mostly carried out at state universities and
15. Simmons D, Williams DRR, Powell MJ. Prevalence of diabetes
medical institutes. Specific research on in a predominantly Asian community: preliminary findings
national diabetes problems, particularly of the Coventry diabetes study. BMJ 1989; 298:18-21.
in the fields of epidemiology and socio- 16. Samad N, Shera As, Ara JH. Gestational Diabetes Mellitus
– Screening in a Developing Country. J Pak Med Assoc 1996;
economics, is gaining increased interest. 46(11):249-252.
Some diabetes associations have 17. Shera AS, Jawad F, Maqsood A, Jamal S, Azfar M, Ahmed U.
contributed and published extensive Prevalence of chronic complications and associated factors
in type 2 diabetes. Diabetic Association of Pakistan and
epidemiological studies on diabetes and
WHO Collaborating Centre for Diabetes. Unpublished.
its complications, the cost of diabetes Karachi, Pakistan, 2003.
and the effect of lifestyle changes in 18. Arab M, Kafrawy N, Kamel M, Rifaie M. Epidemiology of
diabetes complications in Egypt. Unpublished. Egypt, 2003.
the region.
19. Arab M. The socio-economic impact of diabetes in
developing countries. Proc. of “Advances in type 2 Diabetes
Management” Meeting, Istanbul, May 2002.
235

Chapter 7
7.3 Europe
Among the European Region’s 51

countries, which extend from Kyrgyzstan All diabetes and IGT 2003 2025
in the east to Iceland in the northwest,
exists a great diversity of populations and Total population (millions) 871.8 862.6
affluence, with GDP varying from over Adult population (millions)
US$40,000 per capita for Luxembourg (20-79 years) 621.2 646.3
to less than US$4,000 for several of the Diabetes prevalence (%)
former socialist republics. (20-79 years) 7.8 9.1
Diabetes numbers (millions)
Diabetes and IGT prevalence (20-79 years) 48.4 58.6
IGT prevalence (%)
Abnormal glucose tolerance in this region (20-79 years) 10.2 10.9
shows little association with affluence, IGT numbers (millions)
and there was no evidence that any (20-79 years) 63.2 70.6
difference in urban/rural prevalence
existed except in Turkey (1), and the
Central Asian Republics of Kazakhstan,
Kyrgyzstan, Tajikistan and Turkmenistan
(for which data were extrapolated from
neighbouring Uzbekistan (2)). Prevalence
rates for diabetes show a wide variation from Augsburg (6). Similarly data from
from 2.0% in Iceland to 10.2% in Germany two regions of Italy (7, 8) were applied
(see Figure 7.5). to more than 100 million people from
Italy and France. There is a clear need
The lack of data from many of the former for better data from those countries that
socialist republics required that data for can afford to ascertain the extent of the
many countries be extrapolated from two epidemic.
studies from Poland - urban Krakow (3),
and the urban and rural areas near Lublin To a large degree the high prevalence
(4). These data suggested high levels of of abnormal glucose tolerance is a
diabetes currently, and such high levels consequence of the relatively old
of IGT that the diabetes prevalence will population of the region, such that
almost certainly increase by 2025 to currently a third of the region’s
levels above those indicated in Tables population is over 50 years of age, which
1.18 and 1.20 in Chapter 1, as these took is expected to increase to over 40% by
no account of the higher incidence of 2025. Thus the number of persons with
diabetes among those with IGT. diabetes and IGT will increase, although
the total regional population will have
Surprisingly there is a paucity of good decreased. This will place an increasing
data from many of the more affluent financial burden on the declining
western countries of the region. The working age population to provide
largest nationwide survey from Germany resources for the health consequences
indicated only those with known diabetes of rising diabetes prevalence in the older
(5), with total diabetes prevalence population. The region has the resources
determined by applying the 1:1 ratio to be at the forefront of efforts to amend
for known:newly diagnosed diabetes lifestyle factors contributing to the
determined from an age restricted survey prevalence of diabetes.
237

Chapter 7
At a glance
In the central European countries
formerly related to the Soviet bloc, such
Type 1 diabetes 2003 as Hungary, Poland, Czech Republic,
Romania, Slovenia and Slovakia, the
Child population (millions) quality of care is rapidly evolving to
(0-14 years) 161.5 the most advanced standards. In other
countries such as Bulgaria, Georgia,
Type 1 diabetes prevalence (%) Ukraine, Moldova, Belarus and Russia,
(0-14 years) 0.06 existing economic and environmental
difficulties have an impact on the
Type 1 diabetes numbers (thousands) availability of good quality diabetes
(0-14 years) 90.1 care throughout the country, although
the growth of specialized and advanced
centres is creating a basis for positive
development when it will be allowed by
more favourable conditions.
In the most eastern part of the region,

Incidence of type 1 diabetes socio-economic and geographical
Compared with other regions, the conditions make it difficult to foresee
European Region has by far the most a satisfactory progression towards
complete and reliable data on the rates adequate standards of care in the near
of childhood type 1 diabetes with a large future if appropriate international support
proportion of countries having registries is not provided. In the Balkan area, for
that are either nationwide or cover instance, there are significant gradients in
several different parts of the country. The adequate diabetes care availability within
countries making the largest contribution a restricted geographical area. Diabetes
to the total rates for childhood type 1 care in Croatia has benefited from long-
diabetes were United Kingdom, Germany standing experience and from stability
and Russia reflecting to some degree for nearly a decade, while other countries
the large childhood populations in these and provinces are still affected from the
countries (see Chapter 2). recent civil war and still unstable political
situations.
Diabetes care
In the most advanced countries the
The European Region is characterized by shared care approach consisting of an
a wide variety of diabetes care delivery integration of different levels of care,
due to differences in national healthcare from highly specialized to primary
systems and available resources of the care with the involvement of medical
country. and non-medical professionals such as
dietitians, podologists, nurse educators,
Within the region, it is possible to find the psychologists, is becoming an increasing
most advanced healthcare systems and reality while in nearby deprived countries
some of the most deprived. The level of regular access to insulin is still a major
the quality of diabetes care in the western issue.
and northern areas of the continent is
rather high with a tendency towards In some countries, intensified therapy
a certain degree of homogeneity in both for type 1 and type 2 diabetes is
European Union (EU) member countries, the normal standard, and campaigns
although some differences still exist even for screening of undiagnosed diabetes
in that cluster. and for complications are regularly
238

Chapter 7
performed. There are also widespread an adequate level of care, which would
pilot initiatives, primarily in Finland, overcome language and cultural barriers
for the primary prevention of type and take into consideration differences
2 diabetes, while in other countries in nutritional habits, behaviours, beliefs,
resources are lacking for minimal values and, in most of the cases,
interventions for the prevention of major socio-economic circumstances.
complications and to even secure the
survival of people with diabetes. National diabetes programmes
A pressing issue has arisen from Most countries in the European Region
migration within the European Region have a national diabetes programme.
and from other parts of the world. The The St Vincent Declaration has been used
need is more and more evident for by many as a framework for strategic
greater attention to be paid to migrants action (see Chapter 8). The prevention of
affected by diabetes in order to guarantee type 2 diabetes is the main focus of many
Figure 7.5
Prevalence estimates of diabetes in selected countries – European Region
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Chapter 7
national diabetes programmes with key especially the Finnish Diabetes

action being taken to raise awareness Association which played a leading role.
among the public.
Each national model should be unique
While some countries have yet to to meet national needs and cultural
implement their programmes, others specifics. The expertise gathered in other
have made great strides in countries however could be very useful
implementation and development. for a specific country when planning a
A good example is Finland where an national diabetes programme. Cyprus,
extensive national diabetes programme is for instance, has recently started working
now underway (see Box 7.1). The on a national plan for diabetes using
programme, implemented in 2000, was the Finnish model and learning from
developed with the participation of the Finns’ practical experiences from
different stakeholders in diabetes care, preparing a national programme.
Figure 7.6
Prevalence estimates of impaired glucose tolerance in selected countries – European Region
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Chapter 7
The United Kingdom (UK) is a good

Box 7.1
example of a governmental approach
towards tackling the problem of diabetes
National diabetes programme:
but in general, the role of governments
the Finnish model
has not been strong enough in this area.
The St Vincent Declaration has been
in existence since the late 1980s but
its goals related to improving health
F inland has a very extensive national programme called
the Development Programme for the Prevention and
Care of Diabetes in Finland (DEHKO 2000−2010). The
outcome have yet to be reached in programme took two years, between 1998 and 2000, to
most countries and thus are still valid. develop by nearly 100 diabetes experts, including people
However, the raised awareness of with diabetes. It was approved at a consensus meeting in
diabetes, increased research and greater 2000, and implementation started in the same year.
practical collaboration with regard to
complications, diabetes economics and By the beginning of 2003 there had been three rounds of
prevention can be attributed in some auditing carried out by external auditors. The programme
itself was audited in 2000, feedback by primary healthcare
way to the St Vincent Declaration and
professionals were audited in 2001, and the preparation
its original action programme. Today,
process and the first three years of implementation were
there are enough knowledge and skills
audited in 2003.
in the region to really start building and
implementing concrete national diabetes The programme defines clear goals and 25 action
programmes. recommendations, of which 10 are key actions. Through
these, the programme covers the primary, secondary and
Initiatives tertiary prevention of diabetes and its complications. The
most important key action is prevention of type 2 diabetes,
The problem of overweight and lack of and a detailed prevention programme for 2002-2003 was
physical activity is as much an issue in prepared and distributed to primary and occupational
this region as elsewhere in the world. healthcare institutions.
Awareness campaigns in favour of a
The national diabetes programme is initiated and
healthy lifestyle are being promoted
coordinated by the Finnish Diabetes Association (FDA)
at EU, regional and national levels by
and financed by a governmental body, corporate partners
diabetes organizations. These campaigns and the FDA. The programme is available in English, both
are meeting with success in convincing printed and on the website: www.diabetes.fi.
top decision makers to take action to
prevent or delay type 2 diabetes. A recent
event held at the European Parliament,
for example, obtained strong support
from the European Commission President
as well as the EU Health Commissioner
and President of the European Parliament. table at the European Parliament in order
to involve decision makers at the highest
Another key initiative has been the level in influencing policies and for
establishment of an EU diabetes working raising awareness on the ‘diabetes time
group by members of the European bomb’.
Parliament to discuss issues such as the
inclusion of diabetes on the public health Diabetes organizations have also taken
agenda and in EU policy, discrimination initiatives at the national level with the
against people with diabetes and the aim to eradicate laws which discriminate
diabetes situation in EU candidate against people with diabetes. Issues
countries. regarding discrimination in driving
licences, insurance and at work are
The IDF European Region has also been being raised in some parliaments, for
instrumental in organizing a yearly round example in the UK, and studies are being
241

Chapter 7
undertaken in several countries including References

Ireland, Denmark and UK.
1. Satman I, Yilmaz T, Sengul A, Salman S, et al. Population-
Based Study of Diabetes and Risk Characteristics in Turkey:
Cultural and strategic initiatives Results of the Turkish Diabetes Epidemiology Study
promoted by the IDF European Region, (TURDEP). Diabetes Care 2002; 25(9):1551-1556.
2. King H, Abdullaev B, Djumaeva S, Nikitin V, et al. Glucose
especially under the umbrella of the
intolerance and associated factors in the Fergana Valley,
St Vincent Declaration, have raised Uzbekistan. Diabet Med 1998; 15(12):1052-1062.
awareness of diabetes throughout the 3. Szurkowska M, Szybinski S, Nazim A, Szafraniec K, et al.
Prevalence of type II diabetes mellitus in population of
region and a further follow-up is taking
Krakow. Pol Arch Med Wewn 2001; 106(3):771-779.
place, adapted to new environmental and 4. Lopatynski J, Mardarowicz G, Nicer T, Szczesniak G, et al.
behavioural circumstances. The prevalence of type II diabetes mellitus in rural urban
population over 35 years of age in Lublin region (Eastern
Poland). Pol Arch Med Wewn 2001; 106(3):781-786.
Diabetes research 5. Thefeld W. Prevalence of diabetes mellitus in the adult
German population. Gesundheitswesen 1999;
Diabetes research is carried out in the 61 Spec No.:S85-89.
6. Rathmann W, Haastert B, Icks A, Lowel H, et al. High
European Region at the highest level in
prevalence of undiagnosed diabetes mellitus in Southern
all possible fields, from basic to more Germany: Target populations for efficient screening. The
clinically oriented. A number of centres KORA survey 2000. Diabetologia 2003; 46(2):182-189.
7. Garancini MP, Calori G, Ruotolo G, Manara E, et al.
of excellence have been established
Prevalence of NIDDM and impaired glucose tolerance in
throughout the region. However the Italy: an OGTT-based population study. Diabetologia 1995;
amount of funds made available by 38(3):306-313.
national governments and international 8. Verrillo A, de Teresa A, La Rocca S, Giarrusso PC. Prevalence
of diabetes mellitus and impaired glucose tolerance
agencies is not adequate. One result in a rural area of Italy. Diabetes Res 1985; 2(6):301-306.
of this has been the drain of scientists
towards better funded institutions, in
particular in the United States.
Nonetheless, an alliance between the

IDF European Region and the European
Association for the Study of Diabetes
(EASD) has resulted in success in
influencing the European Commission to
reintroduce research funding for diabetes
within the Sixth Framework Programme
for research, the most important research
programme in the EU. IDF member
associations played a significant role,
coordinated by the IDF European Region,
in mobilizing national governments and
parliaments in a successful lobbying
initiative that was unprecedented, and at
the same time gained IDF an accreditation
as the reference institution for any
diabetes initiative in Europe.
243

Chapter 7
7.4 North America The North American Region has focused

its efforts over the last few years in
implementing the goals relating to
education, awareness and quality of care
At a glance
in the Declaration.
All diabetes and IGT 2003 2025 Although the region has 23 countries and
areas, 69% of the adult population resides
Total population (millions) 441.7 533.8 in the USA, with a further 20% living in
Adult population (millions) Mexico and 8% in Canada. The remaining
(20-79 years) 289.6 374.5 3% of the region’s adult population reside
Diabetes prevalence (%) in the other 20 smaller nations. Whereas
(20-79 years) 7.9 9.7 the USA, Canada and Bermuda have per
Diabetes numbers (millions) capita GDPs of over US$25,000, many of
(20-79 years) 23.0 36.2 the smaller nations have per capita GDPs
IGT prevalence (%) of less than US$5,000 with Haiti having
(20-79 years) 7.0 7.9 the lowest at US$1,700.
IGT numbers (millions)
(20-79 years) 20.3 29.6 Diabetes and IGT prevalence
The high prevalence of abnormal glucose
tolerance in Canada and the USA are
very much a consequence of their older
age distribution, such that 29% of their
population are currently over 50 years
of age, and this is expected to increase
to 37% by 2025. This contrasts with 14%
Introduction increasing to 25% for Mexico, and 19%
increasing to 28% for the Caribbean (see
The North American (NA) Region has the Chapter 1).
highest prevalence of diabetes among
the IDF regions with 7.9%, or 23 million, The data published in Tables 1.24 and
in the adult population. The countries in 1.25 in Chapter 1 indicated the expected
the region represent not only different number of persons with impaired fasting
geographical characteristics and levels glucose (IFG) for Canada and the USA,
of socio-economic development but also based on the data from NHANES III, which
diverse cultures. concentrated on assessment based on
the fasting glucose. When the published
Faced with a dramatic increase in data were extrapolated to determine IGT
diabetes as well as mounting costs in numbers, the results suggested that in
diabetes care, the Declaration of the 2003 for the USA, the prevalence of IGT
Americas on Diabetes (DOTA) was created would be 11% (21.6 million persons), and
in 1996 with the collaboration of the IDF’s for Canada also 11% (2.5 million persons);
North American, and South and Central both figures being about 50% higher
American Regions, the Pan American than the IFG numbers and prevalences.
Health Organization (PAHO) and industry. By 2025 the expected prevalences are
The Declaration recognizes diabetes as expected to be about 12%, with numbers
a common, growing, serious and costly still about 50% higher than for IFG.
public health problem affecting millions
in the Americas and PAHO has endorsed As all the Caribbean islands other than
it as a guide to national programme Barbados, Guadeloupe and Martinique
development (see Chapter 8). had their estimates extrapolated from
244

Chapter 7
Jamaican data (1), the differences in

At a glance
prevalence are a consequence only
of different age distributions for the
islands, and for those islands whose Type 1 diabetes 2003
population distributions were based on
the world population (2), their lower Child population (millions)
prevalences suggest that their actual age (0-14 years) 105.2
structure is probably older than the world
distribution. Type 1 diabetes prevalence (%)
(0-14 years) 0.06
Incidence of type 1 diabetes
Although no published rates were Type 1 diabetes numbers (thousands)
available for childhood type 1 diabetes in (0-14 years) 64.7
many of the smaller Caribbean islands in
the North American Region, it was usually
possible to extrapolate rates from an
island in close proximity, although such
rates were often based on very small
numbers of cases. The USA estimate,
which accounts for more than three-
quarters of the region’s total, and to a been diagnosed, some five million
lesser extent the estimate for Canada unfortunately are not aware that they
predominate (see Chapter 2). have the disease.
United States of America Each day approximately 2,700 people

Diabetes is the fifth leading cause of are diagnosed with diabetes; about one
disease in the United States, where million people will be diagnosed this year.
some 16 million people, or 8% of the The prevalence is expected to increase to
adult population have diabetes. While 9%, affecting some 23 million adults by
an estimated 11 million people have 2025. The prevalence of diabetes rises
Figure 7.7
Prevalence estimates of diabetes in selected countries – North American Region
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245

Chapter 7
with age in the United States, as it does in an overall rate 2.6 times that of the
other parts of the world. While the rate of general population. The rate varies
diabetes for all adults 20 years or older is greatly by region and tribe; in some
8%, the prevalence rate climbs to 20%, or tribes over 50% of the adults have
7 million, for the age group 65 and older. diabetes.
The problem of diabetes is likely to be Diabetes is one of the most costly health
compounded by the high prevalence rate problems in America. The total annual
of IGT in the adult population. Today, economic cost of diabetes in 2002 was
some 21 million people, or 11% in the estimated to be US$131 billion dollars,
adult population, have IGT. including some US$91 billion in direct
medical and treatment costs and almost
Of the 16 million adults with diabetes, US$40 billion for indirect costs attributed
more than 90% have type 2 diabetes. to disability and mortality.
Type 2 diabetes is more common among
these ethnic groups: Canada
Diabetes mellitus is a major health
• African Americans are twice as likely problem affecting some 9%, or 2 million,
to have type 2 diabetes as the general in the adult Canadian population. The
population. An estimated 2.8 million prevalence of diabetes is expected to rise
African Americans, or 13%, have to some 3 million, or 11% in the adult
diabetes. population by 2025.
• Hispanic/Latino Americans are
almost twice as likely to have type 2 As in many other western countries
diabetes as the general population. about 90% of the diabetic population
Diabetes affects 2 million, or 10%, of have type 2 diabetes with prevalence on
the Hispanic/Latino population in the the increase as the general population
United States. ages. The prevalence of diabetes in the
• Native Americans and Alaska natives indigenous population, however, appears
have the highest prevalence of to be increasing much more rapidly than
diabetes in the United States, with in other population groups.
Figure 7.8
Prevalence estimates of impaired glucose tolerance in selected countries – North American Region
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246

Chapter 7
In addition the growing multicultural rates of between 5% and 10% in the adult
nature of the country means that new population, and IGT prevalence rates of
Canadians are unusually susceptible to between 7% and 18%.
type 2 diabetes as they assume western
culture. This rising trend is reflected in New advances
the high prevalence of IGT which affects
2.5 million adults, or 11% in the adult The overall thrust in this region has been
population. to raise awareness of diabetes among the
general population and intensify diabetes
Major studies into the risks and education amongst the health team and
complications of diabetes are underway people with diabetes in particular.
or have been recently completed. The
linkage between diabetes and obesity has There are new advances on the horizon in
been identified while the complications the prevention and treatment of diabetes.
of heart disease, renal failure, blindness Government-supported and industry
and lower extremity amputations have researchers in the region, mainly USA
been explored. Action is being taken and Canada, are pursuing advances in
to increase public and professional treatment and prevention for both type 1
awareness of these linkages. and type 2 diabetes. For prevention of
type 1, studies are underway to identify
The major challenge facing Canada environmental triggers that may be
is to change the behaviour of its subject to modification or elimination,
people so that they assume increased which could effectively prevent type 1
responsibility for their own health and diabetes in those at risk. In type 2
wellbeing. Governments are considering diabetes, recently concluded trials have
preventative healthcare strategies to shown that a majority of this type of
assist in this regard. diabetes can be prevented or at least
delayed by sustained lifestyle changes
Mexico (diet and exercise).
The estimated prevalence rate in Mexico
is 7% in the adult population, or 4.4 Other research is aimed at lessening the
million people, which puts it among the burden of diabetes by improving glucose
top 10 countries in the world in terms monitoring, including the use of non-
of the number of people with diabetes. invasive or minimally invasive glucose
Estimates show that the number of sensors. New types of insulin and insulin
people is expected to more than double delivery devices are being developed that
to some 9 million by 2025. may allow needle-free insulin delivery
and more physiologically normal insulin
Data for IGT show that almost as delivery. Drug development sponsored
many people, some 4 million, have the by industry is exploring new methods
condition, and that this too is set to to improve management of type 2
increase to 6 million by 2025. diabetes and to arrest and even reverse
the progression of complications such as
Caribbean islands neuropathy, nephropathy and vascular
There are few studies done on diabetes disease.
prevalence in the Caribbean. There
is a study currently underway on the
prevalence of diabetes and hypertension
in Haiti as well as a pilot project on
quality of care. Nonetheless, estimates
from the islands based on previous
studies indicate diabetes prevalence
248

Chapter 7
References
1. Wilks R, Rotimi C, Bennett F, McFarlane-Anderson N,

Kaufman JS, Anderson SG, Cooper RS, Cruickshank JK,
Forrester T. Diabetes in the Caribbean: results of a
population survey from Spanish Town, Jamaica. Diabet
Med 1999; 16:875-883.
2. United Nations Population Division. World Population
Prospects: The 2000 Revision. United Nations, Geneva,
2001.
249

Chapter 7
7.5 South and Central America
and Paraguay to less than 20% in

At a glance
Argentina and Uruguay, where there was
a strong white non-Hispanic immigration,
All diabetes and IGT 2003 2025 mainly from Italy. There has also been a
significant immigration from Japan and
Total population (millions) 422.8 544.6 the Middle East.
Adult population (millions)
(20-79 years) 251.8 363.9 Diabetes prevalence
Diabetes prevalence (%)
(20-79 years) 5.6 7.2 Considerable extrapolation was required
Diabetes numbers (millions) in this region as 15 countries do not have
(20-79 years) 14.2 26.2 any epidemiological data from which
IGT prevalence (%) diabetes prevalence could be derived (see
(20-79 years) 7.3 8.1 Chapter 1).
IGT numbers (millions)
(20-79 years) 18.5 29.5 Nonetheless, both South America
and Central America have similar age
distribution profiles, currently about 15%
of the population older than 50 years,
with this figure likely to increase to 25%
by 2025. Thus the region has a markedly
younger age distribution than most of
North America, and otherwise would
Introduction have a similar burden of diabetes. The
likelihood is that diabetes will become a
The South and Central American (SACA) more major health priority for the region
Region encompasses 22 countries with given the decreasing difference in age
a population of more than 420 million. distribution between this region and
Most of the countries are still developing North America, and with the continuing
economically, with Argentina, having momentum for urbanization.
the highest per capita GDP (US$10,200)
despite a recent fall, and Cuba the lowest Between 30% and 50% of people with
at US$2,300 (1). type 2 diabetes are not aware that they
have the condition (in the rural areas it
Some 82% of the region’s population can be as high as 100%). Type 2 is often
live in South America, 9% in Central diagnosed late.
America and 9% in the Caribbean islands.
The admixture between native Indians, Incidence of type 1 diabetes
white Iberians and black Africans has The variable ethnic composition of the
been occurring since the 16th century. SACA Region may have an influence on
There are still countries such as Bolivia, the incidence of type 1 diabetes mellitus.
Guatemala and Peru where more than For example, the incidence of type 1
40% of the population is considered diabetes is relatively high in Uruguay
American Indian. (mainly Caucasoid population) and very
low in Peru (mainly mestizos population).
The proportion of mestizos (descendants There are some exceptions such as Puerto
of American Indians and Spaniards) in Rico, where, although its population has
the population range from 80% or more an admixture of Hispanic, African and
in Chile, Ecuador, El Salvador, Honduras Taíno Indian, there is a high incidence of
250

Chapter 7
type 1 diabetes in youngsters that has

At a glance
been increasing recently. Thus, although
the incidence of childhood type 1
diabetes in the SACA Region is generally Type 1 diabetes 2003
low, there are some sharp contrasts
between the rates in neighbouring Child population (millions)
countries (see Chapter 2). (0-14 years) 126.0
Diabetes care Type 1 diabetes prevalence (%)

(0-14 years) 0.03
National diabetes associations have
been the main promoters of public Type 1 diabetes numbers (thousands)
awareness and diabetes education in the (0-14 years) 40.4
SACA Region. The oldest, such as the
Uruguayan and the Colombian Diabetes
Associations, have been active for more
than 40 years. These non-governmental
and non-profit organizations, usually with
very small budgets, provide educational
courses and materials, and organize under control, particularly in the case of
diabetes awareness programmes. those who are insulin-dependent.
The associations in some countries In many countries of the region less than
run diabetes care centres which offer 20% of the population are covered by
specialized medical care and education as social security and the rest have to rely
well as medications, laboratory tests and on very deficient and overcrowded public
self-monitoring equipment at a very low health centres with scarce resources,
cost. This has been for a long time the or go to the private sector which most
only means for many people with low and cannot afford. Only a few countries such
very low incomes to keep their diabetes as Costa Rica and Cuba have a social
Figure 7.9
Prevalence estimates of diabetes in selected countries – South and Central American Region
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Chapter 7
security system that covers the whole The Latin American Diabetes Association,
population. ALAD, a scientific organization formed
by health professionals, has developed
In countries such as Argentina, Chile, evidence-based guidelines for the
Uruguay, Puerto Rico and Colombia, prevention and treatment of type 2
health maintenance organizations provide diabetes and its complications. The
a basic health plan for most of the ALAD working groups on diabetes and
working population and their families pregnancy, GTDE, and on diabetes in
which includes some medicines such as children and adolescents, GELADNA,
insulin and a few oral agents but no self- have also developed guidelines on the
monitoring elements. Everyone, including treatment of these specific problems.
the unemployed, has the legal right to
benefit from this plan in some countries National diabetes programmes
but the resources needed to make this
possible are still far from adequate. The interest in diabetes mellitus as a
Argentina has passed a law protecting public health problem is increasing in
people with diabetes but its enforcement the region. The prevention and treatment
has been slow and difficult for the same of non-communicable chronic diseases
reasons. is now considered one of the main
priorities in most countries where not
In the Dominican Republic, IDF member long ago most of the resources went to
associations in collaboration with the the mother and child programmes. Some
community have established the National countries such as Argentina, Brazil, Chile,
Institute of Diabetes, Endocrinology Colombia, Cuba, Costa Rica, Paraguay
and Nutrition (INDEN), the only diabetes and Venezuela are implementing national
hospital in Latin America, which provides diabetes programmes.
excellent services for people with
diabetes. It is also a training centre for The impetus to implement national
multidisciplinary healthcare professions. diabetes programmes was given a boost
Figure 7.10
Prevalence estimates of impaired glucose tolerance in selected countries – South and Central
American Region
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Chapter 7
with the signing of the Declaration of the Reference

Americas on Diabetes (DOTA) in 1996, in
1. CIA. World Factbook 2002. Central
San Juan, Puerto Rico (see Chapter 8). Intelligence Agency, 2002.
Regional initiatives
The IDF SACA Region is the most
representative organization, and the
most structured at national and regional
levels in Latin America in the field of
diabetes, with participation by people
with diabetes and their relatives, as well
as healthcare professionals and industry
partners.
Different task forces have been appointed

to meet particular regional needs, such as
the Task Forces on Emergencies, Diabetes
in Children, Education, Association
Development and National Diabetes
Programmes.
Examples of the work of these task forces

include the involvement of the Task
Force on Emergencies in procuring aid
during disaster situations in Venezuela,
Colombia, Peru and El Salvador. A task
force on anti-fraud in medications has
dealt with unethical medication issues
and has been successful recently in
identifying a network from another region
marketing and selling products as though
they were in Latin America.
In addition, the Task Force on National

Diabetes Programmes has developed a
model diabetes law for Latin American
countries that is being considered
by several national assemblies or
parliaments in the region.
Training courses for diabetes educators,

with field testing courses in three model
centres in Puerto Rico, Colombia and
Argentina, have been organized by
the Task Force on Education. Ongoing
projects include national training courses
for educators in Brazil, and possibly in
Uruguay and Bolivia.
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Chapter 7
7.6 South-East Asia
The South-East Asian (SEA) Region

includes only seven countries, but as All diabetes and IGT 2003 2025
with the USA numerically dominating the
North America Region, so here does India, Total population (millions) 1,251.4 1,629.7
with its adult population comprising 85% Adult population (millions)
of the region. Mauritius has the highest (20-79 years) 705.3 1,081.0
per capita GDP at US$10,800, while the Diabetes prevalence (%)
other countries all have per capita GDPs (20-79 years) 5.6 7.5
of less than US$4,000, although India Diabetes numbers (millions)
with a current annual growth of 5% is (20-79 years) 39.3 81.6
experiencing economic development at a IGT prevalence (%)
faster pace than almost anywhere in the (20-79 years) 13.2 13.5
world except its neighbour, China. IGT numbers (millions)
(20-79 years) 93.4 146.3
Diabetes and IGT prevalence
Economic progress is inevitably
associated with increasing urbanization,
and it appears that features of urban
life tend to increase the prevalence of
diabetes among adults of Indian ethnic
background to a greater extent than for than double to 73 million by 2025. The
other populations (1), which is why a world’s highest regional IGT prevalence
4:1 ratio for urban:rural prevalence was is further evidence of the likely marked
applied for the Indian, Nepalese and increase in the diabetes prevalence.
Bhutan populations (see Chapter 1).
Mauritius, the second smallest country
The anticipated increase in diabetes in the region, highlights the extent to
prevalence for the region from 5.6% which persons of Indian ethnicity appear
to 7.5% by 2025 is very much a predisposed to diabetes, when exposed
consequence of the increasing life to more affluent economic circumstances.
expectancy in India, where the proportion This island has the world’s eighth highest
of the population over 50 years is diabetes prevalence, currently 11% and
expected to increase from 15% to 23% expected to rise to 15% by 2025, and
between 2003 and 2025, and the urban a similarly high IGT prevalence of 16%,
proportion from 30% to 42% (2). Evidence likely to increase to nearly 18% (see
suggests that in more affluent parts Figures 7.11 and 7.12).
of the country the rural prevalence is
higher than less affluent rural areas (3), A substantial number of clinical and
indicating that increasing economic epidemiological studies on diabetes have
growth will escalate diabetes prevalence been published by various centres in
in India even more than these possibly India and by the Bangladesh Institute of
conservative estimates have suggested. Research and Rehabilitation in Diabetes,
Endocrine and Metabolic Disorders
India currently has the world’s largest (BIRDEM). These centres have also
diabetic population with an estimated 35 developed basic research facilities on
million people. This is expected to more diabetes and related areas.
255

Chapter 7
more frequently used and it therefore

At a glance
plays a pivotal role in the estimates for
this region.
Type 1 diabetes 2003
The South-East Asian Region contributes
Child population (millions) more than any other to the worldwide
(0-14 years) 412.2 childhood type 1 diabetes total. Diabetes-
associated mortality and tropical or
Type 1 diabetes prevalence (%) malnutrition diabetes are also likely
(0-14 years) 0.03 to play important roles in this region,
but unfortunately there is inadequate
Type 1 diabetes numbers (thousands) information to address these issues.
(0-14 years) 104.8 These points reinforce the need for much
more detailed data on childhood diabetes
in this region.
Diabetes care
Increasing prevalence of diabetes
and diabetes-related disorders and
Incidence of type 1 diabetes complications pose a serious threat to
Only two countries in the region have the healthcare delivery systems in the
published rates for type 1 diabetes in region. This region is expected to have
childhood and therefore extrapolation the largest diabetic population in the
of rates was necessary for the data in world by 2025 with almost 82 million
Chapter 2. The rate from China, although people. Unfortunately, diabetes is not yet
outside the region, was used for some considered a national problem with high
extrapolations, but the rate for India was priority in almost all the countries of the
Figure 7.11
Prevalence estimates of diabetes – South-East Asian Region
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256

Chapter 7
region, where only diabetes associations of trained manpower, non-availability

give focused attention to the disease. of comprehensive care and absence of
good tertiary care departments dedicated
In general diabetes is treated as any to diabetes. According to a World Bank
other ordinary disease in national health report the public sector is still the main
policy. There is no demand analysis and provider of healthcare services and is
separate budget for diabetes care and grossly under-funded.
research. It is now important to integrate
diabetes healthcare into national health Private sector care
policies and also into the curricula of As a result of the inadequate care in the
undergraduate and postgraduate studies. public sector, a number of people with
diabetes go to private practitioners and
The existing system of diabetes clinics for their care. In reality, there
healthcare may be broadly divided into is a substantial contribution of public
two sectors: public and private. The sector to this type of private sector.
relative contribution of the different For example, almost all public sector
sectors greatly varies from country to physicians are engaged in private practice
country and even locality to locality. in chamber, clinic and private hospitals.
With the exception of a few centres, no
Public sector care well-planned system of diabetes care,
Reasonable infrastructure has already particularly in primary services, have
been built for delivering a good level been developed in this sector.
of services in the region. However,
diabetes care is still inadequate in Education and awareness
public facilities due to governmental
priority to communicable diseases Professional bodies, healthcare societies
over non-communicable diseases. This and associations, in general, play an
situation is exacerbated by a lack of appreciable role in creating awareness
focused attention to diabetes, scarcity about diabetes, and its prevention and
Figure 7.12
Prevalence estimates of impaired glucose tolerance – South-East Asian Region
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257

Chapter 7
management through media. It is the References

national diabetes associations, however,
1. Ramachandran A, Snehalatha C, Latha E, Manoharan M,
which have played a significant role in Vijay V. Impacts of urbanisation on the lifestyle and
diabetes healthcare in the region. on the prevalence of diabetes in native Asian Indian
population. Diabetes Res Clin Pract 1999; 44:207-213.
2. United Nations. Department for Economic and Social
The Diabetic Association of India plays
Information - Population Division. World urbanization
an important role in creating public prospects: the 1994 revision. Estimates and projections
awareness and also in training healthcare of urban and rural populations and of urban
agglomerations. United Nations, New York, 1995.
providers and professionals particularly
3. Kutty VR, Soman CR, Joseph A, Pisharody R, Vijayakumar K.
through the All India Institute of Diabetes Type 2 diabetes in southern Kerala: variation in
in Bombay (4). The Institute also provides prevalence among geographic divisions within a region.
diabetes healthcare to a substantial Natl Med J India 2000; 13:287-292.
4. Diabetic Association of India. 1999 Problem Census Report
number of people with diabetes. of India. Questionnaire proforma of IDF SEA Region for the
mid-term regional meeting held on March 26, 1999.
Bangladesh appears to have the most
well organized diabetes association
with countrywide coordination among
branches and a dynamic system of
comprehensive healthcare delivery for
people with diabetes. It has become
highly successful in creating diabetes
awareness. It also has a programme of
manpower development, community
mobilization and generation of resources
for self-sustenance.
A programme for diabetes education

in the public sector is generally absent
in this region. There are, however,
educational activities run by the national
diabetes associations. These activities
include both training for healthcare
providers as well as diabetes education
for people with diabetes. Other
educational activities include public
awareness promotion, for example
in India, through newsletters and
journals (4).
The Diabetic Association of Bangladesh

provides a more systematic series of
programmes on diabetes education.
Through its central institute, BIRDEM,
it also runs postgraduate degrees
and diplomas under the University of
Dhaka. BIRDEM has been a World Health
Organization collaborating centre
since 1980.
259

Chapter 7
7.7 Western Pacific
as well as the diabetes epidemic, and

At a glance
the problem of limited resources and
lack of government awareness of the
All diabetes and IGT 2003 2025 seriousness of the diabetes threat to their
populations.
Total population (millions) 2,110.7 2,445.7
Adult population (millions) The countries also have populations
(20-79 years) 1,383.6 1,750.5 of diverse ethnicity, with Singapore
Diabetes prevalence (%) having large Chinese, Malay and Indian
(20-79 years) 3.1 4.3 communities, Australia and New Zealand
Diabetes numbers (millions) being principally Caucasian but also
(20-79 years) 43.0 75.8 having extremely culturally diverse
IGT prevalence (%) populations, and the Pacific islands
(20-79 years) 5.7 6.9 having Polynesian, Melanesian and
IGT numbers (millions) Micronesian populations, as well as more
(20-79 years) 78.6 120.2 recent Indian immigrant communities.
Diabetes and IGT prevalence

Not surprisingly there is a great diversity
in the prevalence of diabetes in adults,
with the world’s highest found in the
Introduction Micronesian population of Nauru, and
the ethnically mixed population of
The Western Pacific (WP) Region is a Singapore currently has the sixth highest
huge region in terms of both geography documented prevalence (see Chapter 1).
and population. The region extends
from Mongolia and Japan in the north to However, simply because of its
New Zealand in the south. Apart from population size, it is in China that the
sheer size, the region is characterized diabetes epidemic has the greatest
by great diversity of lifestyle, affluence, potential to explode. Although the
economics, culture, social circumstances current prevalence there of 2.7% is
and geography. among the region’s lowest, the high
prevalence among Chinese populations in
The world’s most populous region the more urbanized and affluent cities of
contains 39 disparate countries and Hong Kong and Singapore indicate what
territories with populations ranging from may develop as China rapidly urbanizes
1.3 billion for China to less than 5,000 and expands economically. The data
in the smallest Pacific island nations of indicated for 2025 are likely to represent
Niue and Tokelau. Similarly the economic an underestimate of the diabetes problem
profile varies from per capita GDPs of in China if it continues to develop
about US$25,000 for Australia, Hong economically faster than almost any other
Kong, Japan and Singapore to less than country in the world.
US$2,000 in Cambodia and some of the
smallest Pacific islands. These numbers, while alarming in their
own right, still do not tell the whole
The less economically advanced countries story. Although type 1 diabetes is
of the region struggle with the double relatively less common in the region,
burden of managing infectious diseases with the exception of Australia and New
260

Chapter 7
Zealand, than among countries with population. This trend towards a younger
predominantly Caucasian populations, age of development of the disease has
there is an emerging problem of type 2 major health implications, particularly as
diabetes in children and adolescents, it targets specifically the economically
particularly in an urbanized setting and productive sector of the population.
in strong association with rising rates of
obesity in children. Incidence of type 1 diabetes
With the exception of Australia and New
In Japan, for example, 80% of children Zealand, the rates of childhood type 1
with diabetes now have type 2 diabetes. diabetes in this region appear uniformly
In the adult population also, increasing low. Despite its very low incidence, China
numbers of young adults are developing accounts for almost half of the region’s
the condition and the age group under total. However, the Western Pacific Region
greatest threat from the rising prevalence makes the smallest contribution of all
rates is the 40-59 year age group. to the world total of type 1 diabetes
This age group now comprises the even though it has the largest childhood
largest group, about 45% in the diabetic population (see Chapter 2).
Figure 7.13
Prevalence estimates of diabetes in selected countries – Western Pacific Region
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Chapter 7
The plan proposes objectives, strategies

At a glance
and expected outcomes for each goal
and provides examples of activities
Type 1 diabetes 2003 which might be undertaken at a regional,
national or local level to work towards
Child population (millions) achievement of the goals.
(0-14 years) 516.2
National diabetes programmes
Type 1 diabetes prevalence (%) As would be expected from a region
(0-14 years) 0.004 as large and diverse as this, standards
of management and care show much
Type 1 diabetes numbers (thousands) variation, as do healthcare delivery
(0-14 years) 21.6 systems. Standards of management
and care vary from very high indeed
in centres of excellence in the more
developed and affluent nations to almost
non-existent in impoverished or strife-
torn nations.
The WPDD and its action plan recognize

Diabetes initiatives the need to address these discrepancies
and provide a mechanism for countries to
Western Pacific Declaration plan and put into place countermeasures.
on Diabetes Further, steps are being taken now that
The working relationship between the the action plan has provided a structure
IDF WP Region and the WHO Western within which work can be done.
Pacific Regional Office (WHO/WPRO) is
of prime importance to the development The priority given to diabetes by
of effective programmes and strategies governments also varies greatly, but
within the region. This relationship increased cooperation within the WPDD
continues to grow following the structure has led to more governments
formation of the alliance with the identifying diabetes as a key health
Secretariat of the Pacific Community initiative and integrating such initiatives
(SPC) that brought about the Western with their non-communicable diseases
Pacific Declaration on Diabetes (WPDD), programmes.
co-signed in 2000 by these three partner
organizations (see Chapter 8). While the seriousness of the problems
facing countries of the Western
A plan of action, to facilitate and guide Pacific Region cannot be ignored, the
implementation of the WPDD, has been enthusiastic adoption of the WPDD and
endorsed by IDF member associations the significance of the plan of action
in the region, health ministers of the provide real hope that the region is
WHO/WPRO member countries and moving to address this epidemic.
territories as well as those of the SPC.
Examples of the influence of the WPDD
The WPDD Plan of Action sets clear include a range of different levels and
goals covering primary prevention, early types of activities. The WHO/WPRO is
diagnosis and care of the diagnosed, and supporting the development of national
building the capacity of health systems to action plans in individual countries
provide equitable, accessible, affordable and fostering the development of
and effective prevention and care services national diabetes guidelines throughout
to people with or at risk of diabetes. the region.
262

Chapter 7
The WPDD was also responsible for of Diabetes Education Strategies for IDF
the Royal Australasian College of WP Region and WPDD’. This workshop
Surgeons adding a diabetes component was outcome driven and charged
to its Pacific Islands Project and many representatives with the responsibility
countries, such as Korea, are using the of returning to their country to develop
WPDD and its plan of action to lobby their and implement a new diabetes education
governments for increased resources for strategy and provide a feedback report.
diabetes and to create broad awareness This approach is in keeping with the
of the disease as a public health threat. philosophy of the WPDD Plan of Action.
Education The SPC, also in support of the WPDD,

The region has seen a continuation and has developed and is implementing an
expansion of education and awareness introductory diabetes training manual for
programmes utilizing mechanisms health workers in Pacific island countries
pioneered in the region. Of note was in an effort to raise the quality of
the workshop entitled ‘Implementation diabetes care provided at the community
Figure 7.14
Prevalence estimates of impaired glucose tolerance in selected countries – Western Pacific Region
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263

Chapter 7
level. This manual, entitled ‘Diabetes is provision of diabetes services where

Everybody’s Business’, promotes personal three years ago no service was provided.
responsibility among community health
workers for identifying people at risk of Major tasks on the work plan of the
diabetes, gives basic risk factor advice, WPDD Steering Committee for the near
and provides improved routine care for future focus on taking stock of diabetes
people with diagnosed diabetes. activities in the region, increasing the
development and implementation of
Practical targets and treatments national diabetes programmes where they
The Western Pacific Region is at the are not already in place, and promoting
forefront of the diabetes epidemic, with strategies aimed at wide implementation
the potential for devastating health of recognized standards of diabetes care
consequences. The overwhelming and prevention.
evidence is, however, that optimal
glycaemic control of type 2 diabetes Many countries have made genuine
can minimize risks and complications and positive progress, assisted by IDF,
and that one of the ways to assist the WHO, SPC and WPDD initiatives in the
achievement of good control is through development of disease management
the provision of treatment guidelines. programmes and in the enhancement
of diabetes awareness and education.
The third edition of the ‘Asia Pacific Cultural barriers, for example in the
Type 2 Diabetes Practical Targets and use of non-healthcare professionals in
Treatments’ was produced by the Asia diabetes care, are now being broken
Pacific Type 2 Diabetes Policy Group (1). down.
The goal has been, since the first edition,
to target the prevention and management Diabetes is now recognized as an
of type 2 diabetes. The third edition issue of vital importance by many
deals with new medications and data on governmental and non-governmental
the prevention of type 2 diabetes and agencies and cooperation within the
addresses the increasing incidence of region is increasing steadily. In addition,
type 2 in children and adolescents. It through the increasing influence of the
seeks not to be a substitute for national WPDD, governments are taking greater
guidelines but to complement them and interest in the need for investment in
add the authority that can be provided addressing the diabetes problem in their
by a regional approach. It also seeks to communities, and more governments
provide guidelines where there are none. are introducing diabetes programmes,
often integrated with non-communicable
Tasks ahead disease programmes and frequently with
the support and involvement of other
The region faces enormous difficulties governmental agencies from within the
and all indications are that this will region. These issues provide a glimmer
worsen in the immediate future. The of hope in what otherwise appears as a
availability of epidemiological and desperate situation in many countries.
other data continues to grow enhancing
knowledge of the true situation in many
countries in the region and with it the
capacity to take effective action. These
data continue to provide a basis for Reference
increased action in many parts of the
region through a number of cooperative 1. Asia Pacific Type 2 Diabetes Policy Group. Asia Pacific Type 2 Diabetes
Practical Targets and Treatments. Third edition. International Diabetes
ventures. Together, the countries of Federation, Western Pacific Region, and World Health Organization,
the region are working to improve the Western Pacific Regional Office, 2002.
265

Reducing the Burden
Chapter 8
Reducing the Burden Chapter 8
I n facing the challenges brought about

by the diabetes epidemic, diabetes
associations and regional organizations
have galvanized into action. Declarations
on diabetes, spelling out strategic
actions, have been signed in five regions:
Eastern Mediterranean and Middle
East, Europe, North America together
with South and Central America, and
Western Pacific.
These declarations reflect the significance

of strategic alliances with organizations
such as the World Health Organization
(WHO) at all levels, as well as with other
stakeholders in healthcare including
governments and industry.
8.1 St Vincent Declaration
8.2 Declaration of the Americas While the declarations are couched in

on Diabetes culturally appropriate terms and geared
toward regional needs, the core of these
8.3 Western Pacific Declaration
initiatives are nonetheless similar. They
on Diabetes
seek to implement national diabetes
8.4 Declaration of the Eastern programmes, empower people with
Mediterranean and Middle diabetes, improve the quality of diabetes
East Region care, promote research and raise public
awareness of a costly health problem.
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Reducing the Burden
Chapter 8
8.1 The St Vincent Declaration
The first decade of the Introduction normal expectations in quality and

SVD has demonstrated quantity.
the feasibility and Diabetes is a major and growing chronic • Prevention and cure of diabetes and
possibility of new disease with a strong impact in terms of of its complications by intensifying
approaches to diabetes health and costs, both at individual and research efforts.
care and the importance societal levels, as shown in the earlier
of focusing on the chapters. In spite of medical progress, A series of specific targets was also
real outcomes of the a large number of people with diabetes identified in order to reach these two
disease rather than on still suffer from the consequences of the goals, in particular to combat diabetic
the processes. It has disease as a result of low quality of care complications:
also demonstrated that and social inequalities (1).
local solutions to local 1 Reduce new blindness due to
problems need to be Several studies had shown a wide diabetes by one-third or more.
defined. variation of care provided throughout 2 Reduce numbers of people entering
Europe; moreover in some cases the end-stage diabetic renal failure by at
quality of healthcare was far from set least one-third.
standards and recognized goals. This was 3 Reduce by one-half the rate of limb
mainly due to the poor use of available amputations for diabetic gangrene.
resources, related in the majority of cases 4 Cut morbidity and mortality from
to a lack of programmatic activities and coronary heart disease in people with
clear healthcare policies. diabetes by vigorous programmes of
risk factor reduction.
Recognizing the wide variation in the 5 Achieve pregnancy outcome
standard of diabetes care, a meeting was in women with diabetes that
convened in St Vincent, Italy, in 1989, to approximates that of non-diabetic
discuss how to implement better quality women.
healthcare for people with diabetes (2).
The meeting was organized under the Reducing diabetic
auspices of the Regional Offices of
complications
IDF and the World Health Organization
(WHO), and involved diabetes experts, Since 1989, several actions have been
representatives of governments and undertaken at different levels throughout
organizations of people with diabetes Europe for the implementation of quality
from a number of European countries. of care programmes according to SVD
goals and targets. Some 51 governments
The immediate outcome of the meeting have nominated liaison persons for
was the St Vincent Declaration (SVD), a formal relationships with the SVD
document identifying goals and targets movement, and 46 have created national
for the improvement of the quality of life diabetes task forces with the mission to
of people with diabetes. develop and implement national and local
diabetes programmes.
Goals and targets
In 37 European countries, representing
The SVD established two general goals 72% of the total, a national diabetes
for people with diabetes: programme has been designed
and officially endorsed by national
• Sustained improvement in health governments (3). It was clear from
experiences and a life approaching the beginning, however, that the
major obstacle to the achievement
268

Reducing the Burden
Chapter 8
of the desired results was the lack of card was produced for data collection and
information about the real entity of the a specific computer program, Save Eyes
problem. in Europe (SEE), was developed for the
management of the screening protocol.
A questionnaire sent to national liaison
persons indicated that data was available Nephropathy
in 55% of the countries for blindness The guidelines for the prevention
due to diabetes, 60% for end-stage renal of renal failure were subdivided
disease leading to kidney transplantation into indications for screening and
and 50% for amputations above ankle indications for treatment. The section
(4). Some of the countries also produced on screening provided guidance on
various national data on the impact of the the best procedures for the detection
disease in terms of late complications (4). of microalbuminuria or persistent
proteinuria. The second part provided
Guidelines for better care clear guidelines for treatment of kidney
disease according to the stage of
A number of SVD working groups progression.
were created with the remit to develop
guidelines for better care. As a Amputation
result of their activity, the St Vincent The guidelines for the prevention of
Declaration Action Programme, a plan foot ulcers and amputations provided
for the practical implementation of the suggestions for screening and diagnostic
declaration, was developed (5). procedures, follow-up of people at risk
and for care of overt lesions. Particular
The programme was accompanied by a attention was given to the definition of
series of guidelines for various aspects of the team of professionals involved in
diabetes care with particular attention to foot care and to the fundamental role of
late complications, including a protocol education in the prevention of the onset
for the screening of diabetic retinopathy, or the progression of lesions.
and guidelines for the prevention of renal
failure, foot ulcers and amputations, and Cardiovascular disease
coronary artery disease. The guidelines on cardiovascular disease
(CVD) and stroke covered primary and
These guidelines were subsequently secondary prevention. Particular attention
updated in the SVD Action Programme was paid to the control of the risk factors
Implementation Document (6). The for macrovascular disease and to the
need for an adaptation of the guidelines target levels for each risk factor.
according to local circumstances was
highly recommended. Local initiatives
Retinopathy The SVD recommendations
The protocol for the screening of diabetic generated several initiatives for local
retinopathy was approved by experts implementation, some of which focused
representing 30 diabetes and ophthalmic mainly on organizational and educational
societies across Europe. The aim of the aspects, while others aimed more at
protocol was the definition of a reliable clinical elements.
screening tool able to identify early
lesions and the most appropriate use Eye complications
of resources in order to guarantee the The SVD implementation in the Stockholm
same opportunities for access to eye County initiative comprised both
examination for people with diabetes in organizational and educational aspects
Europe. A diabetic retinopathy screening in which an educational programme
269

Reducing the Burden
Chapter 8
combined with a campaign for screening in some centres to 90% in others. These
diabetic eye disease and evaluating a results showed that the first step in the
monitoring system for new blindness (7). reduction of complication should be a
coordinated effort both for screening and
The educational programme was divided treatment.
into two sections. The first aimed at
increasing awareness and competence A more recent survey was carried out
of healthcare professionals, people with in Germany with data on new cases of
diabetes, administrators and politicians, blindness collected from 1990 to 1998
and highlighted the effectiveness of (11). The study showed a reduction in
preventative measures. The second was a the incidence rate of 3% for each year
two-week continuous medical educational of observation. All these results showed
programme for professionals working in that screening is an effective measure for
the primary healthcare centres. reducing eye complications in accordance
with the SVD specific guidelines.
The campaign for screening eye disease
was conducted through a mobile photo- Kidney complications
screening service, which contacted all The PROSIT Project (Proteinuria Screening
diabetic patients from hospital inpatient and Intervention Project) was launched
registers, followed by an immediate in Germany as part of the national
referral to an ophthalmologist in cases of implementation of the SVD (12). The
people at risk. project focused on identification
procedures for facilitating the screening
Data collection covered the period of diabetic nephropathy.
1981–1995 while the screening was
performed from 1990 to 1995 (8). One of the major achievements of the
Results showed progressive decrease of project was the validation of self-testing
blindness incidence. The final reduction for microalbuminuria. The study showed
was equivalent to around one-third with that the available self-test methods
respect to the basal level, indicating could be effectively used for screening.
the achievement of the SVD target for The combination of the effectiveness of
diabetic retinopathy. the test and the low price of equipment
created the conditions for widespread
A prerequisite for planning effective screening for diabetic nephropathy.
treatment strategies is the availability Further, the need for action was
of facilities. A study was conducted highlighted in a preliminary study within
in the UK in 1991 to determine which the same project which showed that
treatment facilities were available only a minority of people with diabetes
and how treatment was provided (9). was screened annually for diabetic
Responses, from a questionnaire to all nephropathy in Germany.
ophthalmologists in England and Wales,
showed that screening facilities were A recent study was conducted in 20
inadequate for a large number of people European countries to evaluate the
and that there was a wide variation in compliance to guidelines for first
care provided, especially in waiting times referral to nephrologists (13). It was
for first visit and treatment in different found that only 30% of type 1 and 22%
centres. of type 2 diabetic patients had first
referral according to the guidelines.
A similar study was repeated in 1996 to Moreover 50% of those who were placed
evaluate the possible changes (10); the in replacement therapy had the first
data confirmed a wide variation of care referral within three months prior to
provided for screening, from 25% of cases replacement. The results highlighted
270

Reducing the Burden
Chapter 8
the low standardization of care and the produced as reports from healthcare
negative impact on outcomes. implementation initiatives. At the
same time, methodologies adopted
Amputations for scientific protocols, eg randomized
The Danish Amputation Register Study and control group comparison, are
Group analysed the incidence of major not appropriate for evaluating the
lower limb amputations from 1982 to effectiveness of the action programmes.
1993 (14). In total, 2,848 cases were
studied: a progressive reduction of Moreover, the factors that influence the
incidence, with a total of 40% reduction outcome are not always identifiable, and
occurred by 1993. unpredictable environmental variations
might intervene in long-term, large-scale
Amongst the activities carried out within initiatives, such as political changes,
the regional diabetes project in Umbria, variability of available resources,
Italy, a survey on diabetes-related prevailing educational and cultural
amputations highlighted that 1,283 standards, and conflicts. This has been
non-traumatic amputations were particularly true in Europe in the last
performed in that region from 1991 decade.
to 1998. No significant changes were
observed in the overall incidence rate Other factors that make difficult the
during the observational period; however, documentation of the outcomes are
the ratio between major amputations the lack of precise and well-defined
(above the ankle) and minor amputations healthcare plans of action that have in
(below the ankle) was significantly their stead healthcare policies which
reduced (15). produce scattered initiatives, and the
difficulty in coordinating multidisciplinary
Evaluating the SVD impact initiatives. Moreover it is difficult to
define the role of the SVD movement in
A report, based on information provided ongoing activities that might or might not
by SVD national liaison persons and have taken advantage of the SVD climate.
published data, found that the following
results had been achieved (4): A further element of difficulty is
represented by the absence of baseline
• reduction of blindness in three data collected according to appropriate
countries; epidemiological procedures in areas
• reduction of cardiovascular disease where the interventions have been
and end-stage renal disease in three carried out. Data collected in the quality
countries; development process have frequently
• reduction in major amputations in six been used for providing the evidence that
countries; should have been produced according
• reduction in hospitalization due to to accepted epidemiological analysis.
late complications of diabetes in five However, the information required
countries; and for quality development is gathered
• reduction in healthcare expenditure according to procedures designed for
related to diabetes in two countries. satisfying that specific process and not
for epidemiological purposes.
However, one of the major issues in
SVD-related projects is the difficulty of
scientifically documenting the evidence
of the outcomes due to the intrinsic
characteristics of such activities, which
means that the results are usually
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Reducing the Burden
Chapter 8
Platform for further The development and implementation

development of diabetes registries has been a step
taken to reconcile evidence-based studies
The major achievements of the SVD (16) and quality care benchmarking. Once in
may be summarized as: place the registries will provide reliable
population-based epidemiological data
• the consolidated awareness of the that are continuously updated, allowing
need for and the feasibility of broad monitoring of the diabetes problem.
partnership;
• the promotion of appropriate The platform produced by the quality
approaches for the planning of care networks and installed for the
interventions; registries supports the implementation
• the identification and implementation of standards of care and facilitates a
of specific methodologies for quality widespread adoption of shared care.
development; and A number of projects are flourishing in
• the need to define and apply correct Europe, where advanced projects have
methods for producing evidence. been developed in countries such as
the United Kingdom, Denmark, France,
In many European countries SVD-related Germany, Italy, the Netherlands, Finland
initiatives produced national programmes and Greece (23).
for diabetes adopted by governments,
the impact of which, however, is While the technological aspects no
extremely difficult to quantify owing longer represent a critical issue,
to the complexity and variability of the the most challenging topics are the
different environments. regulatory ones, such as the ownership
of data, confidentiality, access rights,
The promotion of defined and structured etc, and also the human, cultural and
methodologies for the development of environmental barriers that need to
quality of care has been a major focus be surmounted and that are currently
of the SVD movement. Benchmarking responsible for the difficulties in realizing
and external comparison, and quality large-scale projects (24).
circles are well-known procedures, whose
applicability in diabetes care has been Conclusion
demonstrated in many initiatives. For
example, within the DiabCare project, The first decade of the SVD has
indicators for diabetes care have been demonstrated the feasibility and
identified mostly in terms of outcomes possibility of new approaches to diabetes
and processes (17). care and the importance of focusing
on the real outcomes of the disease
Instruments for data collection have rather than on the processes. It has also
been produced, such as the Basic demonstrated that local solutions to local
Information Sheet, and various systems problems need to be defined.
for data transmission such as the
DiabCare programme and DiabCare Fax The experience gained has also shown
solution within the DiabCare Quality that available knowledge is poorly
Network (Qnet). In some countries, for applied, and this problem is not just
example France (18), Germany (19), the found in the less advanced countries.
Netherlands (20), Italy (21) and Spain The awareness of such widely accepted
(22), broad initiatives have proven the findings is creating the conditions for
feasibility and effectiveness of large-scale concrete initiatives aimed at large-
data collection and benchmarking for the scale prevention of end-stage diabetes
improvement of quality of diabetes care. complications.
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Reducing the Burden
Chapter 8
However, given the nature and time

scale for the development of diabetic
complications such as eye disease,
kidney disease and CVD, the real benefit
of the SVD movement will require a
greater length of time to be evident.
It is not inappropriate to claim that, in

many countries worldwide, the effect
of national action plans for diabetes
produced a change in attitude in
healthcare professionals, people with
diabetes and other stakeholders. This
change is likely to reduce successfully
the burden of diabetes by decreasing the
prevalence of blindness, end-stage renal
failure, stroke and myocardial infarction
in the years to come, which would not
have been the case without the SVD
movement.
Adapted from ‘The St Vincent Declaration: experience

gained for better outcome of cardiovascular, eye
and kidney complications in the future’ by M Massi
Benedetti, J Akwe Akwi, P Ferolla, MO Federici. In
Diabetes: From Research to Diagnosis and Treatment,
ed. Itamar R, Skyler J, Eleazar S. London: Martin
Dunitz, 2003.
273

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Chapter 8
19. Selbmann HK, Pietsch-Breitfeld B. DiabCare QNet activities

References Germany. The St Vincent Declaration Newsletter 1995;
Suppl 1:28–29.
1. World Health Organization (Europe) and International 20. DiabCare Q-Net NL. St Vincent goals into practice. Diabetes
Diabetes Federation (Europe). The action programme for Nutr Metab 1997; 10 Suppl 1:59.
the implementation of the St Vincent Declaration for the 21. Massi Benedetti M, Norgiolini R, Capani F, et al. The
improvement of diabetes healthcare. Jointly organized by DiabCare Quality Network as an instrument for quality
WHO Europe and IDF Europe. World Health Organization, development in diabetes. Diabetes Nutr Metab 1997;
ICT/CLR 055, 23 Oct 1990 (8438r). 10 Suppl:68.
2. World Health Organization (Europe) and International 22. Brugues E, Bosch F, Corcoy R, et al. Benefits of the combined
Diabetes Federation (Europe). Diabetes care and research in operation of DiabCare Q-Net and Diabcard system: ‘the
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7:360. 1:64.
3. Background to St Vincent. The SVD Newsletter issue 1998; 23. Diabetes ‘Registers’ Into the Millennium, 7th Workshop of
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Declaration - Monitoring the St Vincent Declaration 24. Vaughan NJA. Confidentiality and diabetes registers.
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14 Autumn:8.
5. Krans HMJ, Porta M, Keen H, Staehr Johansen K. Diabetes
care research in Europe: St Vincent Declaration action
programme. WHO Office, Copenhagen, 1995; EUR/ICT/CLR
055/3.
6. Krans HMJ, Porta M, Keen H, Staehr Johansen K. Diabetes
care research in Europe: St Vincent Declaration action
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Diabetologia 1995; 15:1.
7. Rosenqvist U. Implementation of the St Vincent Declaration
in Stockholm county, Sweden. Giornale Italiano di
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County. Diabet Med 1997; Sep 14:732–740.
9. Kohner EM, Lavin M, Hamilton AM. The management of
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13 Suppl:77–79.
10. Bagga P, Verma D, Walton C, et al. Survey of diabetic
retinopathy screening services in England and Wales. Diabet
Med 1998; 15:780–782.
11. Tautner C, Haastert B, Giani G, Berger M. Incidence of
blindness in southern Germany between 1990 and 1998.
Diabetologia 2001; 44:147–150.
12. Piehlmeier W, Renner R, Kimmerling T, et al. Evaluation of
the Micral-Test S, a qualitative immunologic patient self-
test for microalbuminuria: the PROSIT project. Proteinuria
Screening and Intervention. Diabet Med 1998; 15:883–885.
13. Bergrem H. Quality of care for persons with diabetic
nephropathy: Timeliness of first referral to nephrologist.
Diabetes Nutr Metab 2002; 15:109–115.
14. Ebskov B, Ebskov L. Major lower limb amputation in
diabetic patients: development during 1982 to 1993.
Diabetologia 1996; 39:1607–1610.
15. Scionti L, Massi Benedetti M, on behalf of the Cooperative
Study Group of the ‘Progetto Umbria Diabete’. A 8-year
population-based survey of non-traumatic lower extremity
amputations in diabetic and non-diabetic patients in an
Italian region. Diabetes 2001; 50 Suppl 2:A228.
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Declaration - The main achievements. The SVD Newsletter
10th Anniversary Issue 1999; 14 Autumn:8.
17. Piewernetz K, Home PD, Snorgaard O, et al. Monitoring
the targets of the St Vincent Declaration and the
implementation of quality management in diabetes care:
the DiabCare Initiative. Diabet Med 1993; 10:371–377.
18. Attali J, Klinebreil L. The support of young students in
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declaration. The St Vincent Declaration Newsletter 1995;
Suppl 1:27–28.
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Chapter 8
Box 8.1
Consensus on the aetiology of type 2 diabetes mellitus
Preamble
A specially convened meeting, Diabetes in Asia, was held in Colombo, Sri Lanka in 2002 for the
express purpose of arriving at an aetiological consensus on type 2 diabetes mellitus and the
development of a primary prevention strategy. This meeting was hosted by the Diabetes Association of
Sri Lanka and attended by over 350 opinion leaders representing 30 countries worldwide.
At the conclusion of the deliberations a consensus was reached on the aetiology and primary prevention
of type 2 diabetes, which was submitted for information and possible action by IDF and WHO.
Consensus Document
A consensus was reached on the ‘Aetiology and Prevention of Type 2 Diabetes Mellitus’ at the Diabetes
in Asia 2002 meeting held on 6-7 July 2002 in Colombo, Sri Lanka.
Proposition Cardiovascular Disease (CVD). Physical inactivity

• Current increase in the prevalence of type 2 is independently associated with increased insulin
diabetes mellitus worldwide accepted with resistance. Lifestyle changes in subjects with IGT
Level ‘A’ evidence* decreases progression to diabetes.
• Increased incidence of type 2 diabetes mellitus
in childhood and adolescence accepted with Accepted as a significant aetiological factor
Level ‘A’ evidence – Level ‘A’ evidence.
Genetics Stress
Genetics is recognized as playing an important Compelling animal evidence and mechanistic
role in the aetiopathogenesis of diabetes. studies suggest a relationship between Stress and
Monogenic forms have been identified. Insulin Resistance with predisposition to Type 2
Susceptibility genes have also been identified in Diabetes Mellitus.
the common forms of type 2 diabetes mellitus.
Genetic studies have contributed to the discovery Accepted as an aetiological factor
of new pathogenic mechanisms. – Level ‘B’ evidence*.
• Further evaluation recommended
Accepted as a significant aetiological factor
– Level ‘A’ evidence. Primary prevention
Further studies need to be pursued. All of the above are likely to underline the
Genetic counseling not recommended at present. urgent need for the primary prevention of type 2
diabetes mellitus and facilitate the introduction
Foetal origins of programmes, which must be tailored to local
Epidemiological studies have reported a higher circumstances in order to be effective. These
incidence of type 2 diabetes mellitus in subjects should include lifestyle changes in all those at
with a low birth weight. The hypothesis that risk.
nutrition of the mother can profoundly affect
the metabolic outcome of the offspring has been Concerted actions, by governments and non-
confirmed by elegant mechanistic animal studies. governmental organizations, should be directed
to the following:
Low birth weight accepted as a significant • Increasing awareness
aetiological factor – Level ‘A’ evidence. • Promotion of education at all levels
• Poor nourishment of the foetus increases risk • Multi-sectoral advocacy
of metabolic syndrome and type 2 diabetes
mellitus and postnatal over-nutrition may
aggravate the syndrome.
• Animal studies are confirmatory. Further clinical
research in human beings recommended.
Lifestyle
There is a global epidemic of obesity affecting all
ages. Obesity is associated with insulin resistance. * Level ‘A’ evidence – indicates full acceptance
There is a strong association between Obesity, * Level ‘B’ evidence – partial acceptance with more evidence
Diabetes, Impaired Glucose Tolerance (IGT) and needed.
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Chapter 8
8.2 Declaration of the Americas on Diabetes
Diabetes mellitus is Introduction Diabetes education

a growing pandemic. A standardized programme on diabetes
In 1996, an estimated The Declaration of the Americas on education to train diabetes educators
30 million people with Diabetes (DOTA) movement began with was developed and initially carried out
diabetes live in the a consensus development conference in at three centres in Argentina, Colombia
Americas, more than a 1996 when the Declaration was drafted. and Puerto Rico. An overall diabetes
quarter of the world’s The Declaration recognized diabetes education strategy in DOTA’s strategic
total case load. By the as a pandemic and called for strategic plan addresses the need for more
year 2010 the Americas action in diabetes education, awareness diabetes educators in Latin America.
case load is expected to and advocacy, quality of care, national
increase to 45 million, diabetes programme development, At the same time, the DOTA coalition
taking into account epidemiology and organizational has developed a set of educational
demographic ageing alliances. A resolution was then passed standards for diabetes programmes for
of populations and by the Pan American Health Organization people with diabetes in Latin America
trends in underlying Directing Council recognizing the and the Caribbean. These were based
risk factors which are Declaration as a guide to national on standards already established by the
related to the process programme development. American Diabetes Association (ADA),
of modernization that the American Association for Diabetes
is taking place in all The founding organizations were the Educators and the IDF Diabetes Education
developing countries. North American (NA) and South and Consultative Section (DECS).
Central American (SACA) Regions of IDF,
Declaration of the Americas the Pan American Health Organization A Caribbean Diabetes Education course,
on Diabetes (PAHO), and industry partners. supported by DOTA, was organized in
Barbados by the IDF North American
DOTA has expanded its partnerships Region in association with the Diabetes
to include other diabetes-related Association of Barbados (see Box 6.3 in
organizations in the Americas such as Chapter 6). In addition to utilizing the
the Latin American Diabetes Association DOTA standardized model programme
(ALAD), the Diabetes Association of the and the DECS model, the course
Caribbean, the International Society for incorporated a successful mentor system.
Pediatric and Adolescent Diabetes, the
National Diabetes Education Program A DOTA-PAHO regional workshop,
(US), and the American Association Building Blocks in Diabetes Education,
for Diabetes Educators. Future targets brought together representatives from
include expanding partnerships to 24 countries across the Americas in
support projects at the country level. the Dominican Republic. The aim of the
workshop was to develop a building
Priorities blocks model for educational activities
based on three scenarios detailing
The DOTA coalition has prioritized the national capacity levels. During the
following core areas in its strategic plan: workshop, the scenarios and educational
activities to fit each scenario were
• diabetes education; identified.
• epidemiology (quality of care systems
and surveillance);
• children and adolescents and diabetes;
• national programme development; and
• awareness.
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Chapter 8
Quality of care
A three-year programme on data
collection and assessment, Qualidiab,
has also been started to measure and
evaluate quality of care in six countries
- Argentina, Brazil, Chile, Colombia,
Paraguay and Uruguay. The initial results
from Qualidiab indicate that there is a
need for better quality of care.
A Caribbean pilot on assessment of

quality of care is also underway. The pilot
currently includes Jamaica and St Lucia,
and potentially will include the Bahamas
and Trinidad and Tobago.
Association development
Development and leadership courses,
organized by IDF and PAHO, have been
carried out to strengthen diabetes
associations. This is regarded as an
important step in creating the structures
and cooperation necessary to establish
national diabetes programmes and to
expand DOTA through multi-sectoral
collaborations. A DOTA strategic planning
workshop carried out by PAHO in Bolivia
has supported the efforts on diabetes and
has led to the establishment of a national
diabetes programme.
Public awareness
DOTA has also facilitated the
development of a model public
awareness plan and has encouraged
the development of local awareness
campaigns. A strategic plan on awareness
was formulated at a strategic planning
workshop, which took place in Trinidad
and Tobago. The workshop was
supported by DOTA and organized by the
IDF North American Region in association
with the Diabetes Association of Trinidad
and Tobago (DATT). The strategic plan is
currently being implemented by DATT.
For more information on DOTA and its

initiatives, please visit www.dota.org.
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Reducing the Burden
Chapter 8
8.3 Western Pacific Declaration on Diabetes
A point of particular Introduction • Goal 1: Primary prevention of diabetes

importance in the • Goal 2: Secondary prevention
Western Pacific Region The Western Pacific Declaration on (detection and management of
is that the largest Diabetes (WPDD) was introduced in diabetes and prevention of diabetes
rise in the number of recognition of the massive diabetes complications)
people with diabetes is problem in the Western Pacific Region, • Goal 3: Organization of healthcare
likely to occur in the with current estimates of at least 43 systems.
economically-productive million affected individuals, together
age groups. The with the clear need for a concerted and Endorsement by partners
huge cost of diabetes collaborative approach to tackle the
care and the loss of problem and to stem predicted future Since the launch of the WPDD in Malaysia,
productivity due to rises. the Declaration and its plan of action has
illness will impose a been endorsed and taken into policy by
heavy burden on many The WPDD, launched in 2000, is all three partner organizations. These
developing countries in an alliance between three partner endorsements are essential to empower
the future. organizations in the region: the IDF the WPDD to develop its important role
Western Pacific Region, the Secretariat of advocacy on behalf of the cause of
Western Pacific Declaration of the Pacific Community (SPC) and the diabetes in the region.
on Diabetes World Health Organization Western Pacific
Regional Office (WHO/WPRO). Endorsement at the Regional Committee
Meeting of WHO/WPRO took place in the
The different strengths, approaches Philippines in the same year the WPDD
and overlapping profiles of these three was launched. This endorsement by
partner organizations are being utilized governments was unanimous and led to
within the WPDD to maximize and a resolution urging the WHO Regional
strengthen the resources required for the Director to promote activities supporting
fight against diabetes. For example WHO the Declaration. This was followed by
works through governments whereas IDF further endorsement at a meeting of the
works through its member associations. Pacific Island Country Health Ministers
The SPC also works through governments held in Papua New Guinea the following
of member countries, the Pacific islands, year. The WPDD is also fully endorsed by
and has a particular interest in nutrition the IDF Western Pacific Regional Council
and lifestyle. as well as by the IDF Executive Board.
The potential for synergy is clear. Thus A corporate partner and supporters group
the agreement of the three partners to has also been formed within the structure
the proposals made in the Declaration of the WPDD and has made seeding
can, by both separate and combined financial donations to assist with the
endeavour, allow more effective action to development of the Declaration and the
combat the region’s problems. implementation of the plan of action.
Main goals Initiatives

The Declaration consists of an eight-point A number of activities have already
statement supported by a background been initiated in support of all three
explanatory document. There is also a goals of the WPDD. Numerous individual
comprehensive, detailed five-year plan of programmes have been initiated in
action, 2001 to 2005, organized within areas in support of diabetes prevention
the framework of three main goals: (Goal 1). These have been initiated,
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Reducing the Burden
Chapter 8
promoted or supervised by WHO/WPRO. delegates from developing countries.

Examples include programmes within The WHO/WPRO and SPC made
Vietnam, China, Mongolia, Philippines and additional funding available to allow
several Pacific island countries. some of these delegates to attend the
Third World Congress on Diabetes
A document written from a regional Prevention in Hong Kong.
perspective, ‘Type 2 Diabetes: Practical
Targets and Treatments’, has been 3 The WHO/WPRO and SPC also made
endorsed as being consistent with the funds available, under the auspices
goal of secondary prevention (Goal 2). of the WPDD, to allow delegates
This is a simple reference guide for from Mongolia, Philippines, Vietnam,
front-line workers caring for people with Tonga and Fiji to attend the Third
diabetes in the region. World Congress on Diabetes
Prevention and to contribute by
The development of IDF member making presentations at a one-day
associations is an example of an activity workshop held by the WPDD during
related to the organization of healthcare the congress.
systems (Goal 3). New associations in
Cambodia, Samoa and Vietnam indicate 4 Other activities included support for
the success of this. a train-the-trainer course for diabetes
educators in Singapore, and funds for
A number of projects have also been translation of an information leaflet
supported financially by the WPDD. into Chinese for distribution at the
Examples include: IDF Western Pacific Regional Congress
in Beijing. An exhibition was mounted
1 The Second Asia-Pacific Diabetes to promote the aims and goals of the
Epidemiology Training Course held WPDD at this congress.
at the Chinese University of Hong
Kong. The course received funding For further information about the WPDD
support from WPDD as well as the and its activities, and to obtain copies
National Institutes of Health, USA, the of the various documents including the
Hong Kong Foundation for Research Declaration Statement and Background
and Development in Diabetes, and Document, and Plan of Action, please
further support from Japan and visit www.wpdd.org.
Korea. Students from 15 countries
and areas attended the course -
Australia, Cambodia, China, Hawaii,
Hong Kong, Indonesia, Japan, Korea,
Malaysia, Mongolia, Philippines,
Taiwan, Thailand, Tonga and Vietnam.
Several of the students are already
engaged in major activities in their
own countries eg Vietnam, Cambodia
and Mongolia.
2 The IDF Western Pacific Region

together with the IDF Diabetes
Education Consultative Section (DECS)
held a leadership workshop in Hong
Kong. Funding was made available
to support the activities of the
workshop and, in particular, to assist
279

Reducing the Burden
Chapter 8
8.4 Declaration of the Eastern Mediterranean

The EMME Declaration Introduction problem with great human and economic
seeks to establish burdens. It called for action in the
diabetes as priority The Declaration of the Eastern following core areas:
health concern and Mediterranean and Middle East (EMME) • National diabetes strategies
recognize it as a Region was adopted in 2001 by IDF • Prevention of diabetes and its
serious, common health member associations in recognition of complications
problem with great the increasing prevalence of diabetes • Diabetes education
human and economic in their region, the emergence of • Research
burdens. diabetes complications as a cause of • Collaboration with stakeholders
early morbidity and mortality, and the • Discrimination
enormous and mounting burden on
healthcare. National diabetes strategies
The declaration called for the
The declaration seeks to establish development of national diabetes
diabetes as priority health concern and strategies with clear objectives, process
recognize it as a serious, common health indicators and outcome measures,
Profile: Zehra Naeemullah
“I had no knowledge of diabetes, because no one in my or my husband’s family, or any of

our close friends had diabetes,” says 60 year-old Zehra Naeemullah from Pakistan. “My first
contact with this condition was when my youngest daughter got married and we learned that
her father-in-law and his sister had diabetes. I was perturbed as now this disease would come
into our family never contemplating that very soon I too would be affected.”
Zehra, a housewife and mother of three grown-up

daughters, was diagnosed with type 2 diabetes about
two years ago when she went to the doctor because the
frequency of urination was combined with an urgency
that became very intense and intolerable. The random
blood sugar report of 450mg/dl was a complete
surprise and she could not believe it to be true. “I just
could not imagine at first that the diagnosis was correct
and told my doctor that no one in our family has
diabetes, so how can I have it?”
She now firmly believes that the media can and should
play a central role in increasing knowledge about
diabetes. “A lot still needs to be done to raise awareness
about diabetes,” she points out. “The doctors dealing
with it should write more articles in newspapers and
give talks on television. If everyone with diabetes knows more about their condition, they
could take better care of themselves without any difficulty.” She adds: “Even if one does not
have diabetes one should know what diabetes is as anyone may get it any time just the way it
happened to me.”
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Reducing the Burden
Chapter 8
which would lead to the creation and medications and supplies, especially
implementation of national diabetes insulin. A common information system
programmes according to national health for diabetes to enable health services
priorities. It also recognized the role of to monitor and control the quality of
national organizations in the creation healthcare was also crucial.
and implementation of national diabetes
programmes and thus the need to Prevention of diabetes
develop these organizations in order for and its complications
them to participate in the process. Several courses of action were identified
to meet the goals of the declaration
In addition, the declaration emphasized including raising public awareness by all
the need to develop and implement a possible means of the growing problems
unique and comprehensive healthcare of diabetes and its complications.
model, involving people with diabetes
and healthcare professionals, that The declaration also called for the
could be integrated with related non- allocation of adequate, appropriate and
communicable disease programmes and sustainable resources to prevent diabetes
the primary healthcare system. Such a where possible, and to make effective
model should ensure universal access and efficient use of these resources for
to quality care, training, and essential
Not long after diagnosis, Zehra had a frightening experience when she had a hypo [too
low level of glucose in the blood] and had to be rushed to hospital. It made her realize the
importance of having more knowledge about her condition. Her doctor, besides introducing
her to self-monitoring, advised her to attend the education sessions organized under a
diabetes care programme. She attended a series of lectures where she learned the basics of
diabetes including the need for good blood sugar control, the complications of uncontrolled
diabetes, the importance of exercise in controlling weight and blood sugar, and the need for
regular follow-up. Says Zehra: “I think one does not need to know everything about the disease
like doctors, but people with diabetes should have enough knowledge to be able to take care of
themselves.”
Receiving education and learning self-monitoring has changed Zehra’s life. She is now in good
control, regularly performing blood glucose monitoring at home and feeling much healthier.
Although she still gets a hypo once in awhile but with her glucometer within reach she feels
much more confident in dealing with it. She has also made it a routine to take regular exercise
and go for a daily walk for an hour in the late afternoon.
Zehra believes that if one works sufficiently hard one can achieve anything in life. She married
at 16 when she had just completed her matriculation. She resumed her education along with
the responsibilities of married life and three children. She finally graduated with a master’s
degree (MA) in economics at the age of 30. Zehra is now ready to fulfill another of her dreams
and that is to open a day-care centre for working mothers so that they can pursue their
careers without any hindrance.
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Reducing the Burden
Chapter 8
the development of a regional plan and

activities.
The declaration emphasized the need

to improve the detection and control of
diabetes and impaired glucose tolerance
(IGT), and reduce the onset of diabetic
complications with special focus on
gestational diabetes mellitus, and
diabetes in the elderly and children.
Diabetes education
Diabetes education for people with
diabetes and healthcare professionals
was another key area in the declaration.
The declaration identified the promotion
of health education for people with
diabetes, health professionals and the
public in the prevention and management
of diabetes, and the setting up of
standards and norms for education.
It also called for the establishment
of centres of excellence in diabetes
education and research.
Diabetes education was also crucial to

encouraging self-care for people with
diabetes in order for them acquire
knowledge and skills necessary for
effective self-management of the disease.
Research
Further, the declaration sought to
encourage and promote research to allow
for new knowledge, effective prevention
and better healthcare and management
as well as to collect epidemiological data
through registry and screening.
Collaboration with stakeholders

The declaration also recognized
the importance of collaboration
internationally as well as among the
major stakeholders involved in diabetes
healthcare.
Discrimination
Discrimination against people with
diabetes was another issue the
declaration addressed and called for
action for its removal.
282

Diabetes Associations: from Patients to Partners
Chapter 9
Diabetes Associations: Chapter 9

from Patients to Partners
At a glance
Number of member associations: 183
Number of member countries: 142
Number of people with diabetes represented: 2.7 million
D iabetes associations play a crucial

role in improving the quality of life
of people with diabetes. It is not only in
their position as advocate that diabetes
associations have taken on a much more
proactive role in enhancing the lives of
people with diabetes. An example can
be found in the provision of diabetes
education, a cornerstone of diabetes
management, by associations from all
over the world. The results of the survey
on diabetes associations around the
world undertaken by the International
Diabetes Federation (IDF) show a dynamic
process at work.
The number of diabetes associations

continues to grow worldwide as seen
in the rise of membership in IDF. The
number of people with diabetes that IDF
member associations represent is well
over two million. The growth in diabetes
associations in the last 20 years possibly
reflects the mounting numbers of people
with diabetes as well as the gradual
283

Chapter 9
empowerment of those affected by the Results

disease over the years. This was the second survey undertaken
by IDF on diabetes associations. The
It is significant to note that the majority survey questionnaire was sent to all
of associations, which responded to the IDF member associations but was also
survey, have both people with diabetes made available to non-members. The
Stop discrimination,
and healthcare professionals in their Federation received 92 questionnaires
defend the rights and
membership. This could be due to which represented a response rate of
enhance the lives of
the breakdown of traditional barriers approximately 50%.
people with diabetes
between healthcare professionals and
Mission statement, their patients as well as a reflection of a The first survey conducted in 1999
Georgian Diabetes more collaborative approach to diabetes resulted in a 72.5% response rate. As a
Federation
care and management. result, there is no attempt to make any
comparisons between the two surveys
It would also seem that a new role has in this chapter as this could lead to
emerged for diabetes associations. misinterpretations.
Whereas previously, diabetes associations
worked primarily on behalf of their However, the number of responses was
members, more than 70% of those which sufficient to give a good representation of
responded indicated that they now the structure, organization and activities
engaged in activities for the primary of diabetes associations around the
prevention of type 2 diabetes. world.
While diabetes associations vary in size IDF membership

and influence, they nonetheless reflect Since its inception in 1950, IDF has
the changing role of people with diabetes grown from 16 member associations in
from being patients to being partners in 15 countries to 183 member associations
the healthcare process. in 142 countries in 2003.
Figure 9.1
IDF membership growth, 1950 – 2003
��
��
��
��
��
��
��
��
��
��
��
��
��
��
��
��
��
��
��
�
��
��
284

Chapter 9
The increase has been very steady in Figure 9.2

the last twenty five years, as shown Organizational structure of diabetes associations
in Figure 9.1. This trend reflects the
increasing number of people with ��
diabetes as well as the need for people ��
with diabetes, and their families, to

play an active role in their care and
management of the disease.
Goals
The primary objective of most diabetes
associations could be summarized as
follows: to improve the quality of life of
people with diabetes and their families.
��
To achieve this important mission, the

efforts of the associations have focused
on: Figure 9.3
Governing bodies and strategies
• improving quality care and services;
• promoting education of both ��
��
people with diabetes and healthcare
professionals; ��
• promoting self-management and
empowerment; ��
• encouraging prevention and early
diagnosis of diabetes; ��
• raising awareness on diabetes and its
complications; � ��
• providing assistance and protection, ��
and defending the rights of people
with diabetes;
• establishing national diabetes
programmes; and
• influencing healthcare policies. while about 86% have elected bodies.
In terms of strategy, close to 79% have a
Organizational structure mission statement and 70% produce an
The results of the survey indicated that action plan, as indicated in Figure 9.3.
88% of the respondents were national
associations while 8% were national Type of membership
federations, as shown in Figure 9.2. Some Diabetes associations with a mixed
4% declared a different structure, such as membership, ie both people with
scientific societies, foundations, etc. diabetes and healthcare providers,
represented 43% of the respondents.
Some 84% of the associations charged a Some 33% of the respondents were
membership fee while 38% offered free associations representing only people
membership to people with diabetes. with diabetes and their families while
15% were organizations for healthcare
Most diabetes associations have elected professionals only, as shown in Figure
bodies governed by a constitution. Some 9.4. Healthcare centres make up 7% of
92% of the respondents indicated that the organizations which responded to the
they have a constitution and by-laws survey.
285

Chapter 9
Figure 9.4 Figure 9.5

Type of membership Size of diabetes associations
��

��
��
��
��
��
Size of organizations and 49,999. Only 6% of the respondents

The majority of associations, 48% of have more than 50,000 members, as
respondents, have fewer than 999 shown in Figure 9.5. However, it is
members. This was followed by medium- important to note that this small number
sized associations of between 1,000 and of associations covers around 75% of all
9,999 members, 34%, while 12% were members represented by IDF diabetes
large associations of between 10,000 associations.
Profile: Dijana Lukoseviciene
It came as a surprise to Dijana Lukoseviciene, 50, and to those who knew her, when she was
diagnosed with type 2 diabetes. Dijana was energetic and active, and enjoyed gardening in
the spring and going to the opera in the winter. She found out
very quickly after her recent diagnosis that diabetes is not just
a disease but a way of life. “The truth of this came to me on the
first day home from the hospital,” she says. “A few times a day for
the rest of my life I will have to control the level of blood glucose,
observe a special diet, inject insulin before any substantial meal.
What it means is that I will never have a chance to forget the
disease, I will have to live in constant tension to a certain degree.”
Dijana, who works for the Vilnius municipality in Lithuania, also

realized that she had to take responsibility to learn more about
the disease in order to manage her diabetes in the best possible
way. “Unfortunately the hospital personnel hardly helped in
finding my way through the labyrinth of this complex disease,”
she recalls. “The diabetes school was organized in such a way that only 15 to 20 minutes were
allocated to each patient, this was not satisfactory.”
Instead Dijana turned to the Lithuanian Diabetes Association for support and used the
internet as a resource. “I realized that it was necessary to communicate with people who
286

Chapter 9
Activities Figure 9.6

Education, public awareness and the Activities undertaken by diabetes associations
organization of meetings are the most
common activities undertaken by the ��
��
associations that responded to the
survey, as indicated in Figure 9.6. ��
��
Education ��
Of those who organized diabetes
education, 82% organized courses for ��
people with diabetes while 67% had
courses for healthcare professionals, as ��
shown in Figure 9.7. Some 67% produced
their own education materials. ��
��
Public awareness ��

��
Activities to raise public awareness
included World Diabetes Day, media � ��
events, other national campaigns and ��
diabetes fairs, as shown in Figure 9.8.
It is also significant to note that almost

77% of respondents were involved in
activities for the primary prevention of
type 2 diabetes.
have the same illness, so I became a member of the Lithuanian Diabetes Association and
subscribed to their quarterly magazine, Diabetas [Diabetes].”
Dijana found that she had to make several adjustments to her life: psychological, dietary
and physical. She also had to learn to manage her insulin dosage, which she found the most
difficult. “At the beginning I thought it would be enough to measure the level of blood glucose,
and regulate the amount of insulin and carbohydrate intake,” she states, “today I know this
understanding is quite limited.” Dijana found that her blood glucose level could rise in a
stressful situation or during a complicated conversation with a colleague.
The diabetes association provided advice and helped answer her many questions. Says Dijana:
“There were things that I did not understand due to my lack of experience with the disease.
Practical suggestions helped a lot.” The association’s doctor gave her advice about diet, as well
as an easy nutrition plan and a guide to principles of healthy nutrition. “He also taught me not
to be afraid to reduce the insulin doses depending on fluctuations of the level of glucose.”
For the first two months following diagnosis Dijana found that she had more energy and
strength than before. However, her doctor as well as the association’s doctor warned her that
this was the so-called ‘honeymoon’ period. She was then prepared to meet what was to come
– the fluctuations in her level of glucose, and to adjust her insulin dosage accordingly.
“It is vital to learn from my own mistakes,” emphasizes Dijana, “and to listen to suggestions
from friends with a common fate, share our experiences and just to live on.”
287

Chapter 9
Figure 9.7 Meetings

Diabetes education: type of activity Meetings organized by the associations
were mostly seminars (80% of
�� respondents) followed by workshops
��
and congresses. These meetings were
��
in most cases addressed to healthcare
��
professionals and to a lesser extent to
��
�� people with diabetes.
��
�� Advocacy
�� The top three issues in advocacy were:
� �� 1 ensuring quality care;

�� 2 defending the rights of people with
diabetes; and
3 promoting education to people
Figure 9.8 with diabetes and healthcare
Public awareness activities professionals.
�� These top issues were fully in line with

�� the goals set by the associations in their
mission statements. Other major issues
��
raised were prevention, screening, cost
�� of insulin, costs/reimbursement of care,
�� insurance, driving licence, empowerment,
and influencing public health policies
��
through collaboration with governments,
health organizations, other non-
� ��
governmental organizations (NGOs) and
�� universities.
Magazines
Figure 9.9 Magazines published by the diabetes
Magazines: target groups associations are largely addressed
to people with diabetes (92% of
�� respondents), while 80% targeted
�� healthcare professionals and only 48%
�� focused on opinion leaders, as shown in
�� Figure 9.9. Half of these magazines were
addressed to all three target groups at
��
the same time.
� ��
National diabetes programmes
��
More than half of the associations that
responded, close to 58%, indicated that
there is a national diabetes programme
in their country. In 83% of the cases, the
programme is being implemented with
73% of the associations involved in its
implementation.
288

Chapter 9
More than 90% of the associations co- Figure 9.10

operate with a national health authority Services provided by healthcare centres
in their country, this authority in many
��
cases being the Ministry or Department
��
of Health.
��
Healthcare centres ��

Activities undertaken by diabetes
��
healthcare centres are multiple. All ��
of them provide education for people
��
with diabetes and a large majority offer
consultation, dietary guidance, foot care, ��
eye examination as well as seminars
��
for healthcare providers, as seen in ��
Figure 9.10. ��
��
��
� ��
��
289

Chapter 9
Table 9.1
Structure and organization of diabetes associations, 2003
Year of
Region Country Name of organization establishment
AFR
Cameroon Cameroon Diabetes Association (ACADIA) 1989
Central African Republic Association des Diabétiques en Centrafrique / Central Africa Diabetes Association
Chad Association Tchadienne de lutte contre le Diabète / Chad Association for the Fight
against Diabetes
Congo, Democratic Republic of Association Nationale du Diabète de la République Démocratique du Congo
Côte d’Ivoire Association des Diabétiques de Côte d’Ivoire (ADIACI) 1994
Eritrea Eritrean Diabetes Association 1997
Ethiopia Ethiopian Diabetes Association 1985
Gabon Association des Diabétiques du Gabon
Gambia Gambia Diabetes Association 1993
Ghana Ghana Diabetes Association
Guinea Association Guinéenne d’Education et d’Aide aux Diabétiques / Guinean Association
for the Education and Help to Diabetics
Kenya Diabetes Educators Association of Kenya 1999
Kenya Diabetes Association 1971
Madagascar Association Malgache contre le Diabète 1983
Mali Association Malienne de Lutte contre le Diabète (AMLD) 1991
Mozambique Associação Moçambicana dos Diabéticos
Nigeria Diabetes Association of Nigeria 1982
Senegal Association Sénégalaise de Soutien aux Diabétiques (ASSAD) 1967
South Africa Diabetes South Africa 1969
Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA) 1960
Tanzania Diabetes Association of Zanzibar (DAZ) 1986
Tanzania Diabetes Association 1985
Togo Association Togolaise du Diabète (ATD) 1992
Uganda Uganda Diabetic Association
Zambia Diabetes Association of Zambia 1989
Zimbabwe Zimbabwe Diabetic Association 1989
EMME
Bahrain Bahrain Diabetes Association 1989
Egypt Egyptian Diabetes Association 1970
Iran Iranian Diabetes Society (IDS) 1968
Iraq Iraqi Diabetes Association 1982
Jordan Jordanian Association for the Care of Diabetes
Kuwait Kuwait Diabetes Society 1996
Lebanon Lebanese Diabetes Association 1982
Libya Libyan Diabetic Association
Morocco Ligue Marocaine de Lutte contre le Diabète 1991
Pakistan Diabetic Association of Pakistan 1996
Qatar Qatar Diabetes Association 1995
Saudi Arabia Saudi Diabetes and Endocrine Association 1993
Sudan Sudan Diabetic Association
Syria Syrian Diabetes Association 1973
Tunisia Association Tunisienne des Diabétiques / Tunisian Diabetes Association 1971
United Arab Emirates Emirates Diabetes Society
EUR
Albania Shoqata Shqipëtare Diabetike / Albanian Diabetes Association 1992
Austria Österreichische Diabetes-Gesellschaft / Austrian Diabetes Society 1969
Österreichische Diabetiker Vereinigung / Austrian Diabetes Organization
Azerbaijan, Republic of Azerbaijan Diabetes Society
Belarus Belarussian Humanitarian Organization ‘Children’s Diabetes’
Belgium Association Belge du Diabète / Belgian Diabetes Association 1942
Vlaamse Diabetes Vereniging / Flemish Diabetes Association 1972
290

Chapter 9
Free
No. of membership
individual No. of full time No. of active Constitution for people with
members employees volunteers and by-laws Elected bodies Action plan Membership fee diabetes
1,000 ü ü § § ü
4,000 0 10 ü § § ü §
5,000 ü
5,000 1 10 ü ü §
600 0 6 ü ü § ü ü
1,738
65 0 65 ü ü ü ü §
10,524 0 6 ü § § ü §
6,000 1 100 ü ü ü ü ü
3,000 5 15 ü ü ü ü §
19,928 10 19 ü § § ü ü
5,040
250 0 10 ü § § ü §
450 0 0 ü § ü ü §
625 0 5 ü ü ü ü
2,000 4 ü ü § ü §
1,000 0 10 ü ü ü ü §
1,500 2 8 ü ü ü ü §
150
8,032 4 100 ü ü ü ü ü
14,599 12 80 ü ü ü § ü
100
717
1,086 8 20 ü ü ü ü
260
400
1,850
8,480 40 ü ü ü ü §
474 15 40 ü § ü §
3,850
220
3,500
124
1,000 0 7 § ü § § ü
580
5,900
3,000 § ü ü
3,003
7,500
18,580 8 418 ü ü ü ü §
291

Chapter 9
Year of
Bulgaria Bulgarian Diabetes Association 1990
Bulgarian Society of Endocrinology and Gerontology 1954
Croatia Hrvatska Dijabeticka Udruga / Croatian Diabetes Association 1957
Cyprus Cyprus Diabetic Association 1979
Czech Republic Ceska Diabetologicka Spolecnost / Czech Diabetes Society 1963
SVAZ Diabetiku Ceske Republiky / Union of Diabetics of the Czech Republic 1991
Denmark Diabetesforeningen / Danish Diabetes Association 1940
Estonia Estonian Diabetes Association 1992
Finland Finnish Diabetes Association 1955
France Association Française des Diabétiques (AFD) / French Diabetes Association 1938
Georgia, Republic of Georgian Diabetes Federation 1992
Germany Deutsche Diabetes-Union e V / German Diabetes Union 1990
Greece Hellenic Diabetologic Association 1974
Hellenic Federation of Diabetics 1997
Hungary Magyar Diabetes Tarsasag / Hungarian Diabetes Association 1971
Iceland Samtök Sykursjúkra / Icelandic Diabetes Association 1971
Ireland Diabetes Federation of Ireland 1967
Irish Endocrine Society 1984
Israel Israel Diabetes Association 1954
Italy Associazione Italiana Diabetici (AID) 1964
Associazione Medici Diabetologi (AMD) 1974
FAND 1982
Società Italiana di Diabetologia (SID) / Italian Society of Diabetology
Kazakhstan Diabetes Association of the Kazakhstan Republic 1995
Kyrgyzstan Diabetes Association of Kyrgyzstan
Lithuania Lithuanian Diabetes Association 1989
Luxembourg Association Luxembourgeoise du Diabète / Luxembourg Diabetes Association 1979
Macedonia Macedonian Diabetes Association 1991
Malta Ghaqda Kontra D-Dijabete / Maltese Diabetes Association 1983
Netherlands Diabetesvereniging Nederland (DVN) / Dutch Diabetes Association 1945
Nederlandse Vereniging voor Diabetes Onderzoek (NVDO) / Dutch Association for 1974
Diabetes Research
Norway Norges Diabetesforbund / Norwegian Diabetes Association 1948
Poland Polskie Stowarzyszenie Diabetyków Zarzad Glowny / Polish Diabetes Association 1981
Polskie Towarzystwo Diabetologiczne / Polish Diabetological Association 1983
Portugal Associação Protectora dos Diabeticos de Portugal (APDP) / Portuguese Diabetic
Association
Sociedade Portuguesa de Diabetologia (SPD) 1926
Romania Association for the Protection of Romanian Children and Youth with Diabetes
Societatea Romana de Diabet, Nutritie si Boli Metabolice / Romanian Society of
Diabetes, Nutrition and Metabolic Diseases
Russian Federation Russian Diabetes Federation
Serbia and Montenegro Diabetes Association of Serbia and Montenegro 1997
Slovakia Slovenska Diabetologicka Spolocnost / Slovak Diabetes Society 1968
ZVAZ Diabetikov Slovenska / Association of Diabetic Patients of Slovakia 1990
Slovenia Zveza Društev Diabetikov Slovenije (SLODA) / Slovenian Diabetes Association 1956
Spain Asociación de Diabéticos de Tenerife
Federación Española de Diabetes / Spanish Federation of Diabetes
Sociedad Española de Diabetes / Spanish Diabetes Society 1954
Sweden Svenska Diabetes Förbundet / Swedish Diabetes Association 1943
Swedish Society for Diabetology 1982
Switzerland Schweizerische Diabetes-Gesellschaft / Swiss Diabetes Association 1957
Turkey Türk Diabet Cemiyeti / Turkish Diabetes Association 1955
Turkish Diabetes Foundation 1996
Ukraine Ukrainian Diabetic Federation 1993
United Kingdom Diabetes UK 1934
NA
Anguilla Anguilla Diabetes Association
Antigua and Barbuda Antigua and Barbuda Diabetes Association 1986
292

Chapter 9
Free
No. of membership
15,300 5 250 § ü § § ü
160
7,000 2 700 ü ü ü
6,000 1 50 ü ü § ü ü
682
16,000 6 600 ü ü ü ü ü
54,000 27 500 ü ü ü ü
0 All ü ü ü ü §
52,000 60 1,500 ü ü ü
26,000
4,000 0 100 ü ü ü
46,136
2,086
300 1 10 ü ü ü
1,480 0 0 ü ü ü ü §
750
3,087 6 200 ü ü ü ü §
165
12,000 6 220 ü ü ü ü
1,582 3 200 ü ü ü ü §
80,000 0 11 ü ü ü ü §
1,943
3,000 10 ü ü ü ü ü
5,000 4 52 ü ü ü ü ü
906 0 15 ü ü ü ü §
2,500
900 0 ü ü § ü §
53,630 27 4,000 ü ü ü ü §
300
33,000 18 1,200 ü ü ü ü §
100,000 5 1,200 ü ü § ü ü
500
4,389
452
750
1,000,000
7,000 0 3 ü ü ü § ü
669 0 55 ü ü ü ü §
3,000
200 1 10 ü § § ü ü
2,000
830 1 0 ü ü § ü §
35,500 14 ü ü ü ü §
3,000
25,000
2,250
750 3 10 ü ü ü ü ü
17,000 3 75 ü ü ü
183,000 170 ü ü ü ü §
60 0 6 § ü
293

Chapter 9
Year of
Aruba Aruba Diabetes Foundation 1975
Bahamas Bahamas Diabetic Association 1986
Barbados Diabetes Association of Barbados 1975
Belize Belize Diabetes Association 1991
Bermuda Bermuda Diabetes Association 1979
British Virgin Islands British Virgin Islands Diabetes Association 1982
Canada Canadian Diabetes Association 1953
Diabète Québec 1954
Cayman Islands Cayman Islands Diabetic Association 2000
Dominica, Commonwealth of Dominica Diabetes Association
Grenada Grenada Diabetes Association 1983
Guyana Guyana Diabetic Association 1973
Haiti Fondation Haïtienne de Diabète et de Maladies Cardiovasculaires (FHADIMAC)
Jamaica Diabetes Association of Jamaica 1983
Mexico Federación Mexicana de Diabetes / Mexican Diabetes Federation 1979
Sociedad Mexicana de Nutrición y Endocrinología / Mexican Society of Nutrition
and Endocrinology
St Kitts and Nevis St Kitts Diabetes Association
St Lucia St Lucia Diabetic and Hypertensive Association
Trinidad and Tobago Diabetes Association of Trinidad and Tobago 1976
USA American Diabetes Association 1936
SACA
Argentina Liga Argentina de Protección al Diabético (LAPDI) / Argentine League for the 1964
Protection of Diabetics
Mutual Integral Provincial de Ayuda al Diabético (MIPADI) 1994
Sociedad Argentina de Diabetes / Argentinian Diabetes Society 1954
Bolivia Sociedad Boliviana de Endocrinología, Metabolismo y Nutrición / Bolivian Society of
Endocrinology, Metabolism and Nutrition
Brazil Associação de Diabetes Juvenil (ADJ) 1980
Federação Nacional de Associações de Diabéticos (FENAD) 1988
Sociedade Brasileira de Diabetes (SBD) / Brazilian Diabetes Society 1970
Chile Fundación Diabetes Juvenil de Chile / Juvenile Diabetes Foundation of Chile 1988
Sociedad Chilena de Endocrinología y Metabolismo / Chilean Society of
Endocrinology and Metabolism
Colombia Asociación Colombiana de Diabetes 1954
Federación Diabetológica Colombiana (FDC) 1997
Costa Rica Asociación Costarricense de Endocrinología Diabetes y Nutrición (ACEDYN)
Cuba Sociedad Cubana de Diabetes / Cuban Society of Diabetes 1959
Dominican Republic Instituto Nacional de Diabetes, Endocrinología y Nutrición (INDEN) 1972
Sociedad Dominicana de Diabetes (SODODIA) / Dominican Diabetes Society 1966
Ecuador Asociación Ecuatoriana de Diabeticos (AED)
Federación Ecuatoriana de Diabetes (FEDIabetes)
El Salvador Asociación Salvadoreña de Diabéticos (ASADI) 1988
Guatemala Patronato de Pacientes Diabéticos de Guatemala
Honduras Coordinadora Nacional de Lucha contra la Diabetes (CONALUDI)
Netherlands Antilles Sociedat Kurasoleno di Diabetiko (SOKUDI) / Diabetic Association of Curaçao
Nicaragua Fundación Pro Ayuda a Enfermos Crónicos (FUNPEC) 1994
Panama Asociación Panameña de Diabeticos / Panamanian Diabetes Association
Paraguay Fundación Paraguaya de Diabetes
Sociedad Paraguaya de Diabetología / Paraguayan Society of Diabetology 1970
Peru Asociación de Diabéticos Juveniles del Péru (ADJ) / 1990
Juvenile Diabetes Association of Peru
Asociación Peruana de Diabetes / Peruvian Diabetes Association 1973
Puerto Rico Asociación Puertorriqueña de Diabetes 1988
Asociación Puertorriqueña de Educadores en Diabetes / Puerto Rican Association of
Diabetes Educators
Sociedad Puertorriqueña de Endocrinología y Diabetología (SPED) / Puerto Rican 1977
Society of Endocrinology and Diabetology
Suriname Stichting Diabetes Educatie Suriname 1988
294

Chapter 9
Free
No. of membership
50 0 15 ü ü ü § ü
350 1 20 ü ü § ü ü
1,600 ü ü § ü ü
357 0 10 ü ü § ü ü
700 0 12 ü ü ü ü §
150 0 12 § ü §
50,000 310 ü ü ü ü §
22,000 20 2,000 ü ü ü ü §
139 0 § ü § § ü
300
250
100 0 7 ü ü ü ü §
80
35,000 38 7 § ü § ü §
965 6 15 ü ü ü
500
2,100
400,000 900 50,000 ü ü ü ü §
2,000 3 10 ü ü ü ü ü
310
765
56 0 56 ü ü § ü §
1,000
10 58 ü ü ü
920
4,258
206
8,000
300
35
131 0 131 ü ü ü ü §
343
150
3,200 10 40 ü § ü ü ü
600 ü ü ü § ü
980
40 ü ü ü ü §
50 4 12 ü ü ü ü ü
1,000
350 6 ü § § ü
47
70
15 ü § §
295

Chapter 9
Year of
Uruguay Asociación de Diabéticos del Uruguay / Uruguayan Diabetes Association 1951
Sociedad de Diabetología y Nutrición del Uruguay 1978
Venezuela Asociación Venezolana de Diabetes / Venezuelan Diabetes Association
Federación Venezolana de Asociaciones y Unidades de Diabetes (FENADIABETES) 1990
Fundación de Atención al Diabético (FUNDIABETES)
Sociedad Venezolana de Endocrinología y Metabolismo / Venezuelan Endocrinology 1957
and Metabolism Society
SEA
Bangladesh Diabetic Association of Bangladesh (DAB) 1956
India Diabetic Association of India 1955
Mauritius Mauritius Diabetic Association 1981
Nepal Nepal Diabetes Association 1990
Sri Lanka Diabetes Association of Sri Lanka 1984
WP
Australia Diabetes Australia 1952
South Eastern Sidney Division of General Practitioners 1992
Cambodia Cambodian Diabetes Association 1998
China, Hong Kong Diabetes Hong Kong 1996
Society for the Study of Endocrinology, Metabolism and Reproduction 1983
China, Macau Macau Diabetes Association 1997
China, People’s Republic of Chinese Diabetes Society of the Chinese Medical Association (CMA) 1991
Fiji Fiji National Diabetes Foundation 1986
Indonesia Persatuan Diabetes Indonesia / Indonesian Diabetes Association 1986
Japan Japan Diabetes Society 1957
Korea, Republic of Korean Diabetes Association 1968
Malaysia Persatuan Diabetis Malaysia / Malaysian Diabetes Association 1981
New Zealand Diabetes New Zealand 1962
Papua New Guinea Diabetic Association of Papua New Guinea
Philippines Philippine Diabetes Association 1958
Samoa Samoa Diabetes Association
Singapore, Republic of Diabetic Society of Singapore 1971
Taiwan Chinese Taipei Diabetes Association 1980
Thailand Diabetes Association of Thailand 1966
Tonga Tonga Diabetes Association 1997
Total
296

Chapter 9
Free
No. of membership
5,413 19 100 ü ü ü ü
250
250
1,000
150
569
12,270 ü ü ü ü §
300 1 24 ü ü ü ü §
300 3 10 ü ü ü ü ü
494 18 48 ü ü ü ü §
94,044
205 6 0 ü ü § ü §
338 0 12 ü ü ü § ü
2,301 3 103 ü ü ü § ü
70
328 0 5 ü ü ü § ü
500
75
5,000
20,000 4 ü § ü ü §
26,318 2 ü ü ü ü ü
2,800
13,479 3 ü ü ü ü §
16
500 1 ü ü § ü §
3,500 12 10 ü § § ü §
633 1 14 § § ü ü
369
700
2,699,006 1,863 64,642 § § § § §
297

Chapter 9
Table 9.2
Number of registered patients and services provided by diabetes healthcare centres, 2003
Total no. of
Region Country Name of healthcare centre registered patients
AFR
Côte d’Ivoire Centre Antidiabétique d’Abidjan et Service d’Endocrino-Diabétologie du CHU de Yopougon 24,000
Kenya Diabetes Care and Training Ltd 1,456
Madagascar Maison du Diabète 5,500
Senegal Centre de Diabétologie Marc Sankale 19,928
EMME
Libya National Centre for Diabetes and Endocrinology 16,094
Pakistan Diabetic Association of Pakistan 8,477
EUR
Georgia, Republic of Georgian Diabetes Federation 1,500
NA
Bermuda BHB Diabetes Centre 1,500
Jamaica Diabetes Association of Jamaica 35,000
SACA
Nicaragua Fundación Pro Ayuda a Enfermos Crónicos Clinica 1,500
Venezuela Fundación de Atención al Diabético 840
SEA
Bangladesh Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and 245,842
Metabolic Disorders (BIRDEM)
India All India Institute of Diabetes 67,332
Sri Lanka National Diabetes Centre 130,000
WP
Singapore, Republic of Diabetes Education and Care Centre N/A
Total 558,969
N/A not available
298

Chapter 9
Education for Seminar for Routine

Eye people with healthcare Dietary Magazine for laboratory
Consultation examination Hospitalization diabetes providers guidance Foot care patients test
ü § ü ü ü ü ü § §
ü § § ü ü ü § ü ü
ü ü § ü ü ü ü § ü
ü ü ü ü § ü ü § ü
ü ü § ü ü ü ü ü §
ü ü § ü ü § § § §
ü § § ü ü ü ü § §
ü ü § ü ü ü ü ü ü
§ § § ü ü ü ü § §
ü ü ü ü ü ü ü ü ü
ü ü ü ü ü ü ü ü ü
ü ü § ü § ü ü § §
§ § § § § § § § §
299

Prevention and Strategic Action
Chapter 10
Prevention and Strategic Action Chapter 10
At a glance
Priorities
 Prevention of diabetes and its complications

 Improve quality of life
 Ensure affordable insulin and diabetes supplies
 Raise global awareness
 Promote education
T he current mission of the

(IDF) is “to work with its member
associations to enhance the lives of
people with diabetes”. To fulfil its mission
and its role as the global advocate for
people with diabetes, IDF has engaged
in activities to advocate, educate and
inform.
As such, for the last 50 years, the actions

of the Federation have been targeted
accordingly:
• recruiting more member associations;

• organizing activities in the Federation’s
seven regions;
• raising public awareness about
diabetes;
• promoting solidarity through the
associations’ twinning programmes;
• defending the cause of people with
diabetes at national, regional and
international levels;
• cooperating with the World Health
Organization (WHO) and numerous
non-governmental bodies;
301

Chapter 10
• helping to educate healthcare for satisfaction, and of a rise in incidence

professionals to improve diabetes (number of new cases each year), a cause
management through the Federation’s for concern.
Education Foundation;
• promoting diabetes education; Preventing type 1 diabetes to occur is still
• evaluating the costs of diabetes; and a dream. However, the worldwide efforts
• disseminating information about to better understand the mechanisms of
diabetes through its newsletters, the disease, identify what is inherited and
periodicals, non-serial publications, what may be due to the environment,
triennial congresses, website and the and to recognize early those at risk offer
Diabetes Atlas. great hopes that type 1 diabetes may
one day be prevented, halted early in its
By promoting diabetes The need for prevention progression and ultimately cured.
prevention, IDF will
ensure that those As evidenced by the information gathered Priorities for strategic action
millions who already in this edition of the Diabetes Atlas,
have diabetes will not the time has come to consider adding Type 1 diabetes mellitus
face the nightmare of a diabetes prevention to the mission of The priority of the priorities today for
regression in the quality the Federation. Indeed, estimations and the International Diabetes Federation
of care they deserve projections all concur that the number is to ensure that insulin and blood
while, on the contrary, of people with diabetes which may be glucose control materials are available
there is a great need in reached in the next 25 years would and affordable everywhere in the world
many parts of the world qualify diabetes as the largest epidemic for those who need them, an objective
to improve it. humanity has ever experienced. followed assiduously by the IDF Task
Force on Insulin.
If this indeed occurs, and there is little
reason to believe it will not if action is The contribution of IDF to the prevention
not taken, there is a significant risk that of type 1 diabetes will be to maintain
governments and social security systems pressure on raising awareness, encourage
may fail to ensure the appropriate care to research in the field and support all those
the some 333 million people who will be who, through innovative efforts, try to
affected by diabetes in 2025. Some 90% better understand the mechanisms of this
of these people will have type 2 diabetes complex disease.
mellitus. Recent studies have shown that
type 2 diabetes and its complications Type 2 diabetes mellitus
may be prevented or delayed given the Pathways for direct action by IDF are
right action. more obvious regarding type 2 diabetes
mellitus, which affect some 90% of the
By promoting diabetes prevention, IDF 194 million with diabetes today, and
will ensure that those millions who probably even more than 90% tomorrow.
already have diabetes will not face the As emphasized in a recent consensus
nightmare of a regression in the quality statement (see Box 8.1 in Chapter 8) (1),
of care they deserve while, on the there is strong evidence that genetics
contrary, there is a great need in many plays an important role together with
parts of the world to improve it. overweight or obesity resulting from
excess caloric intake and reduction in
Although representing only less than physical activity.
10% of all forms of diabetes, the absolute
number of people with type 1 diabetes Furthermore, there is evidence that a low
will definitely increase in the coming birth weight, as a consequence of poor
years. This is due to the conjunction of nourishment of the foetus, significantly
an increased life expectancy, a reason increases the risk of type 2 diabetes
302

Chapter 10
mellitus and the related ‘metabolic Improve quality of life

syndrome’ in the offspring. In addition, The cornerstone of the action of the
some mechanistic studies suggest a Federation remains helping all those
relationship between stress and insulin affected by diabetes to improve
resistance with predisposition to type 2 their quality of life, prevent diabetes
diabetes mellitus. complications to occur and, if these
occur, slowdown their progression, even
Recent studies have shown that lifestyle if primary prevention of diabetes must
changes (and also some medications) now be considered by IDF.
are effective in preventing type 2
diabetes in individuals at risk, such as In our times of ‘evidence-based’ medicine,
those with impaired glucose tolerance numerous studies performed over
(2-5). IDF is committed to advancing the last 20 years (6) have provided
concerted actions by governments and strong evidence that strict control of
non-governmental organizations to blood glucose reduces the incidence of
raise awareness about the seriousness retinopathy, nephropathy and neuropathy
of type 2 diabetes, promote education in both type 1 and type 2 diabetes
at all levels and exercise multisectoral mellitus, that control of blood pressure
advocacy. reduces the risk of cardiovascular events
and deaths, and that intensive treatment
Global awareness, advocacy and of blood pressure reduces the risk of
action in diabetes programme aggravation of nephropathy in people
A major action in the coming years is the with microalbuminuria or incipiens renal
ambitious ‘Global awareness, advocacy failure.
and action in diabetes’ programme
developed by the WHO Department of
Noncommunicable Diseases Management
in Geneva and the International Diabetes
Federation. Supported by the World The time has come to act…NOW!
Diabetes Foundation, this programme
aims to enhance awareness about
diabetes and its complications amongst
the public, health professionals and As emphasized by Nathan (6), the net
decision makers, with major emphasis effect of these controlled clinical trials
on prevention, particularly in low income has been an expansion of lifespan and
countries. an improvement in quality of life for
persons affected by diabetes. IDF’s role is
The programme is designed to support to disseminate the conclusions of these
WHO/IDF regions and countries in the trials to its member associations, and
reorganization of their health services raise awareness about the progress in
in response to the current epidemic by this field among the public, healthcare
developing coordinated programmes providers, social security authorities and
to promote effective management of governments.
people with diabetes as well as primary
prevention of type 2 diabetes. In these Diabetes programmes
programmes, emphasis will be put IDF recognizes some remarkable national
on healthy dietary habits, promotion programmes for diabetes such as the
of physical activity, and appropriate National Framework Programme on
quantitative and qualitative nutrition of Diabetes in the United Kingdom, the
the pregnant mother. 2000-2010 Development Programme
for Prevention and Care in Finland, the
303

Chapter 10
National Plan against Diabetes in France, Conclusion

and the coming National Prevention
Programme for Diabetes in Sri Lanka, to Monitoring the global diabetes epidemic,
mention only a few. evaluating the overall cost of the disease,
assessing the access to insulin and
Through its regions, IDF has contributed diabetes supplies worldwide, reviewing
to major programmes through the the progress of diabetes education, and
St Vincent Declaration in Europe, promoting the work and achievements of
Declaration of the Americas on Diabetes its member associations are key features
in North, South and Central America, of the present edition of the Diabetes
Western Pacific Declaration on Diabetes in Atlas. However, to observe and report is
the Western Pacific and EMME Declaration one course of action, to act to improve
on Diabetes in the Eastern Mediterranean the condition of people with diabetes
and Middle East. The Federation will and preventing the disease to affect
continue to encourage similar initiatives millions is another. The time has come to
in other parts of the world. act…NOW!
References
1. Diabetes in Asia 2002 Meeting. Consensus on the Aetiology

of Type 2 Diabetes Mellitus and Development of a Primary
Prevention Strategy for Type 2 Diabetes Mellitus. Colombo,
Sri Lanka, July 2002.
2. Pan X-R, Li G-W, Wang J-X, et al. Effect of diet and exercise
in preventing NIDDM in people with impaired glucose
tolerance: the Da Quing IGT and Diabetes Study. Diabetes
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of type 2 diabetes mellitus by changes in lifestyle among
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DIABETES

The mission of the International Diabetes Federation is to

Editor and project manager: Delice Gan

Diabetes Atlas, second edition,

Electronic version of Diabetes Atlas:

© International Diabetes Federation, 2003

No part of this publication may be reproduced

First published, 2000

Permission has been obtained to use material

Copyright permission has been obtained

Design and layout: perplex | Aalst, Belgium

Diabetes Atlas Second Edition

IDF would also like to thank Johnson and Chapter 5

Special thanks to S Murray for coordinating the

Diabetes Atlas Second Edition

N Abdella, K Ajlouni, C Alexander, AS Alkuwari,

IDF gratefully acknowledges the support and

Special thanks to L Al Obaidi, S Ash,

Diabetes Atlas Second Edition

1. The Global Burden of Diabetes 15

2. Diabetes in the Young: a Global Perspective 113

3. The Widening Circle 157

4. The Economic Impact of Diabetes 175

5. Access to Insulin and Diabetes Supplies 193

6. Diabetes Education 207

7. Meeting the Challenges 225

8. Reducing the Burden 267

Diabetes Atlas Second Edition

9. Diabetes Associations: from Patients to Partners 283

10. Prevention and Strategic Action 301

Diabetes Atlas Second Edition

The prevalence of complications is now included – important for planners, health

Diabetes Atlas Second Edition

Sir George Alberti

Diabetes Atlas Second Edition

Diabetes Atlas Second Edition

Diabetes Atlas Second Edition

M any new topics have been included

Diabetes Atlas Second Edition

Diabetes Atlas Second Edition

The new section on diabetic healthcare costs of diabetes worldwide,

Diabetes Atlas Second Edition

Diabetes self-management education The ultimate goal of a publication

Education for people with diabetes has

These declarations also reflect the

By promoting diabetes prevention, IDF

Diabetes Atlas Second Edition

The Global Burden of Diabetes Chapter 1

D iabetes is now one of the most

In addition to diabetes, the condition

This chapter provides estimates of the

concept of the likely future burden should

The data presented here should be

Comparisons of country, regional, and

1.1 Diabetes and Impaired Glucose Tolerance:

Diabetes mellitus and lesser forms of

Diabetes mellitus is classified on

a. Rates are age-standardized to Segi’s World Population for ages 30 to 64 years

Type 2 diabetes constitutes about 85 or urbanized populations that may have

rates (the prevalence at any given age) Figure 1.2

Rates for each country have not been ����

and adolescents is acknowledged as a

(see Chapter 2).

Rates for each country have not been ��

Gender distribution ��

�� • There were inconsistencies in the

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