Elsevier

The Lancet

Volume 378, Issue 9785, 2–8 July 2011, Pages 31-40
The Lancet

Articles
National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2·7 million participants

https://doi.org/10.1016/S0140-6736(11)60679-XGet rights and content

Summary

Background

Data for trends in glycaemia and diabetes prevalence are needed to understand the effects of diet and lifestyle within populations, assess the performance of interventions, and plan health services. No consistent and comparable global analysis of trends has been done. We estimated trends and their uncertainties in mean fasting plasma glucose (FPG) and diabetes prevalence for adults aged 25 years and older in 199 countries and territories.

Methods

We obtained data from health examination surveys and epidemiological studies (370 country-years and 2·7 million participants). We converted systematically between different glycaemic metrics. For each sex, we used a Bayesian hierarchical model to estimate mean FPG and its uncertainty by age, country, and year, accounting for whether a study was nationally, subnationally, or community representative.

Findings

In 2008, global age-standardised mean FPG was 5·50 mmol/L (95% uncertainty interval 5·37–5·63) for men and 5·42 mmol/L (5·29–5·54) for women, having risen by 0·07 mmol/L and 0·09 mmol/L per decade, respectively. Age-standardised adult diabetes prevalence was 9·8% (8·6–11·2) in men and 9·2% (8·0–10·5) in women in 2008, up from 8·3% (6·5–10·4) and 7·5% (5·8–9·6) in 1980. The number of people with diabetes increased from 153 (127–182) million in 1980, to 347 (314–382) million in 2008. We recorded almost no change in mean FPG in east and southeast Asia and central and eastern Europe. Oceania had the largest rise, and the highest mean FPG (6·09 mmol/L, 5·73–6·49 for men; 6·08 mmol/L, 5·72–6·46 for women) and diabetes prevalence (15·5%, 11·6–20·1 for men; and 15·9%, 12·1–20·5 for women) in 2008. Mean FPG and diabetes prevalence in 2008 were also high in south Asia, Latin America and the Caribbean, and central Asia, north Africa, and the Middle East. Mean FPG in 2008 was lowest in sub-Saharan Africa, east and southeast Asia, and high-income Asia-Pacific. In high-income subregions, western Europe had the smallest rise, 0·07 mmol/L per decade for men and 0·03 mmol/L per decade for women; North America had the largest rise, 0·18 mmol/L per decade for men and 0·14 mmol/L per decade for women.

Interpretation

Glycaemia and diabetes are rising globally, driven both by population growth and ageing and by increasing age-specific prevalences. Effective preventive interventions are needed, and health systems should prepare to detect and manage diabetes and its sequelae.

Funding

Bill & Melinda Gates Foundation and WHO.

Introduction

Hyperglycaemia and diabetes are important causes of mortality and morbidity worldwide, through both direct clinical sequelae and increased mortality from cardiovascular and kidney diseases.1, 2, 3, 4, 5, 6 With rising overweight and obesity,7 concern has risen about a global diabetes epidemic, with harmful effects on life expectancy and health-care costs.8, 9 A few studies have examined global patterns of glycaemia and diabetes, finding substantial variation between regions.1, 10, 11, 12, 13 Others have assessed trends in specific countries.14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 Findings from these studies have helped to show that hyperglycaemia and diabetes are important worldwide and regional issues, but these studies also have limitations.

First, diabetes definitions have varied by expert committees and over time.25, 26, 27 Most current studies have either used all definitions without adjustment for incomparability, or selected one definition and excluded data based on other definitions. Second, these studies pooled national, subnational, and community data, regarding them as equally representative of countries' populations. Third, some data included in these studies used random (non-fasting) glucose measurement; other data were from specific occupational groups, communities with high obesity prevalence, health-care facilities and practitioners, registries, or self-reported diabetes. These sources were probably biased because obesity is a risk factor for hyperglycaemia, occupational groups might differ from the general population in their health risks, and some diabetes cases are undiagnosed.28, 29 Fourth, previous analyses assigned estimates to countries without data based on geographical proximity and ad-hoc expert opinion about similarity to countries with data without a formal analytical model. Fifth, these studies pooled data from different years without adjustment for underlying trends. Finally, these studies did not account for all sources of uncertainty including missing and older country data, leading to overly confident estimates.

These shortcomings have hindered our ability to systematically examine trends. In recent years, health examination surveys have measured different glycaemic indicators, providing an opportunity to systematically assess trends by country. We reviewed and accessed unpublished and published studies and collated comprehensive data for different glycaemic metrics. We applied statistical methods to systematically address measurement comparability, missing data, non-linear time trends, age patterns, and national versus subnational and community representativeness. With these data and methods, we estimated trends and associated uncertainties by country and region.

Section snippets

Study design

We estimated 1980–2008 trends in mean fasting plasma glucose (FPG) and diabetes by sex, for 199 countries and territories in the 21 subregions of the Global Burden of Diseases, Injuries, and Risk Factors study, which themselves are grouped into larger regions (webappendix p 6).

We used mean FPG, rather than postprandial glucose or haemoglobin A1c (HbA1c), as the primary measure of glycaemia because it is used in many more population-based studies. We report population mean because there is a

Results

Our final dataset included 370 country-years with 2·7 million participants (figure 1). Of the included studies, 71% had reported mean FPG or diabetes prevalence based on FPG, with others using postprandial glucose or HbA1c (webappendix pp 7–24). 128 country-years were from 22 high-income countries and 242 from 85 low-income and middle-income countries. Japan had the most nationally representative data with 8 years of national data since 1980, followed by the USA and Singapore (webappendix pp

Discussion

Our systematic analysis shows that glycaemia and diabetes are a rising global hazard, with the number of adults with diabetes having more than doubled over nearly three decades. Although population growth and ageing are important contributors to this increase, there is also an important epidemiological component with age-standardised global mean FPG having increased by 0·07 mmol/L per decade or more.

Our estimate of 347 (314–382) million adults with diabetes is higher than Shaw and colleagues'

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