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Abstract
Summary
Background
One of the global targets for non-communicable diseases is to halt, by 2025, the rise
in the age-standardised adult prevalence of diabetes at its 2010 levels. We aimed
to estimate worldwide trends in diabetes, how likely it is for countries to achieve
the global target, and how changes in prevalence, together with population growth
and ageing, are affecting the number of adults with diabetes.
Methods
We pooled data from population-based studies that had collected data on diabetes through
measurement of its biomarkers. We used a Bayesian hierarchical model to estimate trends
in diabetes prevalence—defined as fasting plasma glucose of 7·0 mmol/L or higher,
or history of diagnosis with diabetes, or use of insulin or oral hypoglycaemic drugs—in
200 countries and territories in 21 regions, by sex and from 1980 to 2014. We also
calculated the posterior probability of meeting the global diabetes target if post-2000
trends continue.
Findings
We used data from 751 studies including 4 372 000 adults from 146 of the 200 countries
we make estimates for. Global age-standardised diabetes prevalence increased from
4·3% (95% credible interval 2·4–7·0) in 1980 to 9·0% (7·2–11·1) in 2014 in men, and
from 5·0% (2·9–7·9) to 7·9% (6·4–9·7) in women. The number of adults with diabetes
in the world increased from 108 million in 1980 to 422 million in 2014 (28·5% due
to the rise in prevalence, 39·7% due to population growth and ageing, and 31·8% due
to interaction of these two factors). Age-standardised adult diabetes prevalence in
2014 was lowest in northwestern Europe, and highest in Polynesia and Micronesia, at
nearly 25%, followed by Melanesia and the Middle East and north Africa. Between 1980
and 2014 there was little change in age-standardised diabetes prevalence in adult
women in continental western Europe, although crude prevalence rose because of ageing
of the population. By contrast, age-standardised adult prevalence rose by 15 percentage
points in men and women in Polynesia and Micronesia. In 2014, American Samoa had the
highest national prevalence of diabetes (>30% in both sexes), with age-standardised
adult prevalence also higher than 25% in some other islands in Polynesia and Micronesia.
If post-2000 trends continue, the probability of meeting the global target of halting
the rise in the prevalence of diabetes by 2025 at the 2010 level worldwide is lower
than 1% for men and is 1% for women. Only nine countries for men and 29 countries
for women, mostly in western Europe, have a 50% or higher probability of meeting the
global target.
Interpretation
Since 1980, age-standardised diabetes prevalence in adults has increased, or at best
remained unchanged, in every country. Together with population growth and ageing,
this rise has led to a near quadrupling of the number of adults with diabetes worldwide.
The burden of diabetes, both in terms of prevalence and number of adults affected,
has increased faster in low-income and middle-income countries than in high-income
countries.
Funding
Wellcome Trust.
Type 2 diabetes affects approximately 8 percent of adults in the United States. Some risk factors--elevated plasma glucose concentrations in the fasting state and after an oral glucose load, overweight, and a sedentary lifestyle--are potentially reversible. We hypothesized that modifying these factors with a lifestyle-intervention program or the administration of metformin would prevent or delay the development of diabetes. We randomly assigned 3234 nondiabetic persons with elevated fasting and post-load plasma glucose concentrations to placebo, metformin (850 mg twice daily), or a lifestyle-modification program with the goals of at least a 7 percent weight loss and at least 150 minutes of physical activity per week. The mean age of the participants was 51 years, and the mean body-mass index (the weight in kilograms divided by the square of the height in meters) was 34.0; 68 percent were women, and 45 percent were members of minority groups. The average follow-up was 2.8 years. The incidence of diabetes was 11.0, 7.8, and 4.8 cases per 100 person-years in the placebo, metformin, and lifestyle groups, respectively. The lifestyle intervention reduced the incidence by 58 percent (95 percent confidence interval, 48 to 66 percent) and metformin by 31 percent (95 percent confidence interval, 17 to 43 percent), as compared with placebo; the lifestyle intervention was significantly more effective than metformin. To prevent one case of diabetes during a period of three years, 6.9 persons would have to participate in the lifestyle-intervention program, and 13.9 would have to receive metformin. Lifestyle changes and treatment with metformin both reduced the incidence of diabetes in persons at high risk. The lifestyle intervention was more effective than metformin.
Up-to-date evidence about levels and trends in disease and injury incidence, prevalence, and years lived with disability (YLDs) is an essential input into global, regional, and national health policies. In the Global Burden of Disease Study 2013 (GBD 2013), we estimated these quantities for acute and chronic diseases and injuries for 188 countries between 1990 and 2013.
During the United Kingdom Prospective Diabetes Study (UKPDS), patients with type 2 diabetes mellitus who received intensive glucose therapy had a lower risk of microvascular complications than did those receiving conventional dietary therapy. We conducted post-trial monitoring to determine whether this improved glucose control persisted and whether such therapy had a long-term effect on macrovascular outcomes. Of 5102 patients with newly diagnosed type 2 diabetes, 4209 were randomly assigned to receive either conventional therapy (dietary restriction) or intensive therapy (either sulfonylurea or insulin or, in overweight patients, metformin) for glucose control. In post-trial monitoring, 3277 patients were asked to attend annual UKPDS clinics for 5 years, but no attempts were made to maintain their previously assigned therapies. Annual questionnaires were used to follow patients who were unable to attend the clinics, and all patients in years 6 to 10 were assessed through questionnaires. We examined seven prespecified aggregate clinical outcomes from the UKPDS on an intention-to-treat basis, according to previous randomization categories. Between-group differences in glycated hemoglobin levels were lost after the first year. In the sulfonylurea-insulin group, relative reductions in risk persisted at 10 years for any diabetes-related end point (9%, P=0.04) and microvascular disease (24%, P=0.001), and risk reductions for myocardial infarction (15%, P=0.01) and death from any cause (13%, P=0.007) emerged over time, as more events occurred. In the metformin group, significant risk reductions persisted for any diabetes-related end point (21%, P=0.01), myocardial infarction (33%, P=0.005), and death from any cause (27%, P=0.002). Despite an early loss of glycemic differences, a continued reduction in microvascular risk and emergent risk reductions for myocardial infarction and death from any cause were observed during 10 years of post-trial follow-up. A continued benefit after metformin therapy was evident among overweight patients. (UKPDS 80; Current Controlled Trials number, ISRCTN75451837.) 2008 Massachusetts Medical Society
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