Diabetes prevalence in 2021 and projections to 2030 and 2045 (20–79 years)

The estimates in this 10th edition of the IDF Diabetes Atlas are provided for 215 countries and territories, grouped into the seven IDF Regions: Africa (AFR), Europe (EUR), Middle East and North Africa (MENA), North America and Caribbean (NAC), South and Central America (SACA), South-East Asia (SEA) and the Western Pacific (WP). In total, 219 data sources from 144 countries were included in the analysis.¹

Our projections show a growth of 16% in the expected prevalence of diabetes due to ageing of the population. The greatest percentage increase from 2021 to 2045 in comparative prevalence is estimated to occur in middle-income countries due to their ageing populations.

On the other hand, it is estimated that 94% of the increase in the number of people with diabetes by 2045 will occur in low and middle-income countries, where population growth is expected to be greater (Table 3.2).

Table 3.2

Number of adults (20–79 years) with diabetes per World Bank income classification in 2021 and 2045.

Age distribution

Diabetes estimates for 2021 show increasing prevalence of diabetes by age. Similar trends are predicted for 2045. Prevalence is lowest among adults aged 20–24 years (2.2% in 2021) (Figure 3.1). Among adults aged 75–79 years diabetes prevalence is estimated to be 24.0% in 2021 and predicted to rise to 24.7% in 2045. The aging of the world’s population will produce an increasing proportion of those with diabetes being over the age of 60 years.

Figure 3.1

Number of people with diabetes in adults (20–79 years) by age group in 2021 (columns) and estimated prevalenceⁱ across age groups in 2045 (black line). ⁱPrevalence is standardised to each national population

Gender distribution

The estimated prevalence of diabetes in women aged 20–79 years is slightly lower than in men (10.2% vs 10.8%). In 2021, there are 17.7 million more men than women living with diabetes. (Figure 3.2).

Figure 3.2

Prevalenceⁱ of diabetes among men and women (20–79 years), 2021. ⁱ Prevalence is standardised to each national population

Urban and rural distribution

In 2021, more people with diabetes live in urban (360.0 million) than in rural (176.6 million) areas – the prevalence in urban areas being 12.1% and in rural areas 8.3%. The number of people with diabetes living in urban areas is expected to increase to 596.5 million in 2045 (Figure 3.3), as a result of global urbanisation. By 2045, the predicted prevalence of diabetes in urban areas is estimated to increase to 13.9%, due to population ageing.

Figure 3.3

Number of people with diabetes in adults (20–79 years) living in urban and rural areas in 2021 and 2045.

Regional distribution

As explained in Chapter 2, age is a major determinant of diabetes risk. Thus, comparative prevalence estimates and projections have been used to allow comparisons at IDF regional and country levels. The MENA Region has the highest comparative prevalence of diabetes (18.1%) in people aged 20–79 years in 2021. This estimate is expected to increase, with the MENA Region continuing to have the highest comparative prevalence in 2045 (20.4%).

The AFR Region currently has the lowest comparative prevalence (5.3%), which can be partially attributed to low levels of urbanisation and low prevalence of overweight and obesity. Its prevalence is estimated to rise from 4.5% in 2021 to 5.2% in 2045, an increase of smaller magnitude than in other IDF regions (Table 3.3). This is likely to be an underestimate given the rapid urbanisation and expected changes in lifestyles and ecosystems in this region.

Table 3.3

Prevalence of diabetes in adults (20–79 years) in IDF Regions in 2021 and 2045, ranked by 2021 age-adjusted comparative diabetes prevalence.

Country distribution

The countries with the largest numbers of adults with diabetes aged 20–79 years in 2021 are China, India and Pakistan. They are anticipated to remain so in 2045 (Table 3.4). The countries that have the highest number of people with diabetes do not necessarily have the highest prevalence.

Table 3.4

Top 10 countries or territories for number of adults (20–79 years) with diabetes in 2021 and 2045.

The highest comparative diabetes prevalence rates in 2021 are reported in Pakistan (30.8%), French Polynesia (25.2%) and Kuwait (24.9%) (Table 3.5). These countries are also expected to have the highest overall comparative diabetes prevalence in 2045, with figures in Pakistan reaching 33.6%, Kuwait 29.8% and French Polynesia 28.2%.

Table 3.5

Top 10 countries or territories with age-adjusted comparative diabetes prevalence in adults (20–79 years) in 2021 and 2045.

Undiagnosed diabetes

There were 111 available data sources on the prevalence of undiagnosed diabetes, representing 68 countries. For countries with either low-quality or no in-country data on undiagnosed diabetes (147 countries, 68.4%), the prevalence of undiagnosed diabetes was estimated (see Chapter 2).

In 2021, almost one-in-two (44.7%; 239.7 million) adults living with diabetes (20–79 years old) were found to be unaware of their status. It is fundamental for people with diabetes to be diagnosed as early as possible to prevent or delay complications, avoid a premature death and improve quality of life. A serious concern is that people with diabetes diagnosed later, rather than earlier, are likely to use more healthcare services due to greater likelihood of diabetes complications, placing an added burden on healthcare systems already under pressure.²

Low rates of clinical diagnosis of diabetes are often a result of insufficient access to healthcare and lower capacity in existing health systems.³ Inexpensive screening strategies using validated diabetes risk scores, combined with diagnostic tests⁴ are, therefore, urgently needed to identify people with diabetes earlier and to expand coverage of preventive counselling, diagnosis and clinical care.

Regional disparities in undiagnosed diabetes

Globally, 87.5% of all undiagnosed cases of diabetes are in low and middle-income countries, with low-income countries having the highest proportion undiagnosed (50.5%). However, even in high-income countries, almost a third (28.8%) of people with diabetes have not been diagnosed (Table 3.6).

Table 3.6

Adults (20–79 years) with undiagnosed diabetes by World Bank income classification in 2021.

Large regional differences exist in the proportion of diabetes that was undiagnosed. The highest proportions were in Africa (53.6%), the Western Pacific (52.8%) and South-East Asia (51.3%), respectively (Table 3.7). These parts of the world include significant rural areas that may result in difficulty in identifying undiagnosed diabetes due to limited resources, poor access to healthcare services and the prioritisation of other health issues. The lowest proportion of undiagnosed diabetes was found in the North America and Caribbean Region (24.2%) (Table 3.7).

Table 3.7

Adults (20–79 years) with undiagnosed diabetes in IDF Regions in 2021, ranked by proportion undiagnosed.

The number of people with undiagnosed diabetes varies by country (Map 3.3). However, the countries with the highest number of people with undiagnosed diabetes are those with the largest number of people with diabetes: China, India and Indonesia (Table 3.8). Among countries that have conducted their own surveys, Mozambique, Uzbekistan, Indonesia and Afghanistan have the highest proportion of undiagnosed diabetes.

Table 3.8

Top 10 countries or territories for the number of adults (20–79 years) with undiagnosed diabetes in 2021.

Map 3.3Proportion of adults (20–79 years) with undiagnosed diabetes by country in 2021

Variation in diagnosed diabetes among countries is often linked to several factors, including genetics, social and economic conditions, performance of the local health system, and general awareness about diabetes among the public and health professionals. In total, only 68 of the 215 countries and territories with estimates in the Atlas had reliable in-country data. A greater number of high-quality population-based studies that include diabetes measured by blood test are urgently needed to improve estimates and allocate resources toward diagnosis.

Almost one in two adults with diabetes are unaware they have the condition. Globally, an estimated 240 million people are living with undiagnosed diabetes. There is a clear need to detect diabetes early and initiate action to prevent complications. Healthcare systems everywhere need to provide the quality of care necessary to support the person beyond diagnosis. Unfortunately, continuous and affordable access to treatment and education remains a major problem in many areas, especially in low and middle-income countries.

Almost 1 in 2 adults with diabetes are unaware they have diabetes

Diabetes incidence

The main focus of the IDF Diabetes Atlas has been to track the global impact of diabetes using prevalence. However, increasing prevalence does not always mean that the risk of developing diabetes is rising. Prevalence can increase simply because people with diabetes receive better medical care and live longer. Therefore, it is also important to look at incidence — the rate at which new cases of diabetes are occurring. Unfortunately, while incidence has been the standard reporting metric for type 1 diabetes, the number of published studies reporting the incidence of type 2 diabetes is relatively small.

Two significant reports on the global incidence of diabetes have been published recently. The first is a systematic review which searched the literature for studies reporting trends in diabetes incidence up until December 2017.⁵ The majority of studies reported that diabetes incidence increased from the 1990s to the mid-2000s, but over the period 2006–2014, incidence was either stable or decreasing in 66% of the populations. This systematic review has now been extended to August 2020, to include nine additional publications. Of the 45 populations reporting incidence trends over 2006–2017, 71% showed declining or stable incidences.

The second study is a multi-country analysis of diabetes incidence trends from high and middle-income settings.⁶ Diabetes incidence data were assembled from diabetes registries, administrative data, health insurance and one health survey: 24 data sources across 21 countries. Data were then aggregated by five-year age groups and sex, and analysed using age-period-cohort models with smooth age effects, standardised to the 2010 EU standard population (Figure 3.4). Among the 24 data sources, Ukraine, Singapore, and Lithuania showed increasing incidence across their entire reporting period. Israel (Maccabi Healthcare Services) showed a small rise in some of the more recent years, having shown decreasing incidence in earlier years.

Figure 3.4

Trends in annual incidence of diagnosed diabetes, adapted from Magliano et al. Age- and sex-standardised incidence rates of diagnosed diabetes per 1,000 person-years (EU standard population 2010, with equal weights for men and women). Standardisation (more...)

The data from Kaiser Permanente Northwest showed incidence increasing, followed by a fall until 2006 and then increasing until the end of the reporting period. All of the remaining data sources showed decreasing or stable incidence from around 2010 onwards. Annual changes in incidence before and after 2010 for each data source are shown in figure 3.5. Among those data sources reporting a fall in incidence after 2010, the annual reduction in incidence ranged from 1.1% to 10.8%. Among the data sources reporting a rise after 2010, the annual rise in incidence ranged from 0.9% to 5.6%. Since these data are mainly from administrative sources, the findings are only for diagnosed diabetes and thus incidence trends in undiagnosed diabetes remain uncertain. Further, there was significant heterogeneity in the way the centres diagnosed diabetes. Lastly, there were no data from low-income countries and thus the findings inform us about trends in diabetes incidence in some high and middle-income countries only.

Figure 3.5

Estimated annual change in the incidence of diagnosed total or type 2 diabetes before and after 2010.

In conclusion, the incidence of type 2 diabetes may be falling or stable in many high-income countries. While these findings may hint at the success of prevention strategies implemented in many countries, other factors, such as changes in diabetes screening over time and the introduction of HbA1c for diabetes diagnosis, may have played a role.

Diabetes incidence and prevalence in children and adolescents

Type 1 diabetes is the most common form of diabetes in children and adolescents in the majority of countries, but other forms of diabetes also occur, including type 2 diabetes and monogenic diabetes. Type 1 diabetes is a complex condition to manage. Insulin injections are needed for survival and good outcomes can only be achieved with multiple daily injections or the use of an insulin pump. Successful insulin therapy requires self-monitoring of blood glucose, comprehensive diabetes education and the support of skilled health professionals.

Numbers of new (incident) and existing (prevalent) type 1 diabetes cases are increasing each year due to rising incidence in many countries⁷ and reductions in mortality. In total, 1,211,900 children and adolescents younger than 20 years are estimated to have type 1 diabetes globally. It is estimated that around 108,200 children and adolescents under 15 years are diagnosed each year. This number rises to 149,500 when the age range extends to those under 20 years (Table 3.9).

Table 3.9

Global estimates for type 1 diabetes in children and adolescents (0–14 years and 0–19 years) in 2021.

A complementary publication⁸ provides the incidence data estimated for all countries. Incidence rates are highest in populations of Northern European origin, as well as in an increasing number of countries in the Middle East and North Africa. Of the ten countries with the highest incidence, four are now from non-European populations (Table 3.10). A recent report from Eritrea demonstrating a high incidence, particularly in the 15–24-year age group, confirms observations among migrant populations from this area in Africa.⁹

Table 3.10

Top 10 countries or territories for estimated number of incident (new) cases of type 1 diabetes in children and adolescents (0–19 years) per annum.

Of the 215 countries and territories covered by the IDF Diabetes Atlas, only 97 have their own incidence data. For most, this is limited to children and adolescents under 15-years of age. Among the countries without data for under 20-year-olds are some very populous nations, such as Nigeria, Indonesia, the Philippines, Vietnam, and South Africa. For these countries data are extrapolated from a nearby country with similar characteristics. However there are various reasons why such data may not be accurate. The African Region is the least complete. However, new data from Gabon,¹⁰ Mali¹¹ and Eritrea,⁹ as well as updated data from Tanzania,¹² have helped fill some of the gaps.

Compared with the 9th Edition of the IDF Diabetes Atlas in 2019, the number of new cases has increased sharply in the AFR and MENA regions due to revisions resulting from recent incidence studies.

Incidence is a key element in tracking the progress of epidemics of chronic diseases such as diabetes

Map 3.4Age-sex standardised incidence rates (per 100,000 population per annum) of type 1 diabetes in children and adolescents aged 0–14 years

Comparable measured prevalence data are only available for 12 countries. Due to the paucity of prevalence data, estimation for all countries was not possible and data from these reports was used to estimate prevalence by region. Rapid changes in mortality, diagnosed incidence, and differences between regions within countries may explain larger discrepancies for Mali,¹¹ Maldives,¹³ and Canada.^14,15 The EUR and NAC regions have the highest number of prevalent cases due to high incidence rates. Numbers of people under 20 years of age with type 1 diabetes in AFR have more than doubled since 2019 due to the availability of new data. Figures 3.6 and 3.7 show the breakdown of prevalent and incident cases per IDF Region. By country, India now has the highest estimated number of prevalent type 1 diabetes cases in people under 20 years of age (229,400), followed by USA (157,900) and Brazil 92,300 (Table 3.10).

Figure 3.6

Estimated number of children and adolescents (0–19 years) with prevalent (existing) type 1 diabetes by IDF Region in 2021 (adjusted for mortality).

Figure 3.7

Estimated annual incident (new) cases of type 1 diabetes in children and adolescents (0–19 years) by IDF Region in 2021.

The IDF Diabetes Atlas Committee encourages all countries to ascertain their current rates of new and existing cases of type 1 diabetes for children and adolescents. The IDF Guide for Diabetes Epidemiological Studies¹⁶, provides useful and practical information on how to plan, conduct, and report such studies.

Incidence and prevalence of youth-onset type 2 diabetes

The incidence and prevalence of youth-onset type 2 diabetes vary by ethnicity and other factors. Populations with high incidence and prevalence of type 2 diabetes in youth also have higher risk of type 2 diabetes among adults. The highest incidence rates of type 2 diabetes in youth have been reported from Canadian First Nations, American Indian and Navajo nation, Australian Aboriginal and Torres Strait Islander, and African American populations (31–94 per 100,000 per year), ^17–20 whereas youth from non-Hispanic Caucasian populations, such as those in Europe and the US had the lowest incidence rates (0.1–0.8 per 100,000 per year) (Figure 3.8).^21,22

Figure 3.8

Reported prevalence of type 2 diabetes in youth ranked by region and ethnicity.

Prevalence estimates were the highest in youth from Brazil and Mexico, as well as indigenous populations in the US and Canada, and among Black populations in the Americas (160–3,300 per 100,000),^23–25 and the lowest in populations in Europe (0.6 to 2.7 per 100,000)^26–27 (Figure 3.9).

Figure 3.9

Reported incidence of type 2 diabetes in youth ranked by region and ethnicity.

Obesity is an important modifiable risk factor for type 2 diabetes. However, some populations that have a low prevalence of childhood obesity, such as East Asians, report higher incidence rates of youth-onset type 2 diabetes than populations with a greater burden of childhood obesity.^28–29 Genetic predisposition, disparities in socio-economic status, access to healthcare and cultural practices across people of different ethnic backgrounds or countries may also contribute to differences in the risk of youth-onset type 2 diabetes.^30–31

In countries with trend data for type 2 diabetes, a growth in incidence of type 2 diabetes is observed, with the increase usually greater in non-Caucasian populations.^17,19–21 The reasons for these increases in incidence are multifactorial, including the rising burden of childhood obesity, changes in diet and physical activity, maternal obesity and diabetes, and other as yet unknown factors.²⁸

The incidence of type 2 diabetes is extremely low among pre-pubertal children but rises gradually at puberty, likely due to hormonal changes and insulin resistance associated with puberty. Incidence rates are higher in girls than boys, a sex difference that is not present in adults; this is not well understood but may be due to differential sex-hormone effects or known differences in weight gain and lifestyle habits during and after puberty.^19,21

Complications in youth-onset type 2 diabetes

Youth-onset type 2 diabetes has a unique phenotype and physiology characterised by poorer glycaemic trajectory, higher metformin monotherapy failure rates, and more rapid beta cell functional decline than that seen in adults with type 2 diabetes.³² As compared with type 1 diabetes, youth with type 2 diabetes are more likely to have or develop other cardiometabolic risk factors, such as high blood pressure, elevated triglycerides and central obesity.³³

The prevalence of some microvascular complications is two-to-three-fold higher in youth with type 2 diabetes than those with type 1 diabetes of a similar age.³⁴ Evidence of preclinical cardiovascular disease has also been found in youth with type 2 diabetes,^35,36 and emerging data suggest mortality in excess of type 1 diabetes counterparts and youth from the same populations without diabetes.³⁷

The presence of advanced complications during the most productive time of life is more likely to occur given the early onset of type 2 diabetes. This has significant impact on individuals, families and communities, and places an additional strain on healthcare systems.

Furthermore, the development of type 2 diabetes during reproductive years may amplify intergenerational risk for early onset type 2 diabetes. While multi-nation surveillance of type 1 diabetes is already well established, surveillance of youth-onset type 2 diabetes is not. Therefore, a strong call must be made for the collection of trend data to assess the global burden of type 2 diabetes in youth.

The incidence of type 2 diabetes is extremely low among pre-pubertal children but rises gradually at puberty, likely due to hormonal changes and insulin resistance associated with puberty

Adult-onset type 1 diabetes

It is traditionally thought that type 1 diabetes presents commonly in childhood or adolescence but infrequently in adulthood. Consequently, a large number of studies report on the incidence of type 1 diabetes among children and adolescents, while comparatively fewer studies report data for the incidence of type 1 diabetes in adults.

Despite this, there is increasing recognition of the contribution of type 1 diabetes to the overall burden of diabetes in adults and the need for care provision and related planning for those with adult-onset type 1 diabetes. However, type 1 diabetes is more challenging to diagnose in adults due to various factors and can be misdiagnosed as type 2 diabetes, leading to an underestimation of the burden of adult-onset type 1 diabetes. In order to evaluate the burden of adult-onset type 1 diabetes, a systematic review was recently conducted.³⁸ Among the 46 studies identified, incidence of adult-onset (≥20 years) type 1 diabetes was available for 32 countries and regions reporting estimates between 1973 and 2019.

The incidence of adult-onset type 1 diabetes is, in general, higher among men than women. There is a more than 30-fold variation in the annual incidence of adult-onset type 1 diabetes, with rates varying from less than one per 100,000 in China to more than 30 per 100,000 in parts of Northern Europe and Eastern Africa. In general, the variation in incidence of adult-onset type 1 diabetes mirrors the geographical variation in childhood-onset type 1 diabetes, whereby countries with high rates in children and adolescents also tend to have higher rates in adulthood (Table 3.13). Though type 1 diabetes is typically considered to present in childhood and adolescence, the relationship between T1D incidence and age of onset is not clear. In our review, in countries with available data, the incidence of adult-onset T1D did not decline with increasing age, and remained substantial across the life course.

Table 3.13

Countries with the highest incidence of adult-onset type 1 diabetes.

Most studies reporting the incidence of adult-onset type 1 diabetes rely on a clinical diagnosis, usually defined as physician-diagnosed type 1 diabetes, plus the need for insulin therapy within 12 months of diagnosis.

However, there are several challenges in establishing a diagnosis of type 1 diabetes in adults. This includes the absence of classical symptoms such as Ketoacidosis (KCA) in some cases, as well as slower disease progression, and potential delay in the initiation of insulin treatment. These may lead to cases being misdiagnosed and mismanaged as type 2 diabetes and likely underestimations of the true incidence of adult-onset type 1 diabetes.

Consistent with this, among countries with multiple estimates of type 1 diabetes incidence available, the incidence is generally higher in studies that defined type 1 diabetes using biomarkers, compared to those using algorithms based on administrative data, although these estimates may not be directly comparable for other reasons (such as cohort age or calendar year).

In our review of studies reporting the incidence of adult-onset type 1 diabetes, the majority (85%) did not include the use of biomarkers for defining or diagnosing type 1 diabetes. (Table 3.14)

Table 3.14

Challenges with the diagnosis of adult-onset type 1 diabetes.

There is a lack of data on the incidence of adult-onset type 1 diabetes, particularly in low and middle-income countries, limiting our ability to accurately assess the global burden of type 1 diabetes in adults and the capacity of existing healthcare systems to plan healthcare provision (Map 3.5).

Map 3.5Incidence of adult-onset type 1 diabetes in adults 20–40 years

Annual incidence of type 1 diabetes (per 100,000 per year) among adults aged 20–40 years (men and women) per country/region (estimated from studies between 1973 and 2020)

The majority of available studies are limited by the use of clinical diagnosis or diagnostic codes for ascertainment of type 1 diabetes in adults and, therefore, likely underestimate the true burden. Prompt recognition of type 1 diabetes can facilitate appropriate early insulin therapy, which may improve long-term prognosis.

There is a need for more research in different parts of the world, including more detailed phenotyping of individuals presenting with newly diagnosed diabetes to assess the true global burden of adult-onset type 1 diabetes.

Impaired glucose tolerance and impaired fasting glucose

In 2021, 541 million adults, or 10.6% of adults worldwide, are estimated to have impaired glucose tolerance (IGT). By 2045, this figure is projected to increase to 730 million adults or 11.4% of all adults.

In 2021, there are an estimated 319 million adults, or 6.2% of the global adult population, with impaired fasting glucose (IFG). An estimated 441 million adults or 6.9% of the global adult population are projected to have IFG in 2045.

Regional distribution

The age-adjusted prevalence of IGT in 2021 was highest in the Western Pacific Region and lowest in the South-East Asia Region (Table 3.15). The age-adjusted prevalence of IFG in 2021 was highest in South and Central America and lowest in the Western Pacific (Table 3.16).

Table 3.15

Age-adjusted prevalence of impaired glucose tolerance (20–79 years) by IDF regions, ranked by 2021 prevalence (%).

Table 3.16

Age-adjusted prevalence of impaired fasting glucose in adults (20–79 years) by IDF regions, ranked by 2021 prevalence (%).

Age distribution

The prevalence of IGT is estimated to increase with age (Figure 3.10). In 2045, the prevalence of IGT is expected to increase in young adults (aged 45 years or younger) and the very old (aged 70 years or older), and slightly decrease among middle-aged adults (aged 45–69 years). The 2021 prevalence of IFG was higher in older age categories and peaked among persons aged 60–64 at 8.1%. The prevalence of IFG is projected to increase across all age categories by the year 2045 (Figure 3.11).

Figure 3.10

Prevalence of impaired glucose tolerance in adults (20–79 years) in 2021 and 2045, by age group.

Figure 3.11

Prevalence of impaired fasting glucose in adults (20–79 years) in 2021 and 2045, by age group.

Income distribution

For IGT, the age-adjusted prevalence in 2021 was highest for low-income countries and lowest for middle and high-income countries (Table 3.17). The age-adjusted prevalence estimates of IFG in 2021 were similar across high (5.7%), middle (5.7%), and low-income (5.8%) countries (Table 3.18).

Table 3.17

Age-adjusted prevalence of impaired glucose tolerance in adults (20–79 years), by World Bank income classification.

Table 3.18

Age-adjusted prevalence of impaired fasting glucose in adults (20–79 years), by World Bank income classification.

Summary

The 2021 global prevalence estimates of IGT and IFG are substantial and are projected to increase by 2045. Currently, however, there is no consensus definition of “prediabetes”. There are at least five different definitions endorsed by different clinical organisations and guidelines. Studies that reported only the American Diabetes Association (ADA) threshold for IFG (5.5–6.9 mmol/L [100–125 mg/dL]) were not included in this report.

The prevalence estimates of IFG based on ADA IFG would be higher than for estimates based on the WHO IFG criterion. Regardless of how defined, intermediate states of hyperglycaemia are common and a growing problem, suggesting major challenges for future risk of diabetes across the globe.

Map 3.6Age-adjusted comparative prevalence of impaired fasting glucose in adults in 2021

Map 3.7Age-adjusted comparative prevalence of impaired glucose tolerance in adults in 2021

Hyperglycaemia in pregnancy

A total of 58 studies on hyperglycaemia in pregnancy (HIP) from 47 countries were included in the analysis, including from six new countries since the previous edition of the IDF Diabetes Atlas: Chile, Ethiopia, Italy, Jordan, Mexico and Trinidad.

It is estimated that 21.1 million (16.7%) of live births to women in 2021 had some form of hyperglycaemia in pregnancy. Of these, 80.3% were due to gestational diabetes mellitus (GDM), while 10.6% were the result of diabetes detected prior to pregnancy, and 9.1% due to diabetes (including type 1 and type 2) first detected in pregnancy (Table 3.19).

Table 3.19

Global estimates of hyperglycaemia in pregnancy in 2021.

Differences in these results compared to earlier editions of the IDF Diabetes Atlas are possibly due to improved detection before and during pregnancy. More information on the methods can be found in Chapter 2.

There are some regional differences in the prevalence of HIP, with the SEA Region having the highest age-adjusted comparative prevalence at 28.0%, compared to 8.6% in the MENA Region (Table 3.20). These differences were previously projected for the years 2030 and 2045 in the 9th IDF Atlas. The vast majority (87.5%) of cases of hyperglycaemia in pregnancy are seen in low and middle-income countries, where access to antenatal care is often limited.

Table 3.20

Hyperglycaemia in pregnancy (20–49 years) by IDF Region, ranked by 2021 age-adjusted comparative prevalence estimates.

Prevalence of HIP, as a proportion of all pregnancies, increases rapidly with age, with the highest prevalence (42.3%) in 45–49 year-old women, although there are fewer pregnancies in this age group (Figure 3.12). Of course, this age group also has a higher prevalence of diabetes among non-pregnant women. As a result of higher fertility rates in younger women, half (46.3%) of all cases of HIP (9.8 million) occur in women under the age of 30 years.

Figure 3.12

Prevalence of hyperglycaemia in pregnancy by age group in 2021.

Diabetes-related mortality

Diabetes is a major driver of mortality worldwide, though its impact varies by region. Excluding the mortality risks associated with the COVID-19 pandemic, approximately 6.7 million adults between the age of 20–79 are estimated to have died as a result of diabetes or its complications in 2021. This corresponds to 12.2% of global deaths from all causes in this age group. Approximately one-third (32.6%) of all deaths from diabetes occur in people of working age (under the age of 60) – (Figure 3.13). This corresponds to 11.8% of total global deaths in people under 60.

Figure 3.13

Number of deaths due to diabetes in adults (20–79 years), by age and sex in 2021.

Regional distribution

The IDF Region with the highest estimated number of diabetes-related deaths among 20–79 years old is WP, with approximately 2.3 million deaths. This is followed by EUR, with approximately 1.1 million deaths. The IDF Region with the lowest number of deaths is SACA with approximately 0.4 million deaths. These regional discrepancies are largely driven by the relative size of their respective diabetes populations.

Approximately 6.7 million adults (20–79) are estimated to have died as a result of diabetes, or its complications in 2021

The proportion of total deaths associated with diabetes is an indicator of the relative burden of diabetes within each IDF Region. Diabetes is associated with the highest percentage of deaths from all causes in NAC at 21.7%. The second highest Region is MENA, with 20.2% of all deaths associated with diabetes. The IDF Region with the lowest percentage of deaths associated with diabetes is SEA, at 7.1%.

Diseases which disproportionately impact the working age adult population (20–60 years) can have a unequal economic impact. The IDF Region with the highest proportion of total deaths under the age of 60 associated with diabetes is MENA with 24.5% (Table 3.21), followed by NAC, with 18.4% of total diabetes-related deaths under the age of 60. In the SEA Region, only 6.9% of total deaths under the age of 60 are associated with diabetes.

Table 3.21

Proportion and number of adults who died from diabetes before the age of 60 years in 2021, globally and by IDF Region, ranked by the proportion of deaths due to diabetes.

Country distribution

Partly due to its large population, China has the highest annual number of deaths from diabetes, at approximately 1.4 million. Due to its large population and high prevalence of diabetes, the US has the second highest number of deaths with 0.7 million. The next highest is India (0.6 million), followed by Pakistan (0.4 million) and Japan (0.2 million).

The countries with the highest proportion of total deaths associated with diabetes are Singapore (29%) and Pakistan (29%). The next highest countries are Israel (29%), Barbados (28%) and Italy (26%). The countries with the lowest proportions are Russia and Czechia, each with approximately 1% of total deaths.

Pakistan is the country with the highest proportion of deaths under the age of 60 due to diabetes, with 35.5% (Map 3.8). It is followed by Singapore, Brunei, and Kiribati with 31.4%, 31.3%, and 30.4% respectively. This demonstrates a high burden of diabetes in the working age population. The countries with the lowest proportion of deaths under 60 years of age are Benin (1.7%) and Slovakia (1.6%).

Map 3.8Proportion of total deaths related to diabetes among people under 60

The economic impact of diabetes

Diabetes imposes a substantial economic burden on countries, health systems, people with diabetes, and their families.^39–41

Direct costs of diabetes

Direct costs are the health expenditures that occur due to diabetes – regardless of whether the expenditure is borne out of pocket by people living with diabetes or by private or public payers, including governments. The IDF Diabetes Atlas has included estimates of health expenditure due to diabetes^42–47 since its 3rd edition in 2006. The increase in global health expenditure due to diabetes has been considerable, growing from USD 232 billion in 2007 to USD 966 billion in 2021 for adults aged 20–79 years (Figure 3.14).

Figure 3.14

Total diabetes-related health expenditure for adults (20–79 years) with diabetes from 2006 to 2045.

This represents a 316% increase over 15 years. Part of this increase can be attributed to improved data quality. The direct costs of diabetes are expected to continue to grow. IDF estimates that total diabetes-related health expenditure will reach USD 1.03 trillion by 2030 and USD 1.05 trillion by 2045.

Respectively, these are increases of 66.4% and 9.1% compared to the 2021 estimate. These projections are conservative as they assume that age and sex-specific diabetes-related expenditure and diabetes prevalence remain constant, while taking into account only population size, ageing, changes in sex distribution and urbanisation.

Regional distribution

The NAC Region has the highest total diabetes-related health expenditure of the seven IDF Regions (USD 415 billion), and accounts for 42.9% of total global diabetes-related health expenditure in 2021. The second highest is the WP Region with USD 241.3 billion, followed by the EUR Region (USD 189 billion) corresponding to 25.0% and 19.6% of the total global diabetes-related health expenditure, respectively. Despite being home to 40.8% of people with diabetes in the world, the SACA, MENA, AFR, and SEA Regions are collectively responsible for only 12.5% of global diabetes-related health expenditure (Figure 3.15).

Figure 3.15

Total diabetes-related health expenditure (USD billion) in adults with diabetes (20–79 years) in 2021 by IDF Region. IDF: International Diabetes Federation; AFR: Africa; EUR: Europe; MENA: Middle East and North Africa; NAC: North America and Caribbean; (more...)

The NAC Region also has the highest diabetes-related health expenditure per adult with diabetes (USD 8,209), followed by the EUR Region (USD 3,086), SACA Region (USD 2,190) and WP Region (USD 1,204) (Figure 3.16). Health expenditure is 465 USD per person with diabetes in the MENA region, 547 USD in the AFR region, and 112 USD in the SEA region (Figure 3.16).

Figure 3.16

Diabetes-related health expenditure (USD) per person with diabetes (20–79 years) in 2021 by IDF Region. IDF: International Diabetes Federation; AFR: Africa; EUR: Europe; MENA: Middle East and North Africa; NAC: North America and Caribbean; SACA: (more...)

Expenditure due to diabetes has a substantial impact on total health expenditure worldwide, representing 11.5% of total global health spending. In the SACA Region, an average of 18.4% of the total health expenditure was due to diabetes, the highest percentage from the IDF Regions, followed by 16.6% in the MENA Region. The lowest percentage of health expenditure due to diabetes, was observed in the EUR Region (8.6%) (Figure 3.17).

Figure 3.17

Percentage of diabetes-related health expenditure for adults (20–79 years) with diabetes, by IDF Region in 2021. IDF: International Diabetes Federation; AFR: Africa; EUR: Europe; MENA: Middle East and North Africa; NAC: North America and Caribbean; (more...)

Diabetes-related health expenditure as a percentage of Gross Domestic Product (GDP) is highest in the SACA Region at 1.71%, followed by 1.69% in the NAC Region (Figure 3.18). When considering World Bank income classification, diabetes-related health expenditure as a percentage of GDP is highest amongst high-income countries (1.16%), followed by middle-income countries (1.08%), and followed distantly by low-income countries (0.51%) (Figure 3.19).

Figure 3.18

Diabetes-related health expenditure as a percentage of Gross Domestic Product (GDP), by IDF region. IDF: International Diabetes Federation; AFR: Africa; EUR: Europe; MENA: Middle East and North Africa; NAC: North America and Caribbean; SACA: South and (more...)

Figure 3.19

Diabetes-related health expenditure as a percentage of Gross Domestic Product (GDP), by World Bank income classification.

Country distribution

On a country level, the highest diabetes-related health expenditure is observed in the United States of America (USD 379.5 billion), followed by China and Brazil, (USD 165.3 billion and USD 42.9 billion, respectively) (Table 3.22).

Table 3.22

Ten countries or territories with the highest total health expenditure (USD) due to diabetes (20–79 years) in 2021.

The countries with the lowest diabetes-related health expenditure in 2021 are Gambia and Nauru, with total expenditure of USD 2.4 million and USD 1.6 million, respectively (Map 3.9).

Map 3.9Total diabetes-related health expenditure (USD) for adults (20–79 years) with diabetes, 2021

In 2021, huge disparities exist among countries in per person diabetes-related health expenditure. The countries with the highest yearly expenditure per person are Switzerland (USD 12,828), followed by the United States of America (USD 11,779) and Norway (USD 11,166). Countries with the lowest annual expenditure per person are The Democratic Republic of the Congo (USD 94), Pakistan (USD 80) and Bangladesh (USD 77) (Map 3.10).

Map 3.10Diabetes-related health expenditure (USD) per person with diabetes (20–79 years) in 2021

The total diabetes-related health expenditure will reach one trillion USD by 2030

Of the 10 countries with the highest health expenditure for diabetes per person, nine are from the EUR Region and one is from the NAC Region (Table 3.23).

Table 3.23

Top 10 countries or territories for diabetes-related health expenditure (USD) per person with diabetes (20–79 years) in 2021.

References

1.

Sun H, Saeedi P, Karuranga S, Pinkepank M, Ogurtsova K, Duncan BB, et al. IDF Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diab Res Clin Pract. 2021 (in press) [PubMed: 34879977]

2.

Dall TM, Yang W, Halder P, et al. The economic burden of elevated blood glucose levels in 2012: diagnosed and undiagnosed diabetes, gestational diabetes mellitus, and prediabetes. Diabetes Care 2014; 37: 3172–9; DOI:http://dx​.doi.org/10.2337/dc14-1036. [PubMed: 25414388]

3.

Manne-Goehler J, Geldsetzer P, Agoudavi K, Andall-Brereton G, Aryal KK, Bicaba BW, et al. Health system performance for people with diabetes in 28 low- and middle-income countries: A cross-sectional study of nationally representative surveys. PLOS Med 2019;16:e1002751. https://doi​.org/10.1371/journal​.pmed.1002751. [PMC free article: PMC6396901] [PubMed: 30822339]

4.

Ekoe J-M, Goldenberg R, Katz P. Screening for Diabetes in Adults. Can J Diabetes 2018;42:S16–9. https://doi​.org/10.1016/j​.jcjd.2017.10.004. [PubMed: 29650090]

5.

Magliano DJ, Islam RM, Barr ELM, et al. Trends in incidence of total or type 2 diabetes: systematic review. BMJ 2019; 366: l5003. [PMC free article: PMC6737490] [PubMed: 31511236]

6.

Magliano DJ, Chen L, Islam RM, et al. Trends in the incidence of diagnosed diabetes: a multicountry analysis of aggregate data from 22 million diagnoses in high-income and middle-income settings. Lancet Diabetes Endocrinol 2021; 9(4): 203–11. [PubMed: 33636102]

7.

Tuomilehto J, Ogle GD, Lund-Blix N, Stene LC. Epidemiology of childhood type 1 diabetes. Pediatr Endocrinol Rev 2020;17(Suppl 1):198–209. doi:10.17458/per.vol17.2020.tol.epidemiologychildtype1diabetes. [PubMed: 32208564] [CrossRef]

8.

Ogle GD, James S, Dabelea D, Pihoker C, Svennson J, Maniam J, et al. Global estimates of incidence of type 1 diabetes in children and adolescents; Results from the International Diabetes Federation Atlas, 10th Edition. Diabetes Res Clin Pract 2021 (to be submitted). [PubMed: 34883188]

9.

Mebrahtu G, Maniam J, James S, Ogle GD. High incidence of type 1 diabetes in adolescents and young adults in Eritrea. Diabetic Med 2021 Feb 15;e14544, doi:10.1111/dme.14544. [PubMed: 33587788] [CrossRef]

10.

Pambou-Damiens A, Ganga-Zandzou PS, TsouckaIbounde E, Kayemba-Kay’s S, Baye E, Biloghe P et al. Type 1 diabetes mellitus in Gabon: A study of epidemiological aspects. Int J Pediatr Adolesc Med 2019 Sep;6(3):87–91. doi:10.1016/j.ijpam.2019.02.007. [PMC free article: PMC6824159] [PubMed: 31700966] [CrossRef]

11.

Sandy JL, Besancon S, Sidibe AT, Minkailou M, Togo A, Ogle GD. Rapid increases in observed incidence and prevalence of Type 1 diabetes in children and youth in Mali, 2007–2016. Pediatr Diabetes 2021;2021:1–7. DOI:10.1111/pedi.13191. [PubMed: 33586301] [CrossRef]

12.

Jasem D, Majaliwa ES, Ramiaya K, Najem S, Swai ABM, Ludvigsson J. Incidence, prevalence and clinical manifestations at onset of juvenile diabetes in Tanzania. Diabetes Res Clin Pract 2019 Oct;156:107817. doi:10.1016/j.diabres.2019.107817. [PubMed: 31425767] [CrossRef]

13.

Majeed NA, Shiruhana SA, Maniam J, Eigenmann CA, Siyan A, Ogle GD. Incidence, prevalence and mortality of diabetes in children and adolescents aged under 20 years in the Republic of Maldives. J Paed Child Health 2020;56:746–750. DOI:10.1111/jpc.14726. [PubMed: 31868263] [CrossRef]

14.

Cummings E, Flemming M, Talbot P. Trends in incidence of type 1 diabetes in children and adolescents over 25 years in Nova Scotia Canada: 1994–2018. Pediatr Diabetes 2021;22(Suppl 29) EP003. DOI:10.1111/pedi.13198. [CrossRef]

15.

Fox DA, Islam N, Sutherland J, Reimer K, Amed S. Type 1 diabetes incidence and prevalence trends in a cohort of Canadian children and youth. Pediatr Diabetes 2018; 19(3):501–505. doi:10.1016/j.jpeds.2020.02.069. [PubMed: 28857360] [CrossRef]

16.

International Diabetes Federation. IDF Guide for Diabetes Epidemiological Studies. International Diabetes Federation: Brussels; 2021. Available at: https://idf​.org/our-activities​/epidemiology-research​/idf-guide-for-diabetes-epidemiology-studies​.html

17.

Shulman R, Slater M, Khan S, Jones C, Walker JD, Jacklin K, et al. Prevalence, incidence and outcomes of diabetes in Ontario First Nations children: a longitudinal population-based cohort study. CMAJ Open 2020; 8(1):E48–E55 [PMC free article: PMC6996034] [PubMed: 31992559]

18.

Powell J, Isom S, Divers J, Bellatorre A, Johnson M, Smiley J, et al. Increasing burden of type 2 diabetes in Navajo youth: The SEARCH for diabetes in youth study. Pediatr Diabetes 2019; 20(7):815–820 [PMC free article: PMC6786918] [PubMed: 31260152]

19.

Divers J, Mayer-Davis EJ, Lawrence JM, Isom S, Dabelea D, Dolan L, et al. Trends in incidence of type 1 and type 2 diabetes among youth – selected counties and Indian Reservations, United States, 2002–2015. MMWR Morb Mortal Wkly Rep 2020; 69(6):161–165 [PMC free article: PMC7017961] [PubMed: 32053581]

20.

Haynes A, Kalic R, Cooper M, Hewitt JK, Davis EA. Increasing incidence of type 2 diabetes in indigenous and non-indigenous children in Western Australia, 1990–2012. Med J Aust 2016; 204(8):303 [PubMed: 27125801]

21.

Candler TP, Mahmoud O, Lynn RM, Majbar AA, Barrett TG, Shield JPH. Continuing rise of Type 2 diabetes incidence in children and young people in the UK. Diabet Med 2018; 35(6):737–744 [PMC free article: PMC5969249] [PubMed: 29460341]

22.

Galler A, Stange T, Muller G, Nake A, Vogel C, Kapellen T, et al. Incidence of childhood diabetes in children aged less than 15 years and its clinical and metabolic characteristics at the time of diagnosis: data from the Childhood Diabetes Registry of Saxony, Germany. Horm Res Paediatr 2010; 74(4)):285–291 [PubMed: 20516654]

23.

Telo GH, Cureau FV, Szklo M, Bloch KV, Schaan BD. Prevalence of type 2 diabetes among adolescents in Brazil: Findings from Study of Cardiovascular Risk in Adolescents (ERICA). Pediatr Diabetes 2019; 20(4):389–396 [PubMed: 30737879]

24.

Simental-Mendia LE, Gamboa-Gomez CI, Aradillas-Garcia C, Rodriguez-Moran M, Guerrero-Romero F. The triglyceride and glucose index is a useful biomarker to recognize glucose disorders in apparently healthy children and adolescents. Eur J Pediatr 2020; 179(6):953–958 [PubMed: 32016604]

25.

Lawrence JM, Divers J, Isom S, Saydah S, Imperatore G, Pihoker C, Marcovina SM, Mayer-Davis EJ, Hamman RF, Dolan L, Dabelea D, Pettitt DJ, Liese AD; SEARCH for Diabetes in Youth Study Group. Trends in Prevalence of Type 1 and Type 2 Diabetes in Children and Adolescents in the US, 2001–2017. JAMA. 2021 Aug 24;326(8):717–727 [PMC free article: PMC8385600] [PubMed: 34427600]

26.

Oester IM, Kloppenborg JT, Olsen BS, Johannesen J. Type 2 diabetes mellitus in Danish children and adolescents in 2014. Pediatr Diabetes 2016; 17(5):368–373 [PubMed: 26111830]

27.

Rhanolkar AR, Amin R, Taylor-Robinson D, Viner R, Warner J, Stephenson T. Ethnic minorities are at greater risk for childhood-onset type 2 diabetes and poorer glycemic control in England and Wales. J Adolesc Health 2006; 59(3):354–361 [PubMed: 27426206]

28.

GBD 2015 Obesity Collaborators. Health effects of overweight and obesity in 195 countries over 25 years. N Engl J Med 2017; 377(1):13–27 [PMC free article: PMC5477817] [PubMed: 28604169]

29.

Wei JN, Sung FC, Lin CC, Lin RS, Chiang CC, Chuang LM. National surveillance for type 2 diabetes mellitus in Taiwanese children. JAMA 2003; 290(10):1345–1350 [PubMed: 12966126]

30.

Mahajan A, Taliun D, Thurner M, Robertson NR, Torres JM, Rayner WN et al. Fine-mapping type 2 diabetes loci to single-variant resolution using high-density imputation and islet-specific epigenome maps. Nat Genet 2008; 50(11):1505–1513 [PMC free article: PMC6287706] [PubMed: 30297969]

31.

Seiglie JA, Marcus M-E, Ebert C, Prodromidis N, Geldsetzer P, Theilmann M, et al. Diabetes Prevalence and Its Relationship With Education, Wealth, and BMI in Twenty-Nine Low- and Middle-Income Countries. Diabetes Care 2020; 43(4):767–775 [PMC free article: PMC7085810] [PubMed: 32051243]

32.

RISE Consortium; RISE Consortium Investigators. Effects of treatment of impaired glucose tolerance or recently diagnosed type 2 diabetes with metformin alone or in combination with insulin glargine on β-cell function: Comparison of responses in youth and adults. Diabetes 2019; 68(8):1670–1680 [PMC free article: PMC6692818] [PubMed: 31178433]

33.

Kim G, Divers J, Fino NF, Dabelea D, Lawrence JM, Reynolds K, et al. Trends in prevalence of cardiovascular risk factors from 2002 to 2012 among youth early in the course of type 1 and type 2 diabetes. The SEARCH for Diabetes in Youth Study. Pediatr Diabetes 2019; 20(6):693–701 [PMC free article: PMC6785186] [PubMed: 30903717]

34.

Dabelea D, Stafford JM, Mayer-Davis EJ, D’Agostino R Jr, Dolan L, Imperatore G, et al. Association of type 1 diabetes vs type 2 diabetes diagnosed during childhood and adolescence with complications during teenage years and young adulthood. JAMA 2017; 317(8):825–835 [PMC free article: PMC5483855] [PubMed: 28245334]

35.

TODAY Study Group. Longitudinal changes in cardiac structure and function from adolescence to young adulthood in participants with type 2 diabetes mellitus: The TODAY Follow-Up Study. Circ Heart Fail 2020; 13(6):e006685 [PMC free article: PMC8608548] [PubMed: 32498621]

36.

Shah AS, EI Ghormli L, Vajravelu ME, Bacha F, Farrell RM, Gidding SS, et al. Heart rate variability and cardiac autonomic dysfunction: prevalence, risk factors, and relationship to arterial stiffness in the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study. Diabetes Care 2019; 42(11):2143–2150 [PMC free article: PMC6804614] [PubMed: 31501226]

37.

Reynolds K, Saydah SH, Isom S, Divers J, Lawrence JM, Dabelea D, et al. Mortality in youth-onset type 1 and type 2 diabetes: The SEARCH for Diabetes in Youth Study. J Diabetes Complications 2018; 32(6):545–549 [PMC free article: PMC6089078] [PubMed: 29685480]

38.

Harding JL, Wander PL, Zhang X, Li X, Karuranga S, Chen H, et al. The International Incidence of Adult-onset Type 1 Diabetes: A Systematic Review. Diabetes Care. Provisionally accepted [PMC free article: PMC9016739] [PubMed: 35349653]

39.

Association AD. Economic Costs of Diabetes in the U.S. in 2017. Diabetes Care 2018 May 1;41(5):917–28. [PMC free article: PMC5911784] [PubMed: 29567642]

40.

Peters ML, Huisman EL, Schoonen M, Wolffenbuttel BHR. The current total economic burden of diabetes mellitus in the Netherlands. Neth J Med. 2017 Sep;75(7):281–97. [PubMed: 28956787]

41.

Yang W, Zhao W, Xiao J, Li R, Zhang P, Kissimova-Skarbek K, et al. Medical care and payment for diabetes in China: enormous threat and great opportunity. PLoS ONE. 2012;7(9):e39513. [PMC free article: PMC3458850] [PubMed: 23049727]

42.

International Diabetes Federation. IDF Diabetes Atlas, 8th edition. Brussels, Belgium; 2017

43.

International Diabetes Federation. IDF Diabetes Atlas, 7th edition. Brussels, Belgium; 2015

44.

International Diabetes Federation. IDF Diabetes Atlas, 6th edition. Brussels, Belgium; 2013

45.

International Diabetes Federation. IDF Diabetes Atlas, 5th edition. Brussels, Belgium; 2011

46.

International Diabetes Federation. IDF Diabetes Atlas, 4th edition. Brussels, Belgium; 2009

47.

International Diabetes Federation. IDF Diabetes Atlas, 3rd edition. Brussels, Belgium; 2006