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Diabetes and global ageing among 65-99-year-old adults: findings from the International Diabetes Federation Diabetes Atlas, 9th edition
Journal Pre-proofs Diabetes and global ageing among 65-99-year-old adults: findings from the International Diabetes Federation Diabetes Atlas, 9th edition Alan Sinclair, Pouya Saeedi, Abha Kaundal, Suvi Karuranga, Belma Malanda, Rhys Williams PII: DOI: Reference:
S0168-8227(20)30137-6 https://doi.org/10.1016/j.diabres.2020.108078 DIAB 108078
To appear in:
Diabetes Research and Clinical Practice
Received Date: Accepted Date:
10 February 2020 10 February 2020
Please cite this article as: A. Sinclair, P. Saeedi, A. Kaundal, S. Karuranga, B. Malanda, R. Williams, Diabetes and global ageing among 65-99-year-old adults: findings from the International Diabetes Federation Diabetes Atlas, 9th edition, Diabetes Research and Clinical Practice (2020), doi: https://doi.org/10.1016/j.diabres. 2020.108078
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2020 Published by Elsevier B.V.
Title Diabetes and global ageing among 65-99-year-old adults: findings from the International Diabetes Federation Diabetes Atlas, 9th edition.
Authors Alan Sinclair1, Pouya Saeedi2, Abha Kaundal2, Suvi Karuranga2, Belma Malanda2, Rhys Williams3
Affiliations: 1King’s
College, London, and Diabetes Frail Ltd, Luton, United Kingdom
2International 3Diabetes
Diabetes Federation, Brussels, Belgium
Research Unit Cymru, Swansea University, Swansea, United Kingdom
Corresponding author Pouya Saeedi International Diabetes Federation, Brussels, Belgium Email: [email protected]
1
Abstract Aims The main aims are: (a) to draw attention to the nature and pattern of recent global and regional prevalence estimates and projections of diabetes in older adults (65-99 years), and (b) to describe the societal health implications of these changes on a global scale. Methods Diabetes prevalences and projections were estimated using a logistic regression method to generate smoothed age- and sex-specific prevalence estimates for 5-year age groups. Results In 2019, it is estimated that 19.3% of people aged 65–99 years (135.6 million, 95% CI: 107.6 – 170.6 million) live with diabetes. It is projected that the number of people older than 65 years (65–99 years) with diabetes will reach 195.2 million by 2030 and 276.2 million by 2045. For the regional distribution, the highest prevalence in 2019 being the North America and Caribbean region at 27.0%. Countries with the highest number of people older than 65 years with diabetes are China, the United States of America and India. Conclusions There is a need for more data from national and regional sources on those aged 65 years and over but the prevailing evidence points to diabetes being a considerable global chronic illness burden in ageing societies.
Key Words: Diabetes; older people; ageing; prevalence; survival; International Diabetes Federation
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1.
Introduction
In our global ageing societies, diabetes imposes a significant personal and public health burden in terms of the numbers of people with the condition, diabetes-related complications including frailty and disability, and national health and social care systems’ expenditures [1]. It is apparent that older people with diabetes can represent some of the more complex and difficult challenges facing the health care professionals working in different settings [2]. New data from the International Diabetes Federation (IDF) Diabetes Atlas 9th edition [3] allow us to highlight this research need by assessing what the impact is from an international perspective by focusing on diabetes prevalence estimates for older age groups (>65 years) A major shift in the epidemiology of diabetes towards those aged over 60 years has been recognised for some time [4]. However, it is now universally recognised that all regions of the world are experiencing rapid growth in the prevalence of diabetes and this has been confirmed recently, showing that, in 2019, 488 million adults aged 20-99 years (9.5%) live with diabetes, worldwide [5]. The epicentres of diabetes prevalence in the last decade have been China, India, the United States of America, Pakistan and Brazil. A sobering thought from this latter work [5] indicates that half of all adults with diabetes are unaware of this condition being present and this may be more prevalent in older age groups where illness can be mimicked by non-specific symptoms and atypical presentations of diabetes are seen [1]. The causes of this accelerated increase in diabetes prevalence in ageing societies is similar to those relating to younger people and include unhealthy obesogenic diets, reduced physical activity relating to type 2 diabetes mellitus and rising incidences of type 1 diabetes, all of which are compounded by improved diagnostic rates for type 2 diabetes mellitus, effects of the natural ageing process such as altered glucose metabolism and islet cell dysfunction, and rising life expectancy. With this advancing tide of older people with diabetes, there is an urgent need for national decision makers to have an accurate grasp of diabetes and its potential impact on the ageing population. This would then allow a platform to be developed for interventions that produce the maximum disability-free life 3
years lived combined with the highest quality of life for this vulnerable and often neglected group of adults. The key aims of this paper, therefore, are: (a) to draw attention to the nature and pattern of recent IDF global and regional prevalence estimates and projections of diabetes in older adults (65-99 years), and (b) to describe the societal health implications of these changes on a global scale. 2.
Methods
The methods for estimating global and national prevalences of diabetes in adults have previously been described elsewhere [5,6]. Briefly, the methods used to provide diabetes estimates are given in Box 1. Box 1: Methods of analysis, IDF Diabetes Atlas 9th edition Methods Undertaken
Description
Gathering and
Peer-reviewed publications and national health surveys
selecting
including eligible WHO STEPwise approach to surveillance
data sources
(STEPS) studies. Data from other official sources such as ministries of health and reports from health regulatory bodies were also used. Data sources published before 1990 were excluded. In addition, data sources published between January 2017 and December 2018 were screened and added to the existing database if they met the inclusion criteria.
Estimating diabetes
Logistic regression was used to generate smoothed age- and
prevalence and
sex- specific
projections
prevalence estimates for 5-year age groups, after extracting data from eligible data sources. If more than one data source was available for an individual country, the country level diabetes estimates were derived using an average of the data sources. The number of data sources selected to estimate diabetes prevalence and projections was 255, emanating
4
from 138 countries and territories. In order to project diabetes estimates forward to the years 2030 and 2045, population projections for 2030 and 2045 from the United Nations Population Division (UNPD) were used. Extrapolating data
For countries without in-country data sources estimates were generated by extrapolation using diabetes data from countries that are similar in terms of ethnicity, language, World Bank income classification and geographical proximity.
Estimating
In order to calculate confidence intervals, two separate
confidence
analyses were performed: a bootstrap analysis and a
Intervals
simulation study.
3.
Results
3.1 Diabetes prevalence in 2019 and projections to 2030 and 2045 (65–99 years) In total 255 high-quality data sources from 138 countries met the inclusion criteria and were used to estimate diabetes prevalences. Estimates for the remaining 73 countries and territories were made based on extrapolation from countries deemed to be similar. In 2019, it is estimated that 19.3% of people aged 65–99 years (135.6 million, 95% CI: 107.6 – 170.6 million) live with diabetes. It is projected that the number of people older than 65 years (65–99 years) with diabetes will reach 195.2 million by 2030 and 276.2 million by 2045. 3.2 Regional distribution Table 1 reports diabetes prevalences in people older than 65 years by IDF Region in 2017, 2019, 2030 and 2045. Significant regional differences are present. In 2019, the IDF North America and Caribbean (NAC) Region has the highest prevalence (27.0%) in adults aged 65-99 years and Africa (AFR) has the lowest (8.4%). The same trend has been projected for 2030 and 2045 for the IDF Regions. Compared with 2017, the 2019 prevalences show increases in every Region apart from the IDF Western Pacific (WP) Region, which showed 5.5% decrease.
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3.3 Sex and regional distribution As shown in Table 2, there is an increasing trend in prevalence of diabetes in both men and women in all IDF Regions. In 2019, the WP Region has the highest number of men and women with diabetes, followed by the Europe (EUR) and NAC Region. The same pattern exists in 2030, while it is projected that in 2045, South-East Asia (SEA) will take over NAC for the number of women with diabetes. 3.4 Country distribution Countries with the highest number of people older than 65 years with diabetes are China, the United States of America and India. The United States of America ranked higher than India in the number of people older than 65 years with diabetes for 2019 and 2030. However, trends predict that by 2045 India will exceed the United States of America in the number of people older than 65 years with diabetes (Map 1, Table 3).
3.5 Prevalences of people with diabetes and income group distribution in 2019 As displayed in Figure 1, there is a consistent rise in prevalence in all age groups in each income category up to 60-64 years. In those aged 65 years and over, only high-income countries show a continuing rise until 75-79 years and then a decline in prevalence is observed. In low- and middle-income countries, a short plateau after 65 years is noted followed by continuing declines in prevalence with increasing age. 4.
Discussion
This study presents a more in-depth appreciation of the impact of diabetes in our global ageing society in terms of prevalence of diabetes in the old and very old population: it is estimated that in 2019 nearly 136 million of the adult population (65-99 years) have diabetes, accounting for nearly one in five of the population in this age group. The projections for 2030 (195 million) and 2045 (276 million) for people with diabetes in this age group appear dramatic but are likely to not only represent demographic-related sequelae, but also changes in incidence rates and survival, with the prevalence overall remaining just below the 20% level. It should be noted from a recent systematic review 6
[7] that incidence rates of diabetes have actually declined in many high-income populations across all age groups since 2000 (perhaps because of the introduction of diabetes preventative programmes) although incidence data are lacking from the Pacific Islands, the Middle East, and South Asia, where diabetes prevalence has risen considerably. Other key observations from these new data demonstrate wide differences in the seven IDF Regions in terms of prevalence in those aged 65 years and older, for example, relatively low prevalences in AFR and SEA (8.4% and 13.6%, respectively) compared with 27% and 24.2% in NAC and Middle East and North Africa (MENA), respectively. While projected diabetes prevalences are not forecast to increase appreciably in any IDF Region, the public health impact and challenge of increasing numbers of older people with diabetes particularly in low- and middle-income countries is likely to be substantial. Diabetes is known to be an important cause of excess mortality although the magnitude of this effect is highly variable in different populations with a relative risk of 1.15 - 3.15 with cardiovascular diseases being consistently observed to be the main cause of this risk [8]. The data on mortality from the 9th Edition of the IDF Atlas 2019 [3] demonstrate a wide regional variation, which are also likely to reflect differences in the demographics of those with diabetes, the level of public health investment in diabetes care which will be influenced in turn by socio-economic factors including the availability of medicines. Apart from the AFR Region (where the highest death rate is in the age group 30-39 years), all other Regions show a consistent pattern of increasing mortality due to diabetes in those aged 60 years and older. Factors other than increasing age in determining this risk will include glycaemic control and the presence of renal disease [9]. Excess mortality in those with diabetes aged 75 years and over is thought to match that of the general population [10] although other studies suggest that this risk continues in those older than 75 years [11], particularly those with co-existing renal disease [9]. There are wide regional disparities in diabetes-related health expenditure, which is an indicator of balance between funding available and that provided for diabetes care for the 7
adult population of diabetes up to age 79 years [3]. However, it is likely to be translated into an inequitable shortfall in provision of care in those of advanced age (> 80 years) likely to lead to diminished quality care in older people with diabetes at a time in their adult life when they are most vulnerable and at their highest risk to maintaining their quality of life. The reason behind the large expenditure observed in older age groups is almost certainly the higher frequency of diabetes-related complications and associated consequences such as hospitalisation and amputation particularly in the later stages of life, although in the absence of objective data on frailty, disability, and diabetes-related cognitive dysfunction, all of which are high-impact conditions [12], it is not, at least at present, possible to know which comorbidities account for which proportion of funding spent. It is clear that diabetes in our ageing societies continues to place a tremendous health burden on older individuals with diabetes and is likely to continue to stretch the financial purse for public health and social care services on a global scale even in high income countries such as the United States of America where costs are on average 2.3 times higher for those with diabetes when compared with a similar age- and sex-matched counterparts [13]. An ageing population affects a society’s health status because of increased numbers of people and more years lived with ill health, frailty and disability. We should, therefore, ask the question ‘what can be done in the future to offset these adverse observations in rising prevalence, high mortality rates, and high diabetes-related health expenditure in older people with diabetes?’. The acquisition of high quality and up-to-date national information on diabetes and the development and implementation of multisectoral intervention strategies as part of a coordinated plan to tackle non-communicable diseases (NCDs) has already been called to address the urgent global impact of diabetes [3,5]. As there is firm evidence that primary prevention of type 2 diabetes mellitus can be effective [14], it will be up to stakeholders to prioritise health policies and the allocation of resources to implement preventive strategies, something that will be seen as a particular challenge in low- and middle-income countries, where there are large numbers of older adults with type 2 diabetes mellitus.
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The delivery of diabetes care for older people even in high-income countries can be fragmented and suboptimal [2] bordering on inequality and inequity of healthcare, and the challenge of delivering better care to those older adults in low- and middle-income countries remains a significant obstacle. All diabetes professional organisations place a strong emphasis on individualising treatment goals and strategies to maximise benefits and to minimise harm. For older people with diabetes, this process should take place in primary and community care settings by workers who, wherever possible, should be skilled in geriatric assessment [15]. However, it is up to governments and commissioners or payers of health care to invest in high quality, team-based diabetes care, which capitalises on modern technological advancements [16], again a view that equally applies to the care of older adults with diabetes mellitus. While there is a need for more data from national and regional sources on those aged 65 years and above (a limitation of this current work) the prevailing evidence points to diabetes being a considerable chronic illness burden in global ageing societies. We recognise that at a universal level improving diabetes care is a major challenge to national healthcare systems particularly those of low-income status. However, it depends how and where priorities are set if older people are to receive a fair share of the resources needed to reduce the impact of this chronic NCD. Aligned with these, there is a need to address significant shortfalls in knowledge and understanding of the disease in ageing populations by undertaking more longer-term observational studies, enhancing clinical trial methods, and promoting randomised controlled trials of glucose-lowering and multicomponent interventions specifically in ageing participants. Acknowledgements The authors wish to thank the IDF Diabetes Atlas Committee members for reviewing and contributing to the methods described here. We would also like to thank Professor Trisha Dunning, Deakin university, for reviewing the paper and providing insightful feedback.
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Author contribution Conception and design: AJS, PS, BM, SK, RW; Analysis and interpretation of data: PS and AJS; Drafting the article or revising it critically: AJS, PS, AK, BM, SK, TD, RW; Final approval of the version to be submitted: AJS, PS, AK, BM, SK, TD, RW. Author disclosures The authors have no conflicts of interest to disclose. Role of funding source The 9th edition of the IDF Diabetes Atlas has been produced thanks to an educational grant (2018-2019) from the Pfizer and MSD Alliance, with the additional support from the Lilly Diabetes and Novo Nordisk.
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References [1] Sinclair AJ, Abdelhafiz AH, Forbes A, Munshi M. Evidence-based diabetes care for older people with Type 2 diabetes: a critical review. Diabet Med. 2019 Apr;36(4):399-413 [2] Sinclair A, Dunning T, Rodriguez-Manas L. Diabetes in older people: new insights and remaining challenges. Lancet Diabetes & Endocrinology 2015; Apr; 3(4):275-85 [3] International Diabetes Federation Diabetes Atlas 9th edition, 2019, IDF, Brussels. Available
at:
https://diabetesatlas.org/upload/resources/2019/IDF_Atlas_9th_Edition_2019.pdf [4] Whiting DR, Guariguata L, Weil C, Shaw J. IDF Diabetes Atlas: global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res Clin Pract 2011; 94: 311–321. [5] Saeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, Unwin N et al. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: results from the International Diabetes Federation Diabetes Atlas, 9th edition. Diabetes Res Clin Pract 2019; doi: 10.1016/j.diabres.2019.107843. [6] Guariguata L, Whiting D, Weil C, Unwin N. The International Diabetes Federation diabetes atlas methodology for estimating global and national prevalence of diabetes in adults. Diabetes Res Clin Pract. 2011;94(3):322–32. [7] Magliano DJ, Islam RM, Barr ELM, Gregg EW, Pavkov ME, Harding JL, Tabesh M, Koye DN, Shaw JE. Trends in incidence of total or type 2 diabetes: systematic review. BMJ 2019;366:l5003. [8] Yu OHY, Suissa S. Identifying Causes for Excess Mortality in Patients with Diabetes: Closer but Not There Yet. Diabetes Care 2016 Nov; 39(11): 1851-1853. [9] Tancredi M, Rosengren A, Svensson A-M, Kosiborod M, Pivodic A, Gudbjörnsdottir S, et al. Excess Mortality among Persons with Type 2 Diabetes. N Engl J Med 2015; 373:17201732. [10] Lind M, Garcia-Rodriguez LA, Booth GL, Cea-Soriano L, Shah BR, Ekeroth G, Lipscombe LL. Mortality trends in patients with and without diabetes in Ontario, Canada and the UK from 1996 to 2009: a population-based study. Diabetologia. 2013 Dec;56(12):2601-8.
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[11] Forbes A, Murrels T, Sinclair AJ. Examining factors associated with excess mortality in older people (age ≥ 70 years) with diabetes - a 10-year cohort study of older people with and without diabetes. Diabetes Med 2017; Mar 34(3):387-395 [12] Sinclair AJ, Abdelhafiz AH, Rodríguez-Mañas L. Frailty and sarcopenia - newly emerging and high impact complications of diabetes. J Diabetes Complications 2017; Sep;31(9):1465-1473 [13] American Diabetes Association. Economic Costs of Diabetes in the U.S. in 2017. Diabetes Care 2018; May;41(5):917-928 [14] Cefalu WT, Buse JB, Tuomilehto J, Fleming GA, Ferrannini E, Gerstein HC, et al. Update and Next Steps for Real-World Translation of Interventions for Type 2 Diabetes Prevention: Reflections from a Diabetes Care Editors’ Expert Forum. Diabetes Care 2016;39(7):1186–201. [15] Morley JE, Sinclair A. Individualising treatment for older people with diabetes. Lancet 2013; 382: 378–80. [16] Owolabi MO, Yaria JO, Daivadanam M, Makanjuola AI, Parker G, Oldenburg B, et al. Gaps in Guidelines for the Management of Diabetes in Low- and Middle-Income Versus High-Income Countries-A Systematic Review. Diabetes Care. 2018;41(5):1097– 105.
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Table 1. Diabetes prevalence in people older than 65 years by IDF Region in 2017, 2019, 2030 and 2045, ranked by 2019 prevalence estimates Ran IDF 2019 2030 2045 k Regio 2017 n Prevalence Number of Prevalence Number of Prevalence Number Prevalence Number (%) people with (%) people with (%) of people (%) of people diabetes diabetes with with (millions) (millions) diabetes diabetes (millions) (millions) World 18.8 122.8 19.3 135.6 19.6 195.2 19.6 276.2 1 2 3 4 5 6 7
NAC MENA SACA EUR WP SEA AFR
(15.4-23.4)i
(100.2-152.3)
(15.3–24.2)
(107.6–170.6)
(15.5–24.8)
(154.7– 247.1)
(15.2–25.4)
(214.8– 358.9)
26.3
17.7
27.0
19.2
27.3
26. 9
27.5
34.0
(23.4-29.4)
(15.7-19.7)
(22.2–32.6)
(15.7–23.1)
(22.4–33.0)
(22.0–32.5)
(21.9–33.9)
(27.1–42.0)
20.4
6.5
24.2
8.4
24.7
13.7
25.2
25.2
(12.6-29.0)
(4.0-9.3)
(13.2–34.0)
(4.6–11.8)
(13.7–34.6)
(7.6–19.2)
(13.9–35.6)
(13.9–35.6)
19.0
7.9
22.7
10.3
23.1
15.7
23.1
24.0
(15.1–24.4)
(6.3–10.2)
(18.3–29.3)
(8.3–13.2)
(18.7–29.7)
(12.7–20.2)
(18.5–30.1)
(19.2–31.2)
19.4
28.5
20.1
31.0
20.2
20.5
46.3
(14.9-25.0)
(21.9-36.7)
(15.3–25.8)
(23.5–39.8)
(15.2–26.1)
(29.2–50.0)
(15.2–26.8)
(34.5–60.8)
20.0
48.1
18.9
50.3
19.6
75.4
19.8
107.3
(17.8-23.0)
(42.7-55.2)
(16.7–22.1)
(44.4–58.9)
(17.2–23.1)
(66.4–89.1)
(17.3–23.9)
(93.5– 129.6)
13.5
12.5
13.6
13.6
13.9
20.5
14.0
32.2
(9.5–18.6)
(8.7–17.1)
(10.1–18.6)
(10.1–18.6)
(10.3–19.1)
(15.3–28.2)
(10.4–19.7)
(24.0–45.1)
5.2
1.6
8.4
2.8
8.7
4.2
8.4
7.3
38.8
(2.8–12.8) (0.9–4.0) (3.0–15.5) (1.0–5.1) (3.1–16.2) (1.5–7.8) (3.1–16.8) (2.7–14.6) IDF: International Diabetes Federation; AFR: Africa; EUR: Europe; MENA: Middle East and North Africa; NAC: North America and Caribbean; SACA: South and Central America; SEA: South-East Asia; WP: Western Pacific i 95% confidence intervals are reported in brackets.
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Table 2. Number of people with diabetes in 1,000s and prevalence (%) estimates by sex and IDF Region in 65-99 years old adults 2019
IDF Region AFR EUR MENA NAC SACA SEA WP
2030
2045
Men
Women
Men
Women
Men
Women
1,245 (8.4)i
1,557 (8.4)
1,832 (8.6)
2,334 (8.7)
3,347 (8.6)
3,927 (8.2)
12,775 (20.0)
18,249 (20.2)
16,314 (20.1)
22,478 (20.3)
19,803 (20.2)
26,535 (20.6)
3,835 (22.8)
4,553 (25.4)
6,310 (23.4)
7,368 (25.8)
11,449 (23.8)
13,727 (26.6)
9,998 (31.3)
9,155 (23.6)
14,295 (31.5)
12,559 (23.7)
18,401 (31.9)
15,598 (23.6)
3,981 (20.3)
6,289 (24.6)
6,107 (20.6)
9,639 (25.1)
9,338 (20.5)
14,644 (25.2)
6,097 (12.7)
75,42 (14.5)
9,247 (13.1)
11,295 (14.6)
14,493 (13.5)
17,683 (14.5)
23,123 (18.7)
27,199 (19.1)
33,828 (18.9)
41,602 (20.1)
46,632 (18.6)
60,650 (20.8)
IDF: International Diabetes Federation; AFR: Africa; EUR: Europe; MENA: Middle East and North Africa; NAC: North America and Caribbean; SACA: South and Central America; SEA: South-East Asia; WP: Western Pacific. iNumber of people with diabetes is reported in thousands and prevalence estimates are presented in brackets.
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Table 3. Top 10 countries or territories for the number of people older than 65 years (65-99 years) with diabetes in 2017, 2019, 2030 and 2045 Rank
2017 Country or territory
1
China
Number of people with diabetes (millions) 34.1
Rank
Country or territory
1
China
(31.7-38.3)i
2
United States of America
13.5
2
(12.7-14.2)
3
India
11.0 (7.7-15.1)
4
Germany
4.9
Brazil
4.3
6
Japan
(3.6-5.1)
7
Russian Federation Italy
3.5
8
Mexico
2.5
5 6 7 8 9
(1.4-3.4)
10
Spain
2.2 (1.5-3.1)
i95%
15
confidence intervals are reported in brackets
China
14.6
2
(12.5–17.1)
United States of America
10
20.0
Germany
6.3
4
Brazil
9.6
Brazil
6.1
Germany
7.6
Japan Russian Federation Italy Mexico Pakistan
5
(5.5–6.9)
4.9
6
(4.0–5.7)
3.7
7
(2.2–4.3)
2.9
8
(2.6–3.3)
2.7
9
(1.6–3.8)
2.6 (1.2–3.9)
10
Japan Russian Federation Mexico Pakistan Italy
2045 Country or territory
1
China
2
(17.1–23.4)
18.0
(5.2–7.0)
Rank
(49.7–62.6)
India
4
(2.3-3.0)
9
1
(32.6–40.6)
Number of people with diabetes (millions) 54.3
3
India
(2.0-4.2)
2.6
2030 Country or territory
(9.0–16.4)
3
(3.9-4.8)
4.3
Rank
12.1
(4.1-5.5)
5
United States of America
2019 Number of people with diabetes (millions) 35.5
3
(13.5–24.7)
4
(8.6–10.9)
5
(6.3–8.5)
5.1
6
(4.1–6.0)
4.6
7
(2.7–5.4)
4.3
8
(2.5–5.9)
3.8
9
(1.8–5.9)
3.4 (3.1–3.9)
10
India
Number of people with diabetes (millions) 78.1 (70.9–92.3)
27.5 (20.6–38.6)
United States of America
23.2
Brazil
14.9
Germany
8.7
Mexico Pakistan Japan Turkey Indonesia
(19.8–27.3)
(13.4–17.0) (7.2–9.8)
7.7 (4.5–10.8)
6.4 (3.0–10.0)
5.4 (4.4–6.5)
4.8 (3.3–6.4)
4.8 (4.2–5.5)
Map 1. Number of people older than 65 years with diabetes by country in 2019
16
Figure 1. Prevalence (%) of people with diabetes by age and income group, 2019
17
S0168-8227(20)30137-6 https://doi.org/10.1016/j.diabres.2020.108078 DIAB 108078
To appear in:
Diabetes Research and Clinical Practice
Received Date: Accepted Date:
10 February 2020 10 February 2020
Please cite this article as: A. Sinclair, P. Saeedi, A. Kaundal, S. Karuranga, B. Malanda, R. Williams, Diabetes and global ageing among 65-99-year-old adults: findings from the International Diabetes Federation Diabetes Atlas, 9th edition, Diabetes Research and Clinical Practice (2020), doi: https://doi.org/10.1016/j.diabres. 2020.108078
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2020 Published by Elsevier B.V.
Title Diabetes and global ageing among 65-99-year-old adults: findings from the International Diabetes Federation Diabetes Atlas, 9th edition.
Authors Alan Sinclair1, Pouya Saeedi2, Abha Kaundal2, Suvi Karuranga2, Belma Malanda2, Rhys Williams3
Affiliations: 1King’s
College, London, and Diabetes Frail Ltd, Luton, United Kingdom
2International 3Diabetes
Diabetes Federation, Brussels, Belgium
Research Unit Cymru, Swansea University, Swansea, United Kingdom
Corresponding author Pouya Saeedi International Diabetes Federation, Brussels, Belgium Email: [email protected]
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Abstract Aims The main aims are: (a) to draw attention to the nature and pattern of recent global and regional prevalence estimates and projections of diabetes in older adults (65-99 years), and (b) to describe the societal health implications of these changes on a global scale. Methods Diabetes prevalences and projections were estimated using a logistic regression method to generate smoothed age- and sex-specific prevalence estimates for 5-year age groups. Results In 2019, it is estimated that 19.3% of people aged 65–99 years (135.6 million, 95% CI: 107.6 – 170.6 million) live with diabetes. It is projected that the number of people older than 65 years (65–99 years) with diabetes will reach 195.2 million by 2030 and 276.2 million by 2045. For the regional distribution, the highest prevalence in 2019 being the North America and Caribbean region at 27.0%. Countries with the highest number of people older than 65 years with diabetes are China, the United States of America and India. Conclusions There is a need for more data from national and regional sources on those aged 65 years and over but the prevailing evidence points to diabetes being a considerable global chronic illness burden in ageing societies.
Key Words: Diabetes; older people; ageing; prevalence; survival; International Diabetes Federation
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1.
Introduction
In our global ageing societies, diabetes imposes a significant personal and public health burden in terms of the numbers of people with the condition, diabetes-related complications including frailty and disability, and national health and social care systems’ expenditures [1]. It is apparent that older people with diabetes can represent some of the more complex and difficult challenges facing the health care professionals working in different settings [2]. New data from the International Diabetes Federation (IDF) Diabetes Atlas 9th edition [3] allow us to highlight this research need by assessing what the impact is from an international perspective by focusing on diabetes prevalence estimates for older age groups (>65 years) A major shift in the epidemiology of diabetes towards those aged over 60 years has been recognised for some time [4]. However, it is now universally recognised that all regions of the world are experiencing rapid growth in the prevalence of diabetes and this has been confirmed recently, showing that, in 2019, 488 million adults aged 20-99 years (9.5%) live with diabetes, worldwide [5]. The epicentres of diabetes prevalence in the last decade have been China, India, the United States of America, Pakistan and Brazil. A sobering thought from this latter work [5] indicates that half of all adults with diabetes are unaware of this condition being present and this may be more prevalent in older age groups where illness can be mimicked by non-specific symptoms and atypical presentations of diabetes are seen [1]. The causes of this accelerated increase in diabetes prevalence in ageing societies is similar to those relating to younger people and include unhealthy obesogenic diets, reduced physical activity relating to type 2 diabetes mellitus and rising incidences of type 1 diabetes, all of which are compounded by improved diagnostic rates for type 2 diabetes mellitus, effects of the natural ageing process such as altered glucose metabolism and islet cell dysfunction, and rising life expectancy. With this advancing tide of older people with diabetes, there is an urgent need for national decision makers to have an accurate grasp of diabetes and its potential impact on the ageing population. This would then allow a platform to be developed for interventions that produce the maximum disability-free life 3
years lived combined with the highest quality of life for this vulnerable and often neglected group of adults. The key aims of this paper, therefore, are: (a) to draw attention to the nature and pattern of recent IDF global and regional prevalence estimates and projections of diabetes in older adults (65-99 years), and (b) to describe the societal health implications of these changes on a global scale. 2.
Methods
The methods for estimating global and national prevalences of diabetes in adults have previously been described elsewhere [5,6]. Briefly, the methods used to provide diabetes estimates are given in Box 1. Box 1: Methods of analysis, IDF Diabetes Atlas 9th edition Methods Undertaken
Description
Gathering and
Peer-reviewed publications and national health surveys
selecting
including eligible WHO STEPwise approach to surveillance
data sources
(STEPS) studies. Data from other official sources such as ministries of health and reports from health regulatory bodies were also used. Data sources published before 1990 were excluded. In addition, data sources published between January 2017 and December 2018 were screened and added to the existing database if they met the inclusion criteria.
Estimating diabetes
Logistic regression was used to generate smoothed age- and
prevalence and
sex- specific
projections
prevalence estimates for 5-year age groups, after extracting data from eligible data sources. If more than one data source was available for an individual country, the country level diabetes estimates were derived using an average of the data sources. The number of data sources selected to estimate diabetes prevalence and projections was 255, emanating
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from 138 countries and territories. In order to project diabetes estimates forward to the years 2030 and 2045, population projections for 2030 and 2045 from the United Nations Population Division (UNPD) were used. Extrapolating data
For countries without in-country data sources estimates were generated by extrapolation using diabetes data from countries that are similar in terms of ethnicity, language, World Bank income classification and geographical proximity.
Estimating
In order to calculate confidence intervals, two separate
confidence
analyses were performed: a bootstrap analysis and a
Intervals
simulation study.
3.
Results
3.1 Diabetes prevalence in 2019 and projections to 2030 and 2045 (65–99 years) In total 255 high-quality data sources from 138 countries met the inclusion criteria and were used to estimate diabetes prevalences. Estimates for the remaining 73 countries and territories were made based on extrapolation from countries deemed to be similar. In 2019, it is estimated that 19.3% of people aged 65–99 years (135.6 million, 95% CI: 107.6 – 170.6 million) live with diabetes. It is projected that the number of people older than 65 years (65–99 years) with diabetes will reach 195.2 million by 2030 and 276.2 million by 2045. 3.2 Regional distribution Table 1 reports diabetes prevalences in people older than 65 years by IDF Region in 2017, 2019, 2030 and 2045. Significant regional differences are present. In 2019, the IDF North America and Caribbean (NAC) Region has the highest prevalence (27.0%) in adults aged 65-99 years and Africa (AFR) has the lowest (8.4%). The same trend has been projected for 2030 and 2045 for the IDF Regions. Compared with 2017, the 2019 prevalences show increases in every Region apart from the IDF Western Pacific (WP) Region, which showed 5.5% decrease.
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3.3 Sex and regional distribution As shown in Table 2, there is an increasing trend in prevalence of diabetes in both men and women in all IDF Regions. In 2019, the WP Region has the highest number of men and women with diabetes, followed by the Europe (EUR) and NAC Region. The same pattern exists in 2030, while it is projected that in 2045, South-East Asia (SEA) will take over NAC for the number of women with diabetes. 3.4 Country distribution Countries with the highest number of people older than 65 years with diabetes are China, the United States of America and India. The United States of America ranked higher than India in the number of people older than 65 years with diabetes for 2019 and 2030. However, trends predict that by 2045 India will exceed the United States of America in the number of people older than 65 years with diabetes (Map 1, Table 3).
3.5 Prevalences of people with diabetes and income group distribution in 2019 As displayed in Figure 1, there is a consistent rise in prevalence in all age groups in each income category up to 60-64 years. In those aged 65 years and over, only high-income countries show a continuing rise until 75-79 years and then a decline in prevalence is observed. In low- and middle-income countries, a short plateau after 65 years is noted followed by continuing declines in prevalence with increasing age. 4.
Discussion
This study presents a more in-depth appreciation of the impact of diabetes in our global ageing society in terms of prevalence of diabetes in the old and very old population: it is estimated that in 2019 nearly 136 million of the adult population (65-99 years) have diabetes, accounting for nearly one in five of the population in this age group. The projections for 2030 (195 million) and 2045 (276 million) for people with diabetes in this age group appear dramatic but are likely to not only represent demographic-related sequelae, but also changes in incidence rates and survival, with the prevalence overall remaining just below the 20% level. It should be noted from a recent systematic review 6
[7] that incidence rates of diabetes have actually declined in many high-income populations across all age groups since 2000 (perhaps because of the introduction of diabetes preventative programmes) although incidence data are lacking from the Pacific Islands, the Middle East, and South Asia, where diabetes prevalence has risen considerably. Other key observations from these new data demonstrate wide differences in the seven IDF Regions in terms of prevalence in those aged 65 years and older, for example, relatively low prevalences in AFR and SEA (8.4% and 13.6%, respectively) compared with 27% and 24.2% in NAC and Middle East and North Africa (MENA), respectively. While projected diabetes prevalences are not forecast to increase appreciably in any IDF Region, the public health impact and challenge of increasing numbers of older people with diabetes particularly in low- and middle-income countries is likely to be substantial. Diabetes is known to be an important cause of excess mortality although the magnitude of this effect is highly variable in different populations with a relative risk of 1.15 - 3.15 with cardiovascular diseases being consistently observed to be the main cause of this risk [8]. The data on mortality from the 9th Edition of the IDF Atlas 2019 [3] demonstrate a wide regional variation, which are also likely to reflect differences in the demographics of those with diabetes, the level of public health investment in diabetes care which will be influenced in turn by socio-economic factors including the availability of medicines. Apart from the AFR Region (where the highest death rate is in the age group 30-39 years), all other Regions show a consistent pattern of increasing mortality due to diabetes in those aged 60 years and older. Factors other than increasing age in determining this risk will include glycaemic control and the presence of renal disease [9]. Excess mortality in those with diabetes aged 75 years and over is thought to match that of the general population [10] although other studies suggest that this risk continues in those older than 75 years [11], particularly those with co-existing renal disease [9]. There are wide regional disparities in diabetes-related health expenditure, which is an indicator of balance between funding available and that provided for diabetes care for the 7
adult population of diabetes up to age 79 years [3]. However, it is likely to be translated into an inequitable shortfall in provision of care in those of advanced age (> 80 years) likely to lead to diminished quality care in older people with diabetes at a time in their adult life when they are most vulnerable and at their highest risk to maintaining their quality of life. The reason behind the large expenditure observed in older age groups is almost certainly the higher frequency of diabetes-related complications and associated consequences such as hospitalisation and amputation particularly in the later stages of life, although in the absence of objective data on frailty, disability, and diabetes-related cognitive dysfunction, all of which are high-impact conditions [12], it is not, at least at present, possible to know which comorbidities account for which proportion of funding spent. It is clear that diabetes in our ageing societies continues to place a tremendous health burden on older individuals with diabetes and is likely to continue to stretch the financial purse for public health and social care services on a global scale even in high income countries such as the United States of America where costs are on average 2.3 times higher for those with diabetes when compared with a similar age- and sex-matched counterparts [13]. An ageing population affects a society’s health status because of increased numbers of people and more years lived with ill health, frailty and disability. We should, therefore, ask the question ‘what can be done in the future to offset these adverse observations in rising prevalence, high mortality rates, and high diabetes-related health expenditure in older people with diabetes?’. The acquisition of high quality and up-to-date national information on diabetes and the development and implementation of multisectoral intervention strategies as part of a coordinated plan to tackle non-communicable diseases (NCDs) has already been called to address the urgent global impact of diabetes [3,5]. As there is firm evidence that primary prevention of type 2 diabetes mellitus can be effective [14], it will be up to stakeholders to prioritise health policies and the allocation of resources to implement preventive strategies, something that will be seen as a particular challenge in low- and middle-income countries, where there are large numbers of older adults with type 2 diabetes mellitus.
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The delivery of diabetes care for older people even in high-income countries can be fragmented and suboptimal [2] bordering on inequality and inequity of healthcare, and the challenge of delivering better care to those older adults in low- and middle-income countries remains a significant obstacle. All diabetes professional organisations place a strong emphasis on individualising treatment goals and strategies to maximise benefits and to minimise harm. For older people with diabetes, this process should take place in primary and community care settings by workers who, wherever possible, should be skilled in geriatric assessment [15]. However, it is up to governments and commissioners or payers of health care to invest in high quality, team-based diabetes care, which capitalises on modern technological advancements [16], again a view that equally applies to the care of older adults with diabetes mellitus. While there is a need for more data from national and regional sources on those aged 65 years and above (a limitation of this current work) the prevailing evidence points to diabetes being a considerable chronic illness burden in global ageing societies. We recognise that at a universal level improving diabetes care is a major challenge to national healthcare systems particularly those of low-income status. However, it depends how and where priorities are set if older people are to receive a fair share of the resources needed to reduce the impact of this chronic NCD. Aligned with these, there is a need to address significant shortfalls in knowledge and understanding of the disease in ageing populations by undertaking more longer-term observational studies, enhancing clinical trial methods, and promoting randomised controlled trials of glucose-lowering and multicomponent interventions specifically in ageing participants. Acknowledgements The authors wish to thank the IDF Diabetes Atlas Committee members for reviewing and contributing to the methods described here. We would also like to thank Professor Trisha Dunning, Deakin university, for reviewing the paper and providing insightful feedback.
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Author contribution Conception and design: AJS, PS, BM, SK, RW; Analysis and interpretation of data: PS and AJS; Drafting the article or revising it critically: AJS, PS, AK, BM, SK, TD, RW; Final approval of the version to be submitted: AJS, PS, AK, BM, SK, TD, RW. Author disclosures The authors have no conflicts of interest to disclose. Role of funding source The 9th edition of the IDF Diabetes Atlas has been produced thanks to an educational grant (2018-2019) from the Pfizer and MSD Alliance, with the additional support from the Lilly Diabetes and Novo Nordisk.
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References [1] Sinclair AJ, Abdelhafiz AH, Forbes A, Munshi M. Evidence-based diabetes care for older people with Type 2 diabetes: a critical review. Diabet Med. 2019 Apr;36(4):399-413 [2] Sinclair A, Dunning T, Rodriguez-Manas L. Diabetes in older people: new insights and remaining challenges. Lancet Diabetes & Endocrinology 2015; Apr; 3(4):275-85 [3] International Diabetes Federation Diabetes Atlas 9th edition, 2019, IDF, Brussels. Available
at:
https://diabetesatlas.org/upload/resources/2019/IDF_Atlas_9th_Edition_2019.pdf [4] Whiting DR, Guariguata L, Weil C, Shaw J. IDF Diabetes Atlas: global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res Clin Pract 2011; 94: 311–321. [5] Saeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, Unwin N et al. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: results from the International Diabetes Federation Diabetes Atlas, 9th edition. Diabetes Res Clin Pract 2019; doi: 10.1016/j.diabres.2019.107843. [6] Guariguata L, Whiting D, Weil C, Unwin N. The International Diabetes Federation diabetes atlas methodology for estimating global and national prevalence of diabetes in adults. Diabetes Res Clin Pract. 2011;94(3):322–32. [7] Magliano DJ, Islam RM, Barr ELM, Gregg EW, Pavkov ME, Harding JL, Tabesh M, Koye DN, Shaw JE. Trends in incidence of total or type 2 diabetes: systematic review. BMJ 2019;366:l5003. [8] Yu OHY, Suissa S. Identifying Causes for Excess Mortality in Patients with Diabetes: Closer but Not There Yet. Diabetes Care 2016 Nov; 39(11): 1851-1853. [9] Tancredi M, Rosengren A, Svensson A-M, Kosiborod M, Pivodic A, Gudbjörnsdottir S, et al. Excess Mortality among Persons with Type 2 Diabetes. N Engl J Med 2015; 373:17201732. [10] Lind M, Garcia-Rodriguez LA, Booth GL, Cea-Soriano L, Shah BR, Ekeroth G, Lipscombe LL. Mortality trends in patients with and without diabetes in Ontario, Canada and the UK from 1996 to 2009: a population-based study. Diabetologia. 2013 Dec;56(12):2601-8.
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[11] Forbes A, Murrels T, Sinclair AJ. Examining factors associated with excess mortality in older people (age ≥ 70 years) with diabetes - a 10-year cohort study of older people with and without diabetes. Diabetes Med 2017; Mar 34(3):387-395 [12] Sinclair AJ, Abdelhafiz AH, Rodríguez-Mañas L. Frailty and sarcopenia - newly emerging and high impact complications of diabetes. J Diabetes Complications 2017; Sep;31(9):1465-1473 [13] American Diabetes Association. Economic Costs of Diabetes in the U.S. in 2017. Diabetes Care 2018; May;41(5):917-928 [14] Cefalu WT, Buse JB, Tuomilehto J, Fleming GA, Ferrannini E, Gerstein HC, et al. Update and Next Steps for Real-World Translation of Interventions for Type 2 Diabetes Prevention: Reflections from a Diabetes Care Editors’ Expert Forum. Diabetes Care 2016;39(7):1186–201. [15] Morley JE, Sinclair A. Individualising treatment for older people with diabetes. Lancet 2013; 382: 378–80. [16] Owolabi MO, Yaria JO, Daivadanam M, Makanjuola AI, Parker G, Oldenburg B, et al. Gaps in Guidelines for the Management of Diabetes in Low- and Middle-Income Versus High-Income Countries-A Systematic Review. Diabetes Care. 2018;41(5):1097– 105.
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Table 1. Diabetes prevalence in people older than 65 years by IDF Region in 2017, 2019, 2030 and 2045, ranked by 2019 prevalence estimates Ran IDF 2019 2030 2045 k Regio 2017 n Prevalence Number of Prevalence Number of Prevalence Number Prevalence Number (%) people with (%) people with (%) of people (%) of people diabetes diabetes with with (millions) (millions) diabetes diabetes (millions) (millions) World 18.8 122.8 19.3 135.6 19.6 195.2 19.6 276.2 1 2 3 4 5 6 7
NAC MENA SACA EUR WP SEA AFR
(15.4-23.4)i
(100.2-152.3)
(15.3–24.2)
(107.6–170.6)
(15.5–24.8)
(154.7– 247.1)
(15.2–25.4)
(214.8– 358.9)
26.3
17.7
27.0
19.2
27.3
26. 9
27.5
34.0
(23.4-29.4)
(15.7-19.7)
(22.2–32.6)
(15.7–23.1)
(22.4–33.0)
(22.0–32.5)
(21.9–33.9)
(27.1–42.0)
20.4
6.5
24.2
8.4
24.7
13.7
25.2
25.2
(12.6-29.0)
(4.0-9.3)
(13.2–34.0)
(4.6–11.8)
(13.7–34.6)
(7.6–19.2)
(13.9–35.6)
(13.9–35.6)
19.0
7.9
22.7
10.3
23.1
15.7
23.1
24.0
(15.1–24.4)
(6.3–10.2)
(18.3–29.3)
(8.3–13.2)
(18.7–29.7)
(12.7–20.2)
(18.5–30.1)
(19.2–31.2)
19.4
28.5
20.1
31.0
20.2
20.5
46.3
(14.9-25.0)
(21.9-36.7)
(15.3–25.8)
(23.5–39.8)
(15.2–26.1)
(29.2–50.0)
(15.2–26.8)
(34.5–60.8)
20.0
48.1
18.9
50.3
19.6
75.4
19.8
107.3
(17.8-23.0)
(42.7-55.2)
(16.7–22.1)
(44.4–58.9)
(17.2–23.1)
(66.4–89.1)
(17.3–23.9)
(93.5– 129.6)
13.5
12.5
13.6
13.6
13.9
20.5
14.0
32.2
(9.5–18.6)
(8.7–17.1)
(10.1–18.6)
(10.1–18.6)
(10.3–19.1)
(15.3–28.2)
(10.4–19.7)
(24.0–45.1)
5.2
1.6
8.4
2.8
8.7
4.2
8.4
7.3
38.8
(2.8–12.8) (0.9–4.0) (3.0–15.5) (1.0–5.1) (3.1–16.2) (1.5–7.8) (3.1–16.8) (2.7–14.6) IDF: International Diabetes Federation; AFR: Africa; EUR: Europe; MENA: Middle East and North Africa; NAC: North America and Caribbean; SACA: South and Central America; SEA: South-East Asia; WP: Western Pacific i 95% confidence intervals are reported in brackets.
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Table 2. Number of people with diabetes in 1,000s and prevalence (%) estimates by sex and IDF Region in 65-99 years old adults 2019
IDF Region AFR EUR MENA NAC SACA SEA WP
2030
2045
Men
Women
Men
Women
Men
Women
1,245 (8.4)i
1,557 (8.4)
1,832 (8.6)
2,334 (8.7)
3,347 (8.6)
3,927 (8.2)
12,775 (20.0)
18,249 (20.2)
16,314 (20.1)
22,478 (20.3)
19,803 (20.2)
26,535 (20.6)
3,835 (22.8)
4,553 (25.4)
6,310 (23.4)
7,368 (25.8)
11,449 (23.8)
13,727 (26.6)
9,998 (31.3)
9,155 (23.6)
14,295 (31.5)
12,559 (23.7)
18,401 (31.9)
15,598 (23.6)
3,981 (20.3)
6,289 (24.6)
6,107 (20.6)
9,639 (25.1)
9,338 (20.5)
14,644 (25.2)
6,097 (12.7)
75,42 (14.5)
9,247 (13.1)
11,295 (14.6)
14,493 (13.5)
17,683 (14.5)
23,123 (18.7)
27,199 (19.1)
33,828 (18.9)
41,602 (20.1)
46,632 (18.6)
60,650 (20.8)
IDF: International Diabetes Federation; AFR: Africa; EUR: Europe; MENA: Middle East and North Africa; NAC: North America and Caribbean; SACA: South and Central America; SEA: South-East Asia; WP: Western Pacific. iNumber of people with diabetes is reported in thousands and prevalence estimates are presented in brackets.
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Table 3. Top 10 countries or territories for the number of people older than 65 years (65-99 years) with diabetes in 2017, 2019, 2030 and 2045 Rank
2017 Country or territory
1
China
Number of people with diabetes (millions) 34.1
Rank
Country or territory
1
China
(31.7-38.3)i
2
United States of America
13.5
2
(12.7-14.2)
3
India
11.0 (7.7-15.1)
4
Germany
4.9
Brazil
4.3
6
Japan
(3.6-5.1)
7
Russian Federation Italy
3.5
8
Mexico
2.5
5 6 7 8 9
(1.4-3.4)
10
Spain
2.2 (1.5-3.1)
i95%
15
confidence intervals are reported in brackets
China
14.6
2
(12.5–17.1)
United States of America
10
20.0
Germany
6.3
4
Brazil
9.6
Brazil
6.1
Germany
7.6
Japan Russian Federation Italy Mexico Pakistan
5
(5.5–6.9)
4.9
6
(4.0–5.7)
3.7
7
(2.2–4.3)
2.9
8
(2.6–3.3)
2.7
9
(1.6–3.8)
2.6 (1.2–3.9)
10
Japan Russian Federation Mexico Pakistan Italy
2045 Country or territory
1
China
2
(17.1–23.4)
18.0
(5.2–7.0)
Rank
(49.7–62.6)
India
4
(2.3-3.0)
9
1
(32.6–40.6)
Number of people with diabetes (millions) 54.3
3
India
(2.0-4.2)
2.6
2030 Country or territory
(9.0–16.4)
3
(3.9-4.8)
4.3
Rank
12.1
(4.1-5.5)
5
United States of America
2019 Number of people with diabetes (millions) 35.5
3
(13.5–24.7)
4
(8.6–10.9)
5
(6.3–8.5)
5.1
6
(4.1–6.0)
4.6
7
(2.7–5.4)
4.3
8
(2.5–5.9)
3.8
9
(1.8–5.9)
3.4 (3.1–3.9)
10
India
Number of people with diabetes (millions) 78.1 (70.9–92.3)
27.5 (20.6–38.6)
United States of America
23.2
Brazil
14.9
Germany
8.7
Mexico Pakistan Japan Turkey Indonesia
(19.8–27.3)
(13.4–17.0) (7.2–9.8)
7.7 (4.5–10.8)
6.4 (3.0–10.0)
5.4 (4.4–6.5)
4.8 (3.3–6.4)
4.8 (4.2–5.5)
Map 1. Number of people older than 65 years with diabetes by country in 2019
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Figure 1. Prevalence (%) of people with diabetes by age and income group, 2019
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