- Email: [email protected]
Update of mortality attributable to diabetes for the IDF Diabetes Atlas: Estimates for the year 2013
Accepted Manuscript Title: Update of mortality attributable to diabetes for the IDF Diabetes Atlas: estimates for the year 2013 Author: IDF Diabetes Atlas Group PII: DOI: Reference:
S0168-8227(15)00267-3 http://dx.doi.org/doi:10.1016/j.diabres.2015.05.037 DIAB 6413
To appear in:
Diabetes Research and Clinical Practice
Received date: Accepted date:
12-5-2015 12-5-2015
Please cite this article as: IDF Diabetes Atlas Group, Update of mortality attributable to diabetes for the IDF Diabetes Atlas: estimates for the year 2013, Diabetes Research and Clinical Practice (2015), http://dx.doi.org/10.1016/j.diabres.2015.05.037 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. 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.
Update of mortality attributable to diabetes for the IDF Diabetes Atlas:
Ac ce p
te
d
M
an
us
Correspondence to: [email protected]
cr
IDF Diabetes Atlas Group
ip t
estimates for the year 2013
Page 1 of 14
Abstract
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Background Mortality is an important measure of population health and is often used to assign priorities in health interventions. Estimating mortality due to diabetes has been challenging because more than a third of countries of the world have no reliable data available on mortality. Moreover estimating mortality attributable to Diabetes is especially challenging since most people die of a related vascular complication such as cardiovascular disease or renal failure.
us
cr
Aims The aim of the study was to provide estimate of the number of deaths attributable to diabetes for the year 2013.
M
an
Methods A computerized disease model was used to obtain the estimates. Using WHO life tables for 2010 and IDF diabetes prevalence estimates for 2013, age and sex-specific relative risks of death for persons with diabetes were calculated, in order to estimate the number of deaths attributable to diabetes in people 20-79 years of age.
Ac ce p
te
d
Results This model estimated that globally, 8.4% of all-cause deaths were attributable to diabetes in adults aged 20-79 years, almost 5.1 million deaths. A sensitivity analysis adjusting relative risks by 20% found that the estimate of diabetes-attributable mortality to lie between 5.1% of total mortality (3.3 million deaths) and 10.1% of total mortality (6.6 million deaths). The highest rates of diabetes-attributable mortality were found to be 25.7% in South-East Asian women aged between 50-59 years old. The highest number of deaths attributable to diabetes was found in countries with large populations: 1,271,000 in China, 1,065,000 deaths in India, 386,400 in Indonesia, 197,300 in the Russian Federation and 192,700 in the United States of America. Conclusions Overall, 1 in 12 of global all-cause deaths were estimated to be attributable to diabetes in adults. In general, the number and proportion of deaths was slightly higher in women than in men.
Page 2 of 14
Introduction In 2013, the International Diabetes Federation (IDF) estimated that over 8.3% of the adult population aged between 20 and 79 had diabetes, with 46% of these undiagnosed (1–3). Diabetes is associated with multiple complications (including for example cardiovascular disease, kidney
ip t
disease, eye disease, nerve damage, lower limb amputation, and pregnancy complications) and is
cr
also associated with an increased risk of dying (4–6).
Mortality is one of the key measures for understanding the burden of a disease and its
us
progression. Mortality estimates are also important for the allocation of resources in public health. However, vital registration systems to report cause-specific mortality are often lacking.
an
Itis an especially challenging to estimate true mortality of diabetes since most people die of a related complication such as cardiovascular disease or renal failure (7). As a result, diabetes is often not listed as the underlying cause of death and is consistently underestimated in routine
M
health statistics (8). However, it has been shown that people with diabetes have a higher
d
mortality compared to people without diabetes (9–12).
te
A methodology has been developed using a modelling approach, the DisModII, to provide a more realistic estimate of the burden of attributable mortality to diabetes (13–15). This report
Ac ce p
uses this methodology to update estimates for the year 2013 using new studies on the prevalence of diabetes (2).
Methods
The methods to derive these estimates have been described by Roglic and Unwin (13). Briefly, the number of deaths attributable to diabetes uses the following inputs: World Health Organization (WHO) life tables for 2010 (16) for the expected number of deaths; countryspecific diabetes prevalence by age and sex for the year 2013 (1); and age and sex-specific relative risks of death for persons with diabetes compared to those without diabetes as used in the previous publication (2,13). These inputs were used to model the estimates using DisModII, a programme developed for the Global Burden of Disease study from 2000 and then Miettinen’s formula for the population-attributable fraction was used to calculate the number of deaths attributable to diabetes in people 20-79 years of age (17).
Page 3 of 14
The uncertainty in estimates of relative risks is usually expressed by measures such as the 95% confidence interval. However, such measures of uncertainty are not always available from the published reports of the cohort studies from which the relative risks are derived. In order to
ip t
reflect the uncertainty in the relative risk estimates, sensitivity analyses were conducted
assuming that the true relative risks were 20% lower and 20% higher than those found in each
cr
cohort study. A 20% increase for a relative risk of 2.0 would result in a relative risk of 2.4 and a 20% decrease in a relative risk of 1.6. The relative risks used for these estimates in each region
us
are shown in Table 1. The allocation of countries to regions is described in Guariguata et al (18). (Table 1)
an
Results
It was estimated that almost 5.1 million deaths in 2013 could be attributed to diabetes, or 8.4% of global all-cause mortality among adults (20-79 years) (Table 2). The number and proportion of
M
deaths was also higher in women than in men (Tables 3a and 3b).
d
A sensitivity analysis was conducted to calculate the number of deaths attributable to diabetes if the relative risks of dying were assumed to be 20% lower and 20% higher than what was
te
estimated in the cohort studies. With these assumptions the global proportion of deaths
Ac ce p
attributable to diabetes ranged from 5.1% (3.3 million deaths) to 10.1% (6.6 million deaths) (Table 4).
In the age group 20-79 years the percentage of deaths attributable to diabetes ranged from 15.8% in the Western Pacific Region to 8.6% in the African Region (Table 2). The number and proportion of deaths reached up to a quarter of all deaths in middle-aged women in some regions. For example, in the South-East Asian region, 19.1% of all-cause mortality in 50-59 year old men and 25.7% of all-cause mortality in 50-59 year old women was attributable to diabetes (Tables 3a and 3b). The prevalence of diabetes in the South-East Asian region is estimated to be 21.6% in 50-59 year old men and 14.9% in 50-59 year old women (1). The lower rate of 8.6% of diabetesattributable mortality in Africa is in part associated with the relatively lower age-adjusted prevalence (5.7%) of diabetes in adults aged 20-79 this region, and in part due to the relatively high rates of mortality due to communicable diseases (19).
Page 4 of 14
The highest number of deaths attributable to diabetes was found in countries with large populations: 1,271,000 in China, 1,065,000 in India, 386,400 in Indonesia, 197,300 in the Russian Federation and 192,700 in the United States of America. This is partially due to the fact
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that countries with large populations also contain the highest number of people with diabetes (2).
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Discussion
While there has been a documented decline in the morbidity and mortality of some non-
us
communicable diseases in developing and developed countries (20), no such decline has been reported for diabetes (1). The global population of adults increased by 4.5% between 2011 and
an
2013(21), while estimates of the number of deaths attributable to diabetes have increased by 10.8% over the same period, using the same methods and incorporating new estimates of prevalence (13). This increase in mortality is likely associated with increased incidence in low
M
and middle income countries, offset slightly by improved survival of people with diabetes in
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high income countries (22).
Diabetes contributes substantially to premature adult mortality and close to half of all deaths
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occur in people under the age of 60 (1). A substantial proportion of these premature deaths are
Ac ce p
potentially preventable through public health action directed at prevention of diabetes, early detection, and improvement of care for all people with established diabetes to prevent premature mortality (25). The targets adopted by WHO member states in 2013 reflect their commitment to reducing mortality due to major NCDs by 25% by the year 2025 by reducing risk factors and improving access to essential treatment and technologies (26).
Obtaining accurate estimates of mortality attributable to diabetes with currently available data is difficult, and any attempt will be based on a set of assumptions. Age and sex-specific relative risks of death for persons with diabetes compared to those without diabetes have been derived from a small number of studies, the data of which could be out of date. Future estimates of mortality attributable to diabetes will use data from more recent population-based mortality follow-up studies wherever possible. However, it is highly plausible that the figures presented here are closer to the truth than estimates derived from routine sources of health statistics which
Page 5 of 14
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systematically underestimate the burden of mortality due to diabetes (23).
Page 6 of 14
Conflict of Interest The members of the IDF Diabetes Atlas Group state that they have no conflicts of interest.
Funding
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The IDF Diabetes Atlas was supported by the following sponsors: Lilly Diabetes, Merck and Co, Inc., Novo Nordisk A/S supported through an unrestricted grant by the Novo Nordisk Changing
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Diabetes initiative, Pfizer, Inc. and Sanofi Diabetes.
Page 7 of 14
References
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us
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1. IDF Diabetes Atlas, 6th Ed. Brussels, Belgium: International Diabetes Federation; 2013. 2. Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract. 2014 Feb;103(2):137–49. 3. Beagley J, Guariguata L, Weil C, Motala AA. Global estimates of undiagnosed diabetes in adults. Diabetes Res Clin Pract. 2014 Feb;103(2):150–60. 4. Flores-Le Roux JA, Comin J, Pedro-Botet J, Benaiges D, Puig-de Dou J, Chillarón JJ, et al. Seven-year mortality in heart failure patients with undiagnosed diabetes: an observational study. Cardiovasc Diabetol. 2011;10:39. 5. Plantinga LC, Crews DC, Coresh J, Miller ER 3rd, Saran R, Yee J, et al. Prevalence of chronic kidney disease in US adults with undiagnosed diabetes or prediabetes. Clin J Am Soc Nephrol CJASN. 2010 Apr;5(4):673– 82. 6. Spijkerman AMW, Dekker JM, Nijpels G, Adriaanse MC, Kostense PJ, Ruwaard D, et al. Microvascular complications at time of diagnosis of type 2 diabetes are similar among diabetic patients detected by targeted screening and patients newly diagnosed in general practice: the hoorn screening study. Diabetes Care. 2003 Sep;26(9):2604–8. 7. Morrish NJ, Wang SL, Stevens LK, Fuller JH, Keen H. Mortality and causes of death in the WHO Multinational Study of Vascular Disease in Diabetes. Diabetologia. 2001 Sep;44 Suppl 2:S14–21. 8. Fuller JH, Elford J, Goldblatt P, Adelstein AM. Diabetes mortality: new light on an underestimated public health problem. Diabetologia. 1983 May;24(5):336–41. 9. Raymond NT, Langley JD, Goyder E, Botha JL, Burden AC, Hearnshaw JR. Insulin treated diabetes mellitus: causes of death determined from record linkage of population based registers in Leicestershire, UK. J Epidemiol Community Health. 1995 Dec;49(6):570–4. 10. Gu K, Cowie CC, Harris MI. Mortality in adults with and without diabetes in a national cohort of the U.S. population, 1971-1993. Diabetes Care. 1998 Jul;21(7):1138–45. 11. Koskinen SV, Reunanen AR, Martelin TP, Valkonen T. Mortality in a large population-based cohort of patients with drug-treated diabetes mellitus. Am J Public Health. 1998 May;88(5):765–70. 12. Gatling W, Tufail S, Mullee MA, Westacott TA, Hill RD. Mortality rates in diabetic patients from a community-based population compared to local age/sex matched controls. Diabet Med J Br Diabet Assoc. 1997 Apr;14(4):316–20. 13. IDF Diabetes Atlas Group. Update of mortality attributable to diabetes for the IDF Diabetes Atlas: estimates for the year 2011. Diabetes Res Clin Pract. 2013 May;100(2):277–9. 14. Roglic G, Unwin N, Bennett PH, Mathers C, Tuomilehto J, Nag S, et al. The Burden of Mortality Attributable to Diabetes Realistic estimates for the year 2000. Diabetes Care. 2005 Sep 1;28(9):2130–5. 15. Diabetes Atlas, 3rd Edition. Brussels, Belgium: International Diabetes Federation; 2006. 16. WHO | World Health Statistics 2010 [Internet]. WHO. [cited 2014 Jun 24]. Available from: http://www.who.int/gho/publications/world_health_statistics/2010/en/ 17. Miettinen OS. Proportion of disease caused or prevented by a given exposure, trait or intervention. Am J Epidemiol. 1974 May;99(5):325–32. 18. 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 Dec;94(3):322–32. 19. Mbanya J-C, Ramiaya K. Diabetes Mellitus. In: Jamison DT, Feachem RG, Makgoba MW, Bos ER, Baingana FK, Hofman KJ, et al., editors. Disease and Mortality in Sub-Saharan Africa [Internet]. 2nd ed. Washington (DC): World Bank; 2006 [cited 2014 Jun 26]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK2291/ 20. Tunstall-Pedoe H, Kuulasmaa K, Mähönen M, Tolonen H, Ruokokoski E, Amouyel P. Contribution of trends in survival and coronary-event rates to changes in coronary heart disease mortality: 10-year results from 37 WHO MONICA project populations. Monitoring trends and determinants in cardiovascular disease. Lancet. 1999 May 8;353(9164):1547–57. 21. United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects The 2012 Revision [Internet]. 2013. Available from: http://esa.un.org/wpp/Documentation/pdf/WPP2012_%20KEY%20FINDINGS.pdf 22. Colagiuri S, Borch-Johnsen K, Glümer C, Vistisen D. There really is an epidemic of type 2 diabetes. Diabetologia. 2005 Aug;48(8):1459–63.
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23. Fuller JH. Mortality trends and causes of death in diabetic patients. Diabète Métabolisme. 1993;19(1 Pt 2):96–9.
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Table 1. Age and sex-specific relative risks of death used to estimate the proportion of all deaths attributable to diabetes 2
Age group
Males
Females
Males
Females
20-29
3.66
6.05
3.40
30-39
3.38
5.41
3.50
40-49
1.85
3.14
2.60
50-59
1.63
2.64
2.30
60-69
1.60
2.04
1.60
70-79
1.39
1.79
1.50
5.12
us
DECODE Study
3
DECODA Study [All] Males
Females
3.70
M an
1
DECODA Study [Indians in Mauritius and Fiji]
4
Taiwan Study Males
Females
5
NHANES Males
Females
5.95
5.42
4.68
3.08
3.20
4.98
3.30
5.61
5.26
4.64
4.60
3.10
3.65
1.95
3.41
4.24
4.25
2.80
2.80
3.29
1.65
2.73
3.02
3.44
2.00
2.60
2.51
1.62
2.08
2.22
2.58
1.65
2.10
2.42
1.40
1.78
1.46
1.61
1.40
1.60
Used for Europe, Australia and New Zealand
2
Used for South Asia
3
Used for Africa and Eastern Mediterranean
4
Used for Western Pacific (except Australia and New Zealand)
5
Used for North and South America and the Caribbean
Ac
ce pt
ed
1
Page 10 of 14
ip t
IDF Region
Africa
522,631
Middle East and North Africa
367,699
8.6
13.2
North America and the Caribbean
South-East Asia
World total
10.2
13.5
226,371
11.6
1,200,001
14.2
1,868,811
15.8
Ac
Western Pacific
ce pt
South and Central America
292,895
ed
Europe 619,847
Percentage of all-cause deaths attributable to diabetes in age group 20-79 years
M an
Number of deaths attributable to diabetes in age group 20-79 years
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Table 2 Number of deaths attributable to diabetes in the age group 20-79 years in the year 2013
5,096,955
8.4%
Page 11 of 14
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Table 3 a. Number of male deaths attributable to diabetes in the year 2013 and its percentage of all-cause mortality by age group and IDF Region
20-29
30-39
20,918(5.5) Africa
40-49
50-59
60-69
70-79
34,405(5.9)
33,111(5.9)
37,628(6.5)
23,054(4.3)
M an
IDF Region
us
Age group [years]
49,469(8.4)
7,169(4.7)
16,766(11.1)
18,960(10.2)
31,165(10.6)
41,347(11.2)
30,391(6.9)
2,330(1.7)
11,805(5.3)
19,718(5.2)
55,011(7.4)
94,437(10.2)
107,057(8.2)
1,868(3.6)
8,881(14.3)
17,983(15.5)
33,483(14.5)
45,622(12.9)
41,856(9.5)
2,693(2.6)
12,525(11.9)
17,986(13.4)
27,151(12.9)
32,806(11.6)
27,899(8.1)
10,249(2.9)
49,893(11.3)
102,252(16.8)
179,649(19.1)
113,938(9.5)
63,550(5.2)
22,428(7.6)
54,037(15.6)
162,281(22.5)
285,677(22.6)
352,255(18.0)
203,275(8.0)
67,654.83
203,347.61
373,505.47
644,957.00
717,525.07
496,687.88
ed
Middle East and North Africa
Europe
and
the
ce pt
North America Caribbean
South-East Asia
Ac
South and Central America
Western Pacific
World total
Page 12 of 14
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Table 3 b. Number of female deaths attributable to diabetes in the year 2013 and its percentage of all-cause mortality by age group and IDF
M an
Region
Age group [years]
IDF Region
20-29
30-39
40-49
50-59
60-69
70-79
45,843(9.6)
98,548(14.4)
64,529(12.9)
52,451(12.8)
37,171(8.2)
25,505(5.2)
8,796(8.7)
24,848(22.9)
28,604(22.0)
49,308(24.8)
54,916(20.0)
55,429(14.5)
1,588(3.9)
12,099(16.2)
16,808(11.1)
55,421(15.6)
80,638(14.4)
162,935(13.4)
836(4.1)
4,303(13.1)
11,455(15.8)
31,452(20.9)
49,271(18.6)
45,885(12.3)
913(3.0)
4,483(10.1)
10,041(13.2)
24,178(18.3)
33,797(16.9)
31,899(10.8)
17,687(5.9)
65,052(22.2)
79,819(21.0)
156,951(25.7)
177,604(19.6)
183,356(15.7)
5,661(3.9)
38,959(18.0)
85,679(18.8)
173,055(23.1)
259,987(21.9)
225,516(11.4)
81,324.82
248,292.29
296,933.73
542,816.06
693,383.78
730,526.68
Middle East and North Africa
North America and the Caribbean
ce pt
Europe
ed
Africa
South-East Asia Western Pacific World total
Ac
South and Central America
Page 13 of 14
ip t
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Table 4. Sensitivity analysis where the number of deaths attributable to diabetes in the year 2013 and % of deaths attributable to diabetes in
us
age group 20-79 years, if the true relative risk of dying was 20% lower and 20% higher than estimated in the cohort studies
Relative risk 20% higher Number of deaths (% of all deaths in age group 20-79 years)
Africa
353,631 (5.7)
676,871 (11.1)
Middle East and North Africa
226,861 (8.1)
Europe
338,752 (5.6)
North America and the Caribbean
South-East Asia
Western Pacific
ed
486,257 (17.4)
860,327 (14.1)
171,006 (7.9)
397,742 (18.4)
119,254 (6.1)
314,266 (16.1)
Ac
South and Central America
ce pt
IDF Region
M an
Relative risk 20% lower Number of deaths (% of all deaths in age group 20-79 years)
829,846.13 (9.8)
1,517,305 (18.0)
1,263,889 (10.7)
2,382,916 (20.1)
Page 14 of 14
S0168-8227(15)00267-3 http://dx.doi.org/doi:10.1016/j.diabres.2015.05.037 DIAB 6413
To appear in:
Diabetes Research and Clinical Practice
Received date: Accepted date:
12-5-2015 12-5-2015
Please cite this article as: IDF Diabetes Atlas Group, Update of mortality attributable to diabetes for the IDF Diabetes Atlas: estimates for the year 2013, Diabetes Research and Clinical Practice (2015), http://dx.doi.org/10.1016/j.diabres.2015.05.037 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. 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.
Update of mortality attributable to diabetes for the IDF Diabetes Atlas:
Ac ce p
te
d
M
an
us
Correspondence to: [email protected]
cr
IDF Diabetes Atlas Group
ip t
estimates for the year 2013
Page 1 of 14
Abstract
ip t
Background Mortality is an important measure of population health and is often used to assign priorities in health interventions. Estimating mortality due to diabetes has been challenging because more than a third of countries of the world have no reliable data available on mortality. Moreover estimating mortality attributable to Diabetes is especially challenging since most people die of a related vascular complication such as cardiovascular disease or renal failure.
us
cr
Aims The aim of the study was to provide estimate of the number of deaths attributable to diabetes for the year 2013.
M
an
Methods A computerized disease model was used to obtain the estimates. Using WHO life tables for 2010 and IDF diabetes prevalence estimates for 2013, age and sex-specific relative risks of death for persons with diabetes were calculated, in order to estimate the number of deaths attributable to diabetes in people 20-79 years of age.
Ac ce p
te
d
Results This model estimated that globally, 8.4% of all-cause deaths were attributable to diabetes in adults aged 20-79 years, almost 5.1 million deaths. A sensitivity analysis adjusting relative risks by 20% found that the estimate of diabetes-attributable mortality to lie between 5.1% of total mortality (3.3 million deaths) and 10.1% of total mortality (6.6 million deaths). The highest rates of diabetes-attributable mortality were found to be 25.7% in South-East Asian women aged between 50-59 years old. The highest number of deaths attributable to diabetes was found in countries with large populations: 1,271,000 in China, 1,065,000 deaths in India, 386,400 in Indonesia, 197,300 in the Russian Federation and 192,700 in the United States of America. Conclusions Overall, 1 in 12 of global all-cause deaths were estimated to be attributable to diabetes in adults. In general, the number and proportion of deaths was slightly higher in women than in men.
Page 2 of 14
Introduction In 2013, the International Diabetes Federation (IDF) estimated that over 8.3% of the adult population aged between 20 and 79 had diabetes, with 46% of these undiagnosed (1–3). Diabetes is associated with multiple complications (including for example cardiovascular disease, kidney
ip t
disease, eye disease, nerve damage, lower limb amputation, and pregnancy complications) and is
cr
also associated with an increased risk of dying (4–6).
Mortality is one of the key measures for understanding the burden of a disease and its
us
progression. Mortality estimates are also important for the allocation of resources in public health. However, vital registration systems to report cause-specific mortality are often lacking.
an
Itis an especially challenging to estimate true mortality of diabetes since most people die of a related complication such as cardiovascular disease or renal failure (7). As a result, diabetes is often not listed as the underlying cause of death and is consistently underestimated in routine
M
health statistics (8). However, it has been shown that people with diabetes have a higher
d
mortality compared to people without diabetes (9–12).
te
A methodology has been developed using a modelling approach, the DisModII, to provide a more realistic estimate of the burden of attributable mortality to diabetes (13–15). This report
Ac ce p
uses this methodology to update estimates for the year 2013 using new studies on the prevalence of diabetes (2).
Methods
The methods to derive these estimates have been described by Roglic and Unwin (13). Briefly, the number of deaths attributable to diabetes uses the following inputs: World Health Organization (WHO) life tables for 2010 (16) for the expected number of deaths; countryspecific diabetes prevalence by age and sex for the year 2013 (1); and age and sex-specific relative risks of death for persons with diabetes compared to those without diabetes as used in the previous publication (2,13). These inputs were used to model the estimates using DisModII, a programme developed for the Global Burden of Disease study from 2000 and then Miettinen’s formula for the population-attributable fraction was used to calculate the number of deaths attributable to diabetes in people 20-79 years of age (17).
Page 3 of 14
The uncertainty in estimates of relative risks is usually expressed by measures such as the 95% confidence interval. However, such measures of uncertainty are not always available from the published reports of the cohort studies from which the relative risks are derived. In order to
ip t
reflect the uncertainty in the relative risk estimates, sensitivity analyses were conducted
assuming that the true relative risks were 20% lower and 20% higher than those found in each
cr
cohort study. A 20% increase for a relative risk of 2.0 would result in a relative risk of 2.4 and a 20% decrease in a relative risk of 1.6. The relative risks used for these estimates in each region
us
are shown in Table 1. The allocation of countries to regions is described in Guariguata et al (18). (Table 1)
an
Results
It was estimated that almost 5.1 million deaths in 2013 could be attributed to diabetes, or 8.4% of global all-cause mortality among adults (20-79 years) (Table 2). The number and proportion of
M
deaths was also higher in women than in men (Tables 3a and 3b).
d
A sensitivity analysis was conducted to calculate the number of deaths attributable to diabetes if the relative risks of dying were assumed to be 20% lower and 20% higher than what was
te
estimated in the cohort studies. With these assumptions the global proportion of deaths
Ac ce p
attributable to diabetes ranged from 5.1% (3.3 million deaths) to 10.1% (6.6 million deaths) (Table 4).
In the age group 20-79 years the percentage of deaths attributable to diabetes ranged from 15.8% in the Western Pacific Region to 8.6% in the African Region (Table 2). The number and proportion of deaths reached up to a quarter of all deaths in middle-aged women in some regions. For example, in the South-East Asian region, 19.1% of all-cause mortality in 50-59 year old men and 25.7% of all-cause mortality in 50-59 year old women was attributable to diabetes (Tables 3a and 3b). The prevalence of diabetes in the South-East Asian region is estimated to be 21.6% in 50-59 year old men and 14.9% in 50-59 year old women (1). The lower rate of 8.6% of diabetesattributable mortality in Africa is in part associated with the relatively lower age-adjusted prevalence (5.7%) of diabetes in adults aged 20-79 this region, and in part due to the relatively high rates of mortality due to communicable diseases (19).
Page 4 of 14
The highest number of deaths attributable to diabetes was found in countries with large populations: 1,271,000 in China, 1,065,000 in India, 386,400 in Indonesia, 197,300 in the Russian Federation and 192,700 in the United States of America. This is partially due to the fact
ip t
that countries with large populations also contain the highest number of people with diabetes (2).
cr
Discussion
While there has been a documented decline in the morbidity and mortality of some non-
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communicable diseases in developing and developed countries (20), no such decline has been reported for diabetes (1). The global population of adults increased by 4.5% between 2011 and
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2013(21), while estimates of the number of deaths attributable to diabetes have increased by 10.8% over the same period, using the same methods and incorporating new estimates of prevalence (13). This increase in mortality is likely associated with increased incidence in low
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and middle income countries, offset slightly by improved survival of people with diabetes in
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high income countries (22).
Diabetes contributes substantially to premature adult mortality and close to half of all deaths
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occur in people under the age of 60 (1). A substantial proportion of these premature deaths are
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potentially preventable through public health action directed at prevention of diabetes, early detection, and improvement of care for all people with established diabetes to prevent premature mortality (25). The targets adopted by WHO member states in 2013 reflect their commitment to reducing mortality due to major NCDs by 25% by the year 2025 by reducing risk factors and improving access to essential treatment and technologies (26).
Obtaining accurate estimates of mortality attributable to diabetes with currently available data is difficult, and any attempt will be based on a set of assumptions. Age and sex-specific relative risks of death for persons with diabetes compared to those without diabetes have been derived from a small number of studies, the data of which could be out of date. Future estimates of mortality attributable to diabetes will use data from more recent population-based mortality follow-up studies wherever possible. However, it is highly plausible that the figures presented here are closer to the truth than estimates derived from routine sources of health statistics which
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systematically underestimate the burden of mortality due to diabetes (23).
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Conflict of Interest The members of the IDF Diabetes Atlas Group state that they have no conflicts of interest.
Funding
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The IDF Diabetes Atlas was supported by the following sponsors: Lilly Diabetes, Merck and Co, Inc., Novo Nordisk A/S supported through an unrestricted grant by the Novo Nordisk Changing
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Diabetes initiative, Pfizer, Inc. and Sanofi Diabetes.
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References
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1. IDF Diabetes Atlas, 6th Ed. Brussels, Belgium: International Diabetes Federation; 2013. 2. Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract. 2014 Feb;103(2):137–49. 3. Beagley J, Guariguata L, Weil C, Motala AA. Global estimates of undiagnosed diabetes in adults. Diabetes Res Clin Pract. 2014 Feb;103(2):150–60. 4. Flores-Le Roux JA, Comin J, Pedro-Botet J, Benaiges D, Puig-de Dou J, Chillarón JJ, et al. Seven-year mortality in heart failure patients with undiagnosed diabetes: an observational study. Cardiovasc Diabetol. 2011;10:39. 5. Plantinga LC, Crews DC, Coresh J, Miller ER 3rd, Saran R, Yee J, et al. Prevalence of chronic kidney disease in US adults with undiagnosed diabetes or prediabetes. Clin J Am Soc Nephrol CJASN. 2010 Apr;5(4):673– 82. 6. Spijkerman AMW, Dekker JM, Nijpels G, Adriaanse MC, Kostense PJ, Ruwaard D, et al. Microvascular complications at time of diagnosis of type 2 diabetes are similar among diabetic patients detected by targeted screening and patients newly diagnosed in general practice: the hoorn screening study. Diabetes Care. 2003 Sep;26(9):2604–8. 7. Morrish NJ, Wang SL, Stevens LK, Fuller JH, Keen H. Mortality and causes of death in the WHO Multinational Study of Vascular Disease in Diabetes. Diabetologia. 2001 Sep;44 Suppl 2:S14–21. 8. Fuller JH, Elford J, Goldblatt P, Adelstein AM. Diabetes mortality: new light on an underestimated public health problem. Diabetologia. 1983 May;24(5):336–41. 9. Raymond NT, Langley JD, Goyder E, Botha JL, Burden AC, Hearnshaw JR. Insulin treated diabetes mellitus: causes of death determined from record linkage of population based registers in Leicestershire, UK. J Epidemiol Community Health. 1995 Dec;49(6):570–4. 10. Gu K, Cowie CC, Harris MI. Mortality in adults with and without diabetes in a national cohort of the U.S. population, 1971-1993. Diabetes Care. 1998 Jul;21(7):1138–45. 11. Koskinen SV, Reunanen AR, Martelin TP, Valkonen T. Mortality in a large population-based cohort of patients with drug-treated diabetes mellitus. Am J Public Health. 1998 May;88(5):765–70. 12. Gatling W, Tufail S, Mullee MA, Westacott TA, Hill RD. Mortality rates in diabetic patients from a community-based population compared to local age/sex matched controls. Diabet Med J Br Diabet Assoc. 1997 Apr;14(4):316–20. 13. IDF Diabetes Atlas Group. Update of mortality attributable to diabetes for the IDF Diabetes Atlas: estimates for the year 2011. Diabetes Res Clin Pract. 2013 May;100(2):277–9. 14. Roglic G, Unwin N, Bennett PH, Mathers C, Tuomilehto J, Nag S, et al. The Burden of Mortality Attributable to Diabetes Realistic estimates for the year 2000. Diabetes Care. 2005 Sep 1;28(9):2130–5. 15. Diabetes Atlas, 3rd Edition. Brussels, Belgium: International Diabetes Federation; 2006. 16. WHO | World Health Statistics 2010 [Internet]. WHO. [cited 2014 Jun 24]. Available from: http://www.who.int/gho/publications/world_health_statistics/2010/en/ 17. Miettinen OS. Proportion of disease caused or prevented by a given exposure, trait or intervention. Am J Epidemiol. 1974 May;99(5):325–32. 18. 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 Dec;94(3):322–32. 19. Mbanya J-C, Ramiaya K. Diabetes Mellitus. In: Jamison DT, Feachem RG, Makgoba MW, Bos ER, Baingana FK, Hofman KJ, et al., editors. Disease and Mortality in Sub-Saharan Africa [Internet]. 2nd ed. Washington (DC): World Bank; 2006 [cited 2014 Jun 26]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK2291/ 20. Tunstall-Pedoe H, Kuulasmaa K, Mähönen M, Tolonen H, Ruokokoski E, Amouyel P. Contribution of trends in survival and coronary-event rates to changes in coronary heart disease mortality: 10-year results from 37 WHO MONICA project populations. Monitoring trends and determinants in cardiovascular disease. Lancet. 1999 May 8;353(9164):1547–57. 21. United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects The 2012 Revision [Internet]. 2013. Available from: http://esa.un.org/wpp/Documentation/pdf/WPP2012_%20KEY%20FINDINGS.pdf 22. Colagiuri S, Borch-Johnsen K, Glümer C, Vistisen D. There really is an epidemic of type 2 diabetes. Diabetologia. 2005 Aug;48(8):1459–63.
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23. Fuller JH. Mortality trends and causes of death in diabetic patients. Diabète Métabolisme. 1993;19(1 Pt 2):96–9.
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Table 1. Age and sex-specific relative risks of death used to estimate the proportion of all deaths attributable to diabetes 2
Age group
Males
Females
Males
Females
20-29
3.66
6.05
3.40
30-39
3.38
5.41
3.50
40-49
1.85
3.14
2.60
50-59
1.63
2.64
2.30
60-69
1.60
2.04
1.60
70-79
1.39
1.79
1.50
5.12
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DECODE Study
3
DECODA Study [All] Males
Females
3.70
M an
1
DECODA Study [Indians in Mauritius and Fiji]
4
Taiwan Study Males
Females
5
NHANES Males
Females
5.95
5.42
4.68
3.08
3.20
4.98
3.30
5.61
5.26
4.64
4.60
3.10
3.65
1.95
3.41
4.24
4.25
2.80
2.80
3.29
1.65
2.73
3.02
3.44
2.00
2.60
2.51
1.62
2.08
2.22
2.58
1.65
2.10
2.42
1.40
1.78
1.46
1.61
1.40
1.60
Used for Europe, Australia and New Zealand
2
Used for South Asia
3
Used for Africa and Eastern Mediterranean
4
Used for Western Pacific (except Australia and New Zealand)
5
Used for North and South America and the Caribbean
Ac
ce pt
ed
1
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IDF Region
Africa
522,631
Middle East and North Africa
367,699
8.6
13.2
North America and the Caribbean
South-East Asia
World total
10.2
13.5
226,371
11.6
1,200,001
14.2
1,868,811
15.8
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Western Pacific
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South and Central America
292,895
ed
Europe 619,847
Percentage of all-cause deaths attributable to diabetes in age group 20-79 years
M an
Number of deaths attributable to diabetes in age group 20-79 years
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Table 2 Number of deaths attributable to diabetes in the age group 20-79 years in the year 2013
5,096,955
8.4%
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Table 3 a. Number of male deaths attributable to diabetes in the year 2013 and its percentage of all-cause mortality by age group and IDF Region
20-29
30-39
20,918(5.5) Africa
40-49
50-59
60-69
70-79
34,405(5.9)
33,111(5.9)
37,628(6.5)
23,054(4.3)
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IDF Region
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Age group [years]
49,469(8.4)
7,169(4.7)
16,766(11.1)
18,960(10.2)
31,165(10.6)
41,347(11.2)
30,391(6.9)
2,330(1.7)
11,805(5.3)
19,718(5.2)
55,011(7.4)
94,437(10.2)
107,057(8.2)
1,868(3.6)
8,881(14.3)
17,983(15.5)
33,483(14.5)
45,622(12.9)
41,856(9.5)
2,693(2.6)
12,525(11.9)
17,986(13.4)
27,151(12.9)
32,806(11.6)
27,899(8.1)
10,249(2.9)
49,893(11.3)
102,252(16.8)
179,649(19.1)
113,938(9.5)
63,550(5.2)
22,428(7.6)
54,037(15.6)
162,281(22.5)
285,677(22.6)
352,255(18.0)
203,275(8.0)
67,654.83
203,347.61
373,505.47
644,957.00
717,525.07
496,687.88
ed
Middle East and North Africa
Europe
and
the
ce pt
North America Caribbean
South-East Asia
Ac
South and Central America
Western Pacific
World total
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Table 3 b. Number of female deaths attributable to diabetes in the year 2013 and its percentage of all-cause mortality by age group and IDF
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Region
Age group [years]
IDF Region
20-29
30-39
40-49
50-59
60-69
70-79
45,843(9.6)
98,548(14.4)
64,529(12.9)
52,451(12.8)
37,171(8.2)
25,505(5.2)
8,796(8.7)
24,848(22.9)
28,604(22.0)
49,308(24.8)
54,916(20.0)
55,429(14.5)
1,588(3.9)
12,099(16.2)
16,808(11.1)
55,421(15.6)
80,638(14.4)
162,935(13.4)
836(4.1)
4,303(13.1)
11,455(15.8)
31,452(20.9)
49,271(18.6)
45,885(12.3)
913(3.0)
4,483(10.1)
10,041(13.2)
24,178(18.3)
33,797(16.9)
31,899(10.8)
17,687(5.9)
65,052(22.2)
79,819(21.0)
156,951(25.7)
177,604(19.6)
183,356(15.7)
5,661(3.9)
38,959(18.0)
85,679(18.8)
173,055(23.1)
259,987(21.9)
225,516(11.4)
81,324.82
248,292.29
296,933.73
542,816.06
693,383.78
730,526.68
Middle East and North Africa
North America and the Caribbean
ce pt
Europe
ed
Africa
South-East Asia Western Pacific World total
Ac
South and Central America
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Table 4. Sensitivity analysis where the number of deaths attributable to diabetes in the year 2013 and % of deaths attributable to diabetes in
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age group 20-79 years, if the true relative risk of dying was 20% lower and 20% higher than estimated in the cohort studies
Relative risk 20% higher Number of deaths (% of all deaths in age group 20-79 years)
Africa
353,631 (5.7)
676,871 (11.1)
Middle East and North Africa
226,861 (8.1)
Europe
338,752 (5.6)
North America and the Caribbean
South-East Asia
Western Pacific
ed
486,257 (17.4)
860,327 (14.1)
171,006 (7.9)
397,742 (18.4)
119,254 (6.1)
314,266 (16.1)
Ac
South and Central America
ce pt
IDF Region
M an
Relative risk 20% lower Number of deaths (% of all deaths in age group 20-79 years)
829,846.13 (9.8)
1,517,305 (18.0)
1,263,889 (10.7)
2,382,916 (20.1)
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