9 Diabetes

Burden, epidemiology and

priority interventions
Pascal Bovet, Isabelle Hagon-Traub, Jean Claude N Mbanya,
Nicholas J Wareham

Diabetes is one of the biggest challenges facing society in the 21st century. In
the past three decades the prevalence of type-2 diabetes (T2D), which is closely
related to obesity, has risen dramatically in almost all countries.1 A number of
interventions are available to control all forms of diabetes and for the preven-
tion of T2D.

Definitions
Diabetes mellitus is a chronic, metabolic disease characterized by elevated lev-
els of blood glucose. Over time the high glucose levels and the associated
metabolic disorders can lead to serious damage to the heart, blood vessels, eyes,
kidneys and nerves. The different types of diabetes and their characteristics are
shown in Box 9.1. Around 95% of all cases are T2D.

BOX 9.1 TYPES OF DIABETES (ADAPTED AND

SIMPLIFIED FROM THE WHO CLASSIFICATION)2
Type-1 diabetes (T1D). The immune system attacks and destroys the
cells in the pancreas that produces insulin. Persons with T1D must take
insulin every day to stay alive. Although T1D often develops at an early
age, T1D can appear at any age. There are no known measures to pre-
vent this form of diabetes. Without prompt diagnosis and treatment,
T1D is rapidly fatal. The incidence of T1D may be underestimated in
areas with deficient health services where deaths from T1D may go
unrecognized.
Type-2 diabetes (T2D). The body does not produce enough insulin
to maintain normal glucose levels. In nearly all cases of T2D, there is
‘insulin resistance’, meaning that the pancreas must produce increas-
ingly higher amounts of insulin to ‘force’ blood glucose to enter into
body cells. T2D and insulin resistance largely occur in response to

DOI: 10.4324/9781003306689-11
 Diabetes 67

increased adipose tissue. T2D develops most often in middle-aged and

older people but also increasingly in young adults and adolescents
who are overweight or obese.
Gestational diabetes. This form of diabetes develops during pregnancy
and disappears after giving birth. It appears in the second or third trimes-
ter and is more common in women with a high body mass index (BMI).
Gestational diabetes can affect the pregnancy for both the foetus and the
mother.Women with gestational diabetes have a greater risk of developing
T2D later in life. T1D and T2D can also be diagnosed during pregnancy.
Other causes of diabetes. Less common causes of diabetes include inher-
ited monogenic diabetes and disease of the pancreas (cystic fibrosis-related
diabetes, pancreatitis). Elevated levels of blood glucose can also be seen in
acute or chronic diseases.

Diagnosis of diabetes is based on one of the following:

• Fasting plasma glucose ≥7.0 mmol/l.

• Two-hour post-glucose-load plasma glucose ≥11.1 mmol/l after a 75 g oral
glucose tolerance test (variations are often used for gestational diabetes).
• HbA1c ≥48 mmol/mol (≥6.5%).
• A random blood glucose ≥11.1 mmol/l in the presence of signs and
symptoms.

Pre-diabetes is a term often used to describe moderately elevated levels of blood

glucose (but blood insulin level is generally already substantially increased), which
is associated with metabolic complications and a higher risk of progression to T2D.
Its prevalence in the population can be two or three times higher than that of
diabetes. There is no universally accepted definition of ‘pre-diabetes’ since the
attribution of the diagnostic label has different implications for preventive action in
different countries. Generally, it is based on one of the following criteria:

• Fasting plasma glucose ≥6.1 to <7.0 mmol/l according to WHO or ≥5.5

to <7.0 mmol/l according to the American Diabetic Association (ADA).
• Two-hour post-load plasma glucose ≥7.8 to <11.1 mmol/l after a 75 g oral
glucose tolerance test.
• HbA1c ≥42 to <48 mmol/mol (6.0–<6.5%) in most countries or 5.7–
6.4% according to ADA.

Disease burden
More than 500 million adults have diabetes, of whom 80% live in low- and
middle-income countries, in line with the larger proportion of people living
in these countries.3
68 Pascal Bovet et al.
Table 9.1 Mortality attributable to diabetes and high fasting blood glucose (IHME)

Global HICs Upper-MICs Lower-MICs LICs

1990 2019 1990 2019 1990 2019 1990 2019 1990 2019
Diabetes as a direct cause of death
Proportion of all 1.4 2.7 2.1 2.3 1.4 2.6 1.2 3.3 1.0 1.9
deaths (%)
Age-standardized 18 20 14 10 15 16 36 34 24 33
mortality rates
(per 100,000)
High blood glucose as a risk for
other diseases
Proportion of all 6.2 11.5 11.3 12.8 6.7 11.9 4.3 11.8 2.6 5.7
deaths (%)
Age-standardized 84 83 75 54 83 76 93 123 101 107
mortality rates
(per 100,000)

Diabetes was the direct (immediate) cause (e.g. diabetic renal disease, dia-
betic coma) of 0.7 million deaths (1.4%) in 1990 and 1.5 million, globally, in
2019 (2.7%) (Table 9.1, estimates from IHME). As a risk factor (e.g. high blood
glucose increases the risk of CVD by two to four times4), high blood glucose
(including moderately elevated glucose defining ‘pre-diabetes’) accounted for
6.5 million deaths (11.5% of all deaths in 2019 globally), an increase from 2.9
million in 1990. The percentage of deaths attributable to high blood glucose
increased in all regions between 1990 and 2019, with a steeper increase in
low- and middle-income countries, a twofold increase, than in high-income
countries (HICs), partly owing to aging populations. The age-standardized
mortality rates attributable to high blood glucose (which are not influenced
by the age distribution of the populations compared) were lower in HICs
and upper-middle-income countries (where rates decreased over time) than in
low- and middle-income countries (where rates increased), partly reflecting a
steeper increase in the prevalence of T2D and poorer blood glucose control in
low- and middle-income countries than HICs.5
According to IHME, the following proportions of T2D mortality were
attributable to modifiable risk factors globally in 2019: increased body mass
index 42%, dietary risks (low fruit, high red/processed meat, low whole grain,
high sugar-sweetened drinks) 26%, ambient and household air pollution 20%,
tobacco use 16%, low physical activity 8%.

Consequences of diabetes
Very high blood glucose concentration results in acute symptoms of polyuria
(excessive urination), thirst, loss of weight, hunger and tiredness, the classic
way that those with T1D first present. If T1D is untreated, diabetic ketoacido-
sis, coma and death follow.
 Diabetes 69
Over many years, elevated blood glucose in T1D and T2D affects the inner
linings of both large (macrovascular damage) and small arteries (microvascu-
lar damage). Microvascular damage can result in blindness and kidney failure
and destroys the sensory nerves, particularly in the lower limbs, which makes
injury a major risk. Healing of injuries and wounds is less effective in patients
with diabetes, and this, coupled with vascular impairment, can lead to ulcera-
tion and persistent infection which may require amputation. Macrovascular
complications of diabetes include ischaemic heart disease (IHD), stroke and
peripheral arterial disease. Diabetes is also associated with increased susceptibil-
ity to infections and more serious complications from infections.6

Diabetogenic environment
This concept of a diabetogenic environment is essentially the same as that for
the obesogenic environment described in Chapter 10 on obesity. This has
resulted in the current high and increasing levels in nearly all countries of
‘diabesity’, the combined ‘epidemic’ of obesity and T2D.

Interventions at the population level

Tackling the diabetogenic environment requires the same sorts of macro-pol-
icy interventions across multiple sectors as described for the obesogenic envi-
ronment (Chapter 10, Box 3). Tackling the diabetogenic environment also
requires behaviour change at scale as well as whole-of-government (e.g. legal,
fiscal and regulatory policies to address the commercial determinants of NCDs)
and whole-of-society (e.g. civil society and the private sector) actions. These
issues are considered in more detail in other chapters.

Screening
Although it is unclear if systematic testing of blood glucose in the entire popu-
lation is cost-effective,7 opportunistic testing of high-risk individuals has been
shown to be cost-effective in some settings for detecting diabetes and pre-dia-
betes and reducing their associated disease burden,8 and, for example, the US
Preventive Services Task Force recommends that overweight or obese adults
aged 35–70 years are screened for diabetes and pre-diabetes.9

Interventions at the individual level

Risk factor reduction. Weight control is central to the management of T2D and
pre-diabetes.10 For diabetic patients who are overweight or obese, intensive
weight management (e.g. loss of >10 kg) markedly improves blood glucose and
associated metabolic risk factors11 and can even result in remission to a non-
diabetic state in a significant proportion of patients.12 Interventions targeting
weight control at the individual level are described in Chapter 10 on obesity,
70 Pascal Bovet et al.
including the extreme but highly effective ‘bariatric surgery’.13 Encouraging
physical activity, quitting smoking and reducing alcohol consumption are also
important. WHO best buys include advice on healthy lifestyles and medical
treatment of risk factors among individuals with high CVD risk.
Pharmacologic treatment for T1D. Insulin is the cornerstone of treatment.
However, insulin is not sufficiently available or affordable in many settings,
resulting in an increased risk of death. Good glycaemic control can be achieved
with fastidious attention to insulin dosing and tight monitoring of blood glu-
cose (including self-monitoring). Newer biosimilar products (insulin analogues,
such as glargine which is included in the WHO Essential Medicines List) may
help achieve tighter glycaemic control but at a much higher cost.14,15 Newer
devices, ranging from fairly inexpensive pens that make injections easier, to
complex and very expensive automated insulin delivery systems, are increas-
ingly available to support patients in strengthening their ability to monitor and
control blood glucose levels more effectively.16
Pharmacologic treatment for T2D. Metformin is inexpensive and is the drug
of first-choice. Sulphonylureas, at least first generations, are no longer rec-
ommended as a first–line agent since they may cause weight gain. Insulin is
often required when oral hypoglycaemic medications cannot reduce blood
glucose sufficiently. However, insulin often increases body weight, which fur-
ther increases insulin resistance. This highlights the opportunity that comes
from newer treatments which, like metformin, reduce blood glucose but also
impact favourably on body weight and prevent diabetes complications. GLP-1
analogues (glucagon-like peptide-1 receptor agonists, e.g. semaglutide, exena-
tide) reduce satiety (and thus lower body weight) and also reduce CVD risk.
SGLT-2 inhibitors (sodium-glucose cotransporter-2 inhibitor, e.g. gliflozins)
slow chronic kidney disease progression and reduce heart failure and CVD
risk.17,18 These treatments can be even more effective than insulin, and some
of them also have the advantage of requiring less frequent administration.19
Although expensive, their costs are decreasing, making them increasingly
cost-effective, even in low- and middle-income countries.20 As many patients
with T2D have comorbidities, and given that diabetes is a strong risk factor
for developing CVD, additional drugs, for example, to control BP and lower
blood cholesterol, are most often also required21 (see Chapters 6 on CVD, 36
on high-risk approaches and 20 on cholesterol). Guidelines and protocols for
the management of T2D are widely available.22,23,24

Follow-up
Patients with diabetes need to be able to access care to prevent and manage
acute and long-term complications. Hypoglycaemia (often a result of treatment)
and hyperglycaemia (which can result from insufficient treatment, changes in
diet or levels of physical activity or acute infection) can be life-threatening, so
patients and those around them should be able to recognize hypo- or hypergly-
caemic emergencies and how to manage these situations should be managed.
 Diabetes 71
Patients should be supported to be assiduous in monitoring their blood glu-
cose (including self-monitoring), regularly examining and examining their skin
and feet, and using suitable footwear and bedding. Follow-up also involves dil-
igent and rigorous long-term monitoring for: (i) eye disease (retinopathy, cata-
ract and glaucoma), which should be done every two years at a minimum; (ii)
kidney disease (through annual assessment, including measurement of serum
creatinine and albuminuria); (iii) diabetic neuropathy (through annual assess-
ment); and (iv) long-term macrovascular complications (IHD, cerebrovascular
disease and peripheral vascular disease), which includes regular assessment and
treatment of BP, blood lipids, smoking cessation and daily acetylsalicylic acid
for patients who have had a CVD event and no history of major bleeding.
Patient support groups are an important source of advice and support.

The importance of strong health services and systems

Effective long-term care requires partnerships between patients and multi-
ple healthcare professionals, with both taking responsibility for managing the
disease. As with all NCDs, optimal long-term care for patients with diabetes
requires strong health services and systems (Chapter 42). However, evidence-
based care for people with diabetes is sub-optimal in all countries, even the
most well-off countries.25 In addition, half of all adults across the world with
T2D are undiagnosed, and large proportions of those diagnosed are untreated
or insufficiently treated,26 and these proportions are much higher in low- and
middle-income countries.27 Continuing lack of access to effective care, par-
ticularly access to insulin, highlights a range of deep systemic issues, includ-
ing that: (i) three multinational companies control over 95% of the global
insulin supply, although the inclusion of insulin in the WHO Prequalification
of Medicines Programme is an opportunity to facilitate entry of new com-
panies into the market; (ii) many governments lack policies on the selection,
procurement, supply, pricing and reimbursement of insulin; (iii) mark-ups in
the supply chain affect the final price to the consumer; (iv) expenses related
to diabetes often require out of pocket payments; and (v) the organization of
diabetes management within the healthcare system often affects patient access
to insulin.28

Targets and indicators in the WHO Global NCD Action Plan

Target To halt the rise in diabetes and obesity between 2010 and 2025.
(Combining diabetes and obesity into one target emphasizes the strong
relationship between the two).
Indicators Age-standardized prevalence of overweight and obesity in persons aged
18+ years (respectively BMI ≥25 kg and ≥30 kg/m²).
Prevalence of overweight and obesity in adolescents (defined according
to the WHO growth reference for children and adolescents).
72 Pascal Bovet et al.
Monitoring
Examination population surveys are useful to estimate the proportion of the
population with diabetes/pre-diabetes and the proportion of those who are
treated and adequately controlled. Indicators at health care level are also useful,
including the proportion of patients treated/controlled for blood glucose, BP
and blood lipids, frequency of exams to assess complications (e.g. eye, kidney
or foot), and broader indicators, such as the presence and use of diabetes pro-
tocols, monitoring systems and availability of medicines.
In 2021, WHO launched the Global Diabetes Compact,29 an initiative
to bring partners together to improve access to equitable, comprehensive,
affordable and quality treatment and care, as well as to support the preven-
tion of T2D. The initiative also sets priority metrics and targets to serve as
diabetes-related health objectives for all countries of the world to achieve
by 2030.30

Notes
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6 Casqueiro J et al. Infections in patients with diabetes mellitus: a review of pathogenesis.
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7 Herman WH et al. Early detection and treatment of type 2 diabetes reduce cardiovas-
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domised trial. Lancet Diabetes Endocrinol 2019;7:344–55.
13 Kirwan JP et al. Diabetes remission in the alliance of randomized trials of medicine ver-
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phase 3 SURPASS-3 trial. Lancet Diabetes Endocrinol 2022;10:407–17.
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21 Joseph JJ et al. Comprehensive management of cardiovascular risk factors for adults with
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22 Chatterjee S et al. Type 2 diabetes. Lancet 2017;389:2239–51.
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26 Manne-Goehler J et al. Health system performance for people with diabetes in 28 low-
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27 Basu S et al. Estimation of global insulin use for type 2 diabetes, 2018–30: a microsimula-
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29 The Global Diabetes Compact. WHO, 2021.
30 Reducing the burden of noncommunicable diseases through strengthen in prevention
and control of diabetes. WHO, 2021.