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Update of mortality attributable to diabetes for the IDF Diabetes Atlas: Estimates for the year 2013

      Abstract

      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.

      Aims

      The aim of the study was to provide estimate of the number of deaths attributable to diabetes for the year 2013.

      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.

      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 and 59 years old. The highest number of deaths attributable to diabetes was found in countries with large populations: 1271,000 in China, 1065,000 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.

      Keyword

      1. 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 [

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

      ,
      • Guariguata L.
      • Whiting D.R.
      • Hambleton I.
      • Beagley J.
      • Linnenkamp U.
      • Shaw J.E.
      Global estimates of diabetes prevalence for 2013 and projections for 2035.
      ,
      • Beagley J.
      • Guariguata L.
      • Weil C.
      • Motala A.A.
      Global estimates of undiagnosed diabetes in adults.
      ]. Diabetes is associated with multiple complications (including for example cardiovascular disease, kidney disease, eye disease, nerve damage, lower limb amputation, and pregnancy complications) and is also associated with an increased risk of dying [
      • Flores-Le Roux J.A.
      • Comin J.
      • Pedro-Botet J.
      • Benaiges D.
      • Puig-de Dou J.
      • Chillarón J.J.
      • et al.
      Seven-year mortality in heart failure patients with undiagnosed diabetes: an observational study.
      ,
      • Plantinga L.C.
      • Crews D.C.
      • Coresh J.
      • Miller 3rd, E.R.
      • Saran R.
      • Yee J.
      • et al.
      Prevalence of chronic kidney disease in US adults with undiagnosed diabetes or prediabetes.
      ,
      • Spijkerman A.M.W.
      • Dekker J.M.
      • Nijpels G.
      • Adriaanse M.C.
      • Kostense P.J.
      • 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.
      ].
      Mortality is one of the key measures for understanding the burden of a disease and its 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. It is an especially challenging to estimate true mortality of diabetes since most people die of a related complication such as cardiovascular disease or renal failure [
      • Morrish N.J.
      • Wang S.L.
      • Stevens L.K.
      • Fuller J.H.
      • Keen H.
      Mortality and causes of death in the WHO multinational study of vascular disease in diabetes.
      ]. As a result, diabetes is often not listed as the underlying cause of death and is consistently underestimated in routine health statistics [
      • Fuller J.H.
      • Elford J.
      • Goldblatt P.
      • Adelstein A.M.
      Diabetes mortality: new light on an underestimated public health problem.
      ]. However, it has been shown that people with diabetes have a higher mortality compared to people without diabetes [
      • Raymond N.T.
      • Langley J.D.
      • Goyder E.
      • Botha J.L.
      • Burden A.C.
      • Hearnshaw J.R.
      Insulin treated diabetes mellitus: causes of death determined from record linkage of population based registers in Leicestershire, UK.
      ,
      • Gu K.
      • Cowie C.C.
      • Harris M.I.
      Mortality in adults with and without diabetes in a national cohort of the U.S. population, 1971–1993.
      ,
      • Koskinen S.V.
      • Reunanen A.R.
      • Martelin T.P.
      • Valkonen T.
      Mortality in a large population-based cohort of patients with drug-treated diabetes mellitus.
      ,
      • Gatling W.
      • Tufail S.
      • Mullee M.A.
      • Westacott T.A.
      • Hill R.D.
      Mortality rates in diabetic patients from a community-based population compared to local age/sex matched controls.
      ].
      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 [
      • IDF Diabetes Atlas Group
      Update of mortality attributable to diabetes for the IDF diabetes atlas: estimates for the year 2011.
      ,
      • Roglic G.
      • Unwin N.
      • Bennett P.H.
      • Mathers C.
      • Tuomilehto J.
      • Nag S.
      • et al.
      The burden of mortality attributable to diabetes realistic estimates for the year 2000.
      ,

      Diabetes Atlas, 3rd Edition. Brussels, Belgium: International Diabetes Federation; 2006.

      ]. This report uses this methodology to update estimates for the year 2013 using new studies on the prevalence of diabetes [
      • Guariguata L.
      • Whiting D.R.
      • Hambleton I.
      • Beagley J.
      • Linnenkamp U.
      • Shaw J.E.
      Global estimates of diabetes prevalence for 2013 and projections for 2035.
      ].

      2. Methods

      The methods to derive these estimates have been described by Roglic and Unwin [
      • IDF Diabetes Atlas Group
      Update of mortality attributable to diabetes for the IDF diabetes atlas: estimates for the year 2011.
      ]. Briefly, the number of deaths attributable to diabetes uses the following inputs: World Health Organization (WHO) life tables for 2010 [
      • WHO
      World Health statistics 2010.
      ] for the expected number of deaths; country-specific diabetes prevalence by age and sex for the year 2013 [

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

      ]; and age and sex-specific relative risks of death for persons with diabetes compared to those without diabetes as used in the previous publication [
      • Guariguata L.
      • Whiting D.R.
      • Hambleton I.
      • Beagley J.
      • Linnenkamp U.
      • Shaw J.E.
      Global estimates of diabetes prevalence for 2013 and projections for 2035.
      ,
      • IDF Diabetes Atlas Group
      Update of mortality attributable to diabetes for the IDF diabetes atlas: estimates for the year 2011.
      ]. 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 [
      • Miettinen O.S.
      Proportion of disease caused or prevented by a given exposure, trait or intervention.
      ].
      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 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 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 are shown in Table 1. The allocation of countries to regions is described in Guariguata et al. [
      • 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.
      ].
      Table 1Age and sex-specific relative risks of death used to estimate the proportion of all deaths attributable to diabetes.
      DECODE study
      Used for Europe, Australia and New Zealand.
      DECODA study
      Used for South Asia.
      [Indians in Mauritius and Fiji]
      DECODA study
      Used for Africa and Eastern Mediterranean.
      [All]
      Taiwan study
      Used for Western Pacific (except Australia and New Zealand).
      NHANES
      Used for North and South America and the Caribbean.
      Age groupMalesFemalesMalesFemalesMalesFemalesMalesFemalesMalesFemales
      20–293.666.053.405.123.705.955.424.683.083.20
      30–393.385.413.504.983.305.615.264.644.603.10
      40–491.853.142.603.651.953.414.244.252.802.80
      50–591.632.642.303.291.652.733.023.442.002.60
      60–691.602.041.602.511.622.082.222.581.652.10
      70–791.391.791.502.421.401.781.461.611.401.60
      a Used for Europe, Australia and New Zealand.
      b Used for South Asia.
      c Used for Africa and Eastern Mediterranean.
      d Used for Western Pacific (except Australia and New Zealand).
      e Used for North and South America and the Caribbean.

      3. 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 deaths was also higher in women than in men (Table 3a, Table 3b).
      Table 2Number of deaths attributable to diabetes in the age group 20–79 years in the year 2013.
      IDF regionNumber of deaths attributable to diabetes in age group 20–79 yearsPercentage of all-cause deaths attributable to diabetes in age group 20–79 years
      Africa522,6318.6
      Middle East and North Africa367,69913.2
      Europe619,84710.2
      North America and the Caribbean292,89513.5
      South and Central America226,37111.6
      South-East Asia1200,00114.2
      Western Pacific1868,81115.8
      World total5096,9558.4%
      Table 3aNumber of male deaths attributable to diabetes in the year 2013 and its percentage of all-cause mortality by age group and IDF region.
      Age group [years]
      IDF region20–2930–3940–4950–5960–6970–79
      Africa20,918 (5.5)49,469 (8.4)34,405 (5.9)33,111 (5.9)37,628 (6.5)23,054 (4.3)
      Middle East and North Africa7169 (4.7)16,766 (11.1)18,960 (10.2)31,165 (10.6)41,347 (11.2)30,391 (6.9)
      Europe2330 (1.7)11,805 (5.3)19,718 (5.2)55,011 (7.4)94,437 (10.2)107,057 (8.2)
      North America and the Caribbean1868 (3.6)8881 (14.3)17,983 (15.5)33,483 (14.5)45,622 (12.9)41,856 (9.5)
      South and Central America2693 (2.6)12,525 (11.9)17,986 (13.4)27,151 (12.9)32,806 (11.6)27,899 (8.1)
      South-East Asia10,249 (2.9)49,893 (11.3)102,252 (16.8)179,649 (19.1)113,938 (9.5)63,550 (5.2)
      Western Pacific22,428 (7.6)54,037 (15.6)162,281 (22.5)285,677 (22.6)352,255 (18.0)203,275 (8.0)
      World total67,654.83203,347.61373,505.47644,957.00717,525.07496,687.88
      Table 3bNumber of female deaths attributable to diabetes in the year 2013 and its percentage of all-cause mortality by age group and IDF Region.
      Age group [years]
      IDF region20–2930–3940–4950–5960–6970-79
      Africa45,843 (9.6)98,548 (14.4)64,529 (12.9)52,451 (12.8)37,171 (8.2)25,505 (5.2)
      Middle East and North Africa8796 (8.7)24,848 (22.9)28,604 (22.0)49,308 (24.8)54,916 (20.0)55,429 (14.5)
      Europe1588 (3.9)12,099 (16.2)16,808 (11.1)55,421 (15.6)80,638 (14.4)162,935 (13.4)
      North America and the Caribbean836 (4.1)4303 (13.1)11,455 (15.8)31,452 (20.9)49,271 (18.6)45,885 (12.3)
      South and Central America913 (3.0)4483 (10.1)10,041 (13.2)24,178 (18.3)33,797 (16.9)31,899 (10.8)
      South-East Asia17,687 (5.9)65,052 (22.2)79,819 (21.0)156,951 (25.7)177,604 (19.6)183,356 (15.7)
      Western Pacific5661 (3.9)38,959 (18.0)85,679 (18.8)173,055 (23.1)259,987 (21.9)225,516 (11.4)
      World total81,324.82248,292.29296,933.73542,816.06693,383.78730,526.68
      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 estimated in the cohort studies. With these assumptions the global proportion of deaths attributable to diabetes ranged from 5.1% (3.3 million deaths) to 10.1% (6.6 million deaths) (Table 4).
      Table 4Sensitivity analysis where the number of deaths attributable to diabetes in the year 2013 and % of deaths attributable to diabetes in age group 20–79 years, if the true relative risk of dying was 20% lower and 20% higher than estimated in the cohort studies.
      IDF regionRelative risk 20% lower

      Number of deaths (% of all deaths in age group 20–79 years)
      Relative risk 20% higher

      Number of deaths (% of all deaths in age group 20–79 years)
      Africa353,631 (5.7)676,871 (11.1)
      Middle East and North Africa226,861 (8.1)486,257 (17.4)
      Europe338,752 (5.6)860,327 (14.1)
      North America and the Caribbean171,006 (7.9)397,742 (18.4)
      South and Central America119,254 (6.1)314,266 (16.1)
      South-East Asia829,846.13 (9.8)1517,305 (18.0)
      Western Pacific1263,889 (10.7)2382,916 (20.1)
      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 (Table 3a, Table 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 [

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

      ]. The lower rate of 8.6% of diabetes-attributable 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 [
      • Mbanya J.-C.
      • Ramiaya K.
      Diabetes mellitus.
      ].
      The highest number of deaths attributable to diabetes was found in countries with large populations: 1271,000 in China, 1065,000 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 that countries with large populations also contain the highest number of people with diabetes [
      • Guariguata L.
      • Whiting D.R.
      • Hambleton I.
      • Beagley J.
      • Linnenkamp U.
      • Shaw J.E.
      Global estimates of diabetes prevalence for 2013 and projections for 2035.
      ].

      4. Discussion

      While there has been a documented decline in the morbidity and mortality of some non-communicable diseases in developing and developed countries [
      • 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.
      ], no such decline has been reported for diabetes [

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

      ]. The global population of adults increased by 4.5% between 2011 and 2013 [
      • United Nations, Department of Economic and Social Affairs, Population Division
      World population prospects the 2012 revision.
      ], 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 [
      • IDF Diabetes Atlas Group
      Update of mortality attributable to diabetes for the IDF diabetes atlas: estimates for the year 2011.
      ]. This increase in mortality is likely associated with increased incidence in low and middle income countries, offset slightly by improved survival of people with diabetes in high income countries [
      • Colagiuri S.
      • Borch-Johnsen K.
      • Glümer C.
      • Vistisen D.
      There really is an epidemic of type 2 diabetes.
      ].
      Diabetes contributes substantially to premature adult mortality and close to half of all deaths occur in people under the age of 60 [

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

      ]. A substantial proportion of these premature deaths are 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 [
      • WHO
      Preventing chronic diseases: a vital investment [internet].
      ]. 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 [
      • WHO
      Global Action Plan for the prevention and control of NCDs 2013–2020 [internet].
      ].
      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 systematically underestimate the burden of mortality due to diabetes [
      • Fuller J.H.
      Mortality trends and causes of death in diabetic patients.
      ].

      Conflict of interest statement

      The members of the IDF Diabetes Atlas Group state that they have no conflicts of interest.

      Funding

      The IDF Diabetes Atlas was supported by the following sponsors: Lilly Diabetes (grant number 100227106 ), Merck and Co. Inc. (grant number INT-2014-2461 ), Novo Nordisk A/S (supported through an unrestricted grant by the Novo Nordisk Changing Diabetes Initiative ), Pfizer, Inc. and Sanofi Diabetes.

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