The total number of adults living with either type 1 or type 2 diabetes in the world has surpassed 800 million – over four times the total number in 1990, according to findings from a global analysis published ahead of World Diabetes Day in The Lancet. Additionally, 445 million adults aged 30 years and older with diabetes (59%) did not receive treatment in 2022, three and a half times the number in 1990. 

Of the 828 million adults with diabetes in 2022, over a quarter (212 million) lived in India, with another 148 million in China. The USA (42 million), Pakistan (36 million), Indonesia (25 million), and Brazil (22 million) followed.  

The study was unable to separate type 1 and type 2 diabetes in adults. However, previous evidence suggests that the vast majority of cases of diabetes in adults are type 2. 

Senior author Professor Majid Ezzati, of Imperial College London, said: “Our study highlights widening global inequalities in diabetes, with treatment rates stagnating in many low- and middle-income countries where numbers of adults with diabetes are drastically increasing. This is especially concerning as people with diabetes tend to be younger in low-income countries and, in the absence of effective treatment, are at risk of life-long complications – including amputation, heart disease, kidney damage or vision loss – or in some cases, premature death.” 

A global study with global data 

The new study, conducted by the NCD Risk Factor Collaboration (NCD-RisC), in collaboration with the World Health Organization (WHO), is the first global analysis of trends in both diabetes rates and treatment which includes all countries. Researchers used data from over 140 million people aged 18 years or older from more than 1,000 studies in populations of different countries.  

The authors used statistical tools to bring all the data across different years, ages and countries together, and estimate diabetes rates and treatment in a way that enables comparisons across countries. [1] 

Diabetes was defined as having a fasting plasma glucose (FPG) of 7.0 mmol/L or higher, having a glycated haemoglobin (HbA1c) of 6.5% or higher (two commonly used diagnostic criteria options for diabetes according to modern guidelines) or taking medication for diabetes. Treatment was defined as taking medication for diabetes. [2] 

Most previous studies looking at diabetes rates relied on high FPG as a single measure of diabetes and did not account for people who have high HbA1c, leading to likely underestimates of rates especially in south Asia, where using FPG alone misses more cases of diabetes than in other regions.  

Global rates of diabetes doubled over the last three decades 

From 1990 to 2022, global diabetes rates doubled in both men (6.8% in 1990 to 14.3% in 2022) and women (6.9% to 13.9%). With the additional impact of population growth and ageing, this equates to an estimated 828 million adults with diabetes in 2022, an increase of approximately 630 million people from 1990, when roughly 198 million adults were estimated to have the disease.  

The changes in diabetes rate from 1990 to 2022 varied drastically across different countries with mostly LMICs experiencing the largest increases (eg. the diabetes rate amongst women in Pakistan rose from 9.0% in 1990 to 30.9% in 2022, the largest increase across all countries). Whilst some higher-income countries, such as Japan, Canada and some countries in western Europe (eg. France, Spain and Denmark), saw no change or even a small decrease in diabetes rate over the last three decades.  

Substantial global variations in diabetes rates in 2022 

The countries with the lowest rates of diabetes in 2022 were in western Europe and east Africa for both sexes, and in Japan and Canada for women. For example, diabetes rates in 2022 were as low as 2-4% for women in France, Denmark, Spain, Switzerland, and Sweden, and 3-5% for men in Denmark, France, Uganda, Kenya, Malawi, Spain, and Rwanda.  

By contrast, countries with the highest rates, where 25% or more of the population had diabetes for both men and women, were the Pacific island nations and those located in the Caribbean and the Middle East and north Africa, as well as Pakistan and Malaysia. Among high-income industrialised nations, diabetes rates in 2022 were highest in the USA (11.4% amongst in women and 13.6% in men).  

An important driver of the rise in type 2 diabetes rates, and its variation across countries, is obesity and poor diets. Diabetes rate was either already high or increased more in some of the regions where obesity was or became prevalent between 1990 to 2022, compared to many high-income countries, especially those in the Pacific and western Europe, where, in general, obesity and diabetes rates did not rise or rose by a relatively small amount.  

“Given the disabling and potentially fatal consequences of diabetes, preventing diabetes through healthy diet and exercise is essential for better health throughout the world. Our findings highlight the need to see more ambitious policies, especially in lower-income regions of the world, that restrict unhealthy foods, make healthy foods affordable and improve opportunities to exercise through measures such as subsidies for healthy foods and free healthy school meals as well as promoting safe places for walking and exercising including free entrance to public parks and fitness centres,” said Dr Ranjit Mohan Anjana, Madras Diabetes Research Foundation, India. 

Widening global inequalities in diabetes treatment 

Three out of five (59%) of adults aged 30 years and older with diabetes, a total of 445 million, were not receiving medication for diabetes in 2022, three and half times the number in 1990 (129 million).   

Since 1990, some countries, including many in central and western Europe, Latin America and East Asia and the Pacific, as well as Canada and South Korea have seen vast improvements in treatment rates for diabetes resulting in more than 55% of people with diabetes in these countries receiving treatment in 2022. The highest treatment rates were estimated in Belgium, at 86% for women and 77% for men.  

However, for many LMICs diabetes treatment coverage has stayed low and changed little over the previous three decades, with over 90% of people with diabetes not receiving treatment in some countries in both 1990 and 2022.  

As a result of these trends, the gap between the countries with the highest and lowest treatment coverage for diabetes has widened since 1990 to 2022; from 56 to 78 percentage points in women and from 43 to 71 percentage points in men.  

“Our findings suggest there is an increasing share of people with diabetes, especially with untreated diabetes, living in low- and middle-income countries. In 2022, only 5-10% of adults with diabetes in some sub-Saharan Africa countries received treatment for diabetes, leaving a huge number at risk of the serious health complications.” said Professor Jean Claude Mbanya, University of Yaoundé 1, Cameroon. 

He continues, “Most people with untreated diabetes will not have received a diagnosis, therefore increasing detection of diabetes must be an urgent priority in countries with low levels of treatment. Better diagnosis of diabetes requires innovations such as workplace and community screening programmes, extended or flexible healthcare hours to enable people to visit outside of standard working hours, integration with screening and care for diseases like HIV/AIDS and TB which have well-established programmes, and the use of trusted community healthcare providers.”  

In 2022, almost one third (133 million, 30%) of the 445 million adults aged 30 years or older with untreated diabetes lived in India, more than 50% greater than the next largest number which was in China (78 million) because treatment coverage was higher in China (45% for women and 41% for men) than in India (28% for women and 29% for men). Similarly, Pakistan (24 million) and Indonesia (18 million), the next two countries with the largest number of untreated diabetes, surpassed the USA (13 million), which had higher treatment coverage (65% for women and 67% for men).   

The authors acknowledge some limitations to their study including that most survey data did not separate type 1 and type 2 diabetes in adults. Additionally, some countries where estimates were provided on diabetes rates and treatment had very little, or in some cases, no data and their estimates were informed to a stronger degree by data from other countries. The study included two measures for diabetes: FPG and HbA1c. In studies that did not measure HbA1c, the prevalence of elevated HbA1c was predicted based on the relationship between HbA1c, FPG and other predictors in studies that had measured both, which increased the uncertainty of the study estimates.  

• Evidence-based interventions are too often unavailable, leading to thousands of preventable deaths globally daily.
• The COVID-19 pandemic has highlighted the vulnerability of people with diabetes, and lack of action in tackling key risk factors.

Ahead of World Diabetes Day (14th November), The Lancet publishes a new report calling for action to close the gap in diabetes prevention and care. Worldwide, 463 million people have diabetes, with 80% from low-income and middle- income countries (LMICs). In 2019, 4.2 million people died as a result of the condition and its complications.

On average, diabetes reduces life expectancy in middle-aged people by 4-10 years and independently increases the risk of death from cardiovascular disease, kidney disease, and cancer by 1.3-3 times. Diabetes is among the leading causes of non-traumatic leg and foot amputations and blindness, especially among people of working age.

The COVID-19 pandemic has highlighted the vulnerability of people with diabetes. People with diabetes are at least 2 times increased risk of severe disease or death from the virus, especially in individuals with poorly controlled diabetes, or who have diabetes-related complications, but the risk is also exacerbated by social conditions in disadvantaged communities that lead to lower access to care and higher rates of comorbidities.

While effective treatments and prevention strategies exist, barriers to provision and access mean that, in most care settings, their use is scarce. The Lancet Commission on Diabetes brings together 44 leading experts who collaborated for four years to develop a multicomponent, integrated strategy involving the redesign of clinical workflows and training of non-physician personnel to form diabetes teams to support diabetes care with ongoing data collection to inform practices and policies.

Based on a comprehensive analysis of the available data on diabetes care, the Commission summarises the best evidence for effectively managing diabetes, which relies upon six components:

1) Sustained weight reduction in patients with obesity by 15kg or more can induce remission of type 2 diabetes for up to 2 years

2) Reducing blood sugar levels (HbA1c) by 0.9% (10 mmol/mol), systolic blood pressure by 10 mm Hg, LDL cholesterol concentration by 1 mmol/L (39 mg/dL), or a combination of all three, can independently reduce the risk of cardiovascular disease, all-cause death, or both, by 10-20% in patients with type 2 diabetes

3) Reducing multiple risk factors, including by use of statins and renin-angiotensin system (RAS) inhibitors, can prevent cardiovascular-renal events by 20-40% in individuals with or at risk of having diabetes

4) Use of SGLT2 inhibitors and GLP-1 receptor agonists can reduce cardiovascular-renal events and death rates by up to 40%, independent of their effect on lowering blood glucose concentration

5) Use of data-driven, team-based integrated care through the reorganisation of healthcare provision can reduce cardiovascular and all-cause death in patients with type 2 diabetes by 20-60%

6) Implementing a structured lifestyle intervention and use of metformin can each prevent or delay type 2 diabetes in individuals with impaired glucose tolerance by 30-50%

New modelling by the Commission estimates the impact of these strategies. For instance, the ten LMICs with the greatest burden of diabetes (China, India, Brazil, Mexico, Indonesia, Egypt, Pakistan, Bangladesh, Turkey, Thailand) account for 217 million cases of type 2 diabetes – representing nearly 50% of all diabetes cases. The Commission estimates that 3.2 million of these individuals would die in three years if not treated, with 1.3 million of these deaths due to cardiovascular disease. By reducing HbA1c, blood pressure and LDL cholesterol through achieving a diagnosis rate of 50%, ensuring access to essential medicines such as statins, which are available at extremely low cost even in LMICs, in at least 70% of patients, and with a support system to sustain reductions in these risk factors over three years, up to 800,000 premature deaths could be avoided.

In high income countries, quality care is generally provided to young individuals with type 1 diabetes. By contrast, most young individuals in LMICs countries receive minimal care. Globally, 1.61 million people have type 1 diabetes. The Commission estimates that 14,466 young individuals (aged under 25 years) with type 1 diabetes died in 2017 globally. The vast majority of these deaths are preventable and comprehensive care for type 1 diabetes could lead to over 12,092 fewer deaths each year in this age group.

Lead author Professor Juliana Chan, The Chinese University of Hong Kong, says: “By protecting our environment, changing our practice, and empowering our communities, we can reduce the burden of diabetes as a root cause of many noncommunicable diseases. The diabetes epidemic is a calling that concerns all of us, as everyone has contributed to the ecosystem in one way or another to fuel the epidemic. As such, we all have the collective responsibility to rise to this challenge to sustain our environment and to use our finite resources wisely to preserve humanity. The global challenge of diabetes transcends political, economic, social, and technological domains.” [1]

Writing in a linked Comment, Katie Dain, NCD Alliance, Switzerland, says: “As the world seeks to create a more sustainable, fair, and equal future in the wake of COVID-19, the NCD community must become more effective advocates for change. In celebrating the centenary of insulin discovery, we can create valuable opportunities to do so, with lived experience as the engine to drive further progress. We must collectively call on political leaders and governments to make good on their UN commitments with decisive, inclusive, and accountable leadership and appropriate investment if we are to reach the 2025 NCD targets and 2030 SDGs. Irrespective of the challenging financial landscape, investment in tackling diabetes and other NCDs now will prevent substantial and unsustainable health-care costs in the future.”

The Commission is published ahead of World Diabetes Day 2020, which will also see the announcement of the development of the WHO Global Diabetes Compact, to be launched in April 2021.

A Lancet editorial published alongside the report states: “The evidence-base for improving diabetes prevention and care is strong. The question now for diabetes advocates is how to achieve the comprehensive, systems-level change needed to translate this evidence into action? … Through the [WHO Global Diabetes] Compact, WHO will work with partners to support countries to mobilise resources and accelerate structural transformations that together will enable the scale-up of access to essential diabetes medicines and technologies, the inclusion of diagnosis and treatment of diabetes in primary healthcare and universal health coverage packages, and the reduction of major population-level diabetes risk factors such as obesity. This initiative represents a valuable opportunity to build partnerships between governments, care providers, patient advocates, and non-governmental organisations to implement the Commission’s recommendations through a renewed global diabetes movement. The case to act has never been more urgent.”

Sanofi today announced that new research reveals that negative emotions are jeopardising people living with Type 2 diabetes’ ability to effectively manage their condition. A quarter of people with T2 diabetes feel anxious or fearful about getting ‘hypos’ (low blood glucose levels), with 42% preferring to have high blood glucose levels instead of risking another ‘hypo’, despite this risking life threatening conditions in the future.

UK adults with Type 1 and Type 2 diabetes showed even modest and sustained improvement in blood glucose control could help prevent almost a million serious medical complications such as eye disease, kidney disease, foot ulcer and amputations, and potentially blindness, which could avoid billions in future NHS costs.

Blood sugar: Lowest % of T2s with low blood sugar (5 worst areas of UK for blood sugar management)
• Bristol (45.1%)
• North East Essex (41.6%)
• Central Manchester (40.1%)
• South Reading (40%)
• Kernow (40.9%)

Prevalence: Highest % of people with diabetes (5 areas with highest rates of diabetes in UK)
• Bradford (9.7%)
• Sandwell and West Birmingham (9%)
• Walsall (8.7)
• Harrow (8.7)
• Leicester City (8.9)

The UK has the worst T2 diabetes blood glucose levels in Europe, Sanofi is launching a new campaign dedicated to helping patients – ‘Highs & Lows: Better Balance for a Better Future’, thatincludes a patient support website, to help the 52% of patients with T2 diabetes who find it challenging to balance their blood glucose levels or who worry about doing so