Maturitas 137 (2020) 63–64
Contents lists available at ScienceDirect
Maturitas
journal homepage: www.elsevier.com/locate/maturitas
Trends in diabetes incidence worldwide: Are the findings real?
Over the last two decades, the World Health Organisation and the
International Diabetes Federation have used prevalence of diabetes
from cross-sectional surveys to report the progress of the diabetes
“epidemic”. In epidemiologic parlance, an epidemic (from Greek epi,
upon, + demos, people) is a disease that appears as new cases in a given
population, during a given period, at a rate that substantially exceeds
what is "expected", based on recent experience. The term ‘diabetes
epidemic’ is used frequently to describe the increasing prevalence of the
disease, but a true epidemic would require an increasing incidence of
diabetes. Although prevalence is a good index of overall disease burden,
it can be a poor index of the direction of an epidemic because pre-
valence of diabetes is strongly influenced by a) demographic changes;
b) the age at onset of diabetes; c) mortality among people with diabetes
and in the general population; and d) the incidence of diabetes. Thus,
advances in treatment of diabetes can lead to increases in prevalence by
decreasing mortality rates among those with diabetes. In fact, whenever
mortality among people with diabetes is lower than the incidence of
diabetes, prevalence will rise. In the absence of true diabetes incidence
studies, this rise in prevalence can be misinterpreted as a rise in po-
pulation risk, even though the incidence of diabetes might be falling.
A key challenge in performing studies of incidence is that they need
to be very large and have high follow-up rates to provide valid esti-
mates. Such requirements have limited the number of these studies.
Recently, however, the establishment of registries based on adminis-
trative data sources across the world, especially in high-income coun-
tries, has facilitated population-wide estimates of the incidence of
chronic diseases. Some studies using such resources have shown that
diabetes incidence is starting to stabilise and even fall in some countries
[1–3]. Noting this observation, we undertook a systematic review of
studies of diabetes incidence trends over the time period of 1960–2014
[4]. After reviewing over 25,000 abstracts, 47 studies were included in
which we analysed trends of incidence within populations and across
decades. We observed that among the studies examining incidence from
1990 to the early 2000s, the majority of studies (66 %) reported in-
creasing trends in diabetes incidence over time. However, from 2006 to
2014, this pattern changed; only a third showed increasing trends,
while a third were stable and the remaining third reported declining
incidence trends [4]. We also noted that the majority of studies came
from high-income countries and there was a scarcity of data in low-
income countries, where the diabetes incidence trends may be different.
Although this work is not without limitations, we were able to identify
signs suggesting that there may be some improvements in the world-
wide diabetes epidemic.
There are several possible explanations for reductions in the in-
cidence of diabetes. The first, and most intuitively appealing, ex-
planation for a fall in incidence is that worldwide efforts in diabetes
prevention are finally achieving success. Since the late 1990s, there
https://doi.org/10.1016/j.maturitas.2020.01.011
Received 15 January 2020
0378-5122/ © 2020 Elsevier B.V. All rights reserved.
T
have been efforts in the development of diabetes prevention programs
for those at high diabetes risk, and adoption of population-wide inter-
ventions focusing on health promotion and on taxes on sugar sweetened
beverages and junk food. We have also observed changes in food for-
mulations and changes in the built environment, introduction of bike
and walking paths, all with the aim of reducing the incidence of chronic
disease such as obesity and diabetes. It is clearly possible, and likely,
that these interventions have had at least some impact on trends in
diabetes incidence [4].
We must also consider the reasons why these results may not be a
true representation of what is occurring in diabetes incidence. One
possible reason for our findings could be the shift since 2010 from using
blood glucose measures towards hemoglobin A1c (HbA1c) as a diag-
nostic test. This might lead to a fall in incidence because HbA1c iden-
tifies fewer people as having diabetes than do oral glucose tolerance
tests. This is certainly feasible, but we argue, it is not likely for several
reasons. First, HbA1c and fasting blood glucose produce estimates of
diabetes prevalence that are very similar to each other [5]. Second,
although the use the HbA1c was introduced in 2010, several countries,
including some which have shown decreasing incidence trends, have
not adopted its systematic use for the diagnosis of diabetes [2,6]. Third,
since HbA1c can be measured in the non-fasting state, it is possible that
the reach of HbA1c testing would be greater than the reach of fasting
glucose testing.
Another possible explanation for decreasing trends is that health
systems and clinical practitioners may have become less enthusiastic in
screening for diabetes leading to the identifications of fewer cases.
Evidence in this regard is much harder to find although a small re-
cently-published study [7] has shown that in the US, at least, screening
rates remained stable during the time that national US data showed
declining incidence of diabetes [1]. The examination of screening data
from several countries in our forthcoming work will indeed elucidate
this issue further.
The observation of a downturn in diabetes incidence in not unique
among the epidemiological studies of chronic diseases, nor is scepticism
of the truth of such a finding. The incidence of Alzheimer’s disease [8]
and the incidence of and mortality from cardiovascular events [9] have
fallen in the last few decades. In fact, it is interesting to draw some
parallels from when the declining mortality rates of coronary heart
disease (CHD) were first noted. There was indeed a reluctance at that
time to believe that the falls in CHD mortality were real. The first tid-
ings of a changing CHD epidemic were reported as early as 1964 in the
US and it received little attention. Cardiologists and scientists were still
sounding the alarm of the unstoppable heart disease epidemic for an-
other 10 years and it wasn’t until 1974 when Walker et al. [10] reported
a ‘Sign of Spring’ in JAMA stating the mortality rates of CHD had been
declining since 1963 [10]. Even this announcement was met with
 Maturitas 137 (2020) 63–64

trepidation and it wasn’t until 1978 in a conference known now as the
‘Decline conference’ when delegates agreed that the 20 % reduction in
CHD mortality rates was real.
Our group is currently undertaking other studies which promise to
confirm our initial findings and will overcome some of the limitations of
the recently published systematic review. Whether diabetes incidence is
truly decreasing or this is just a minor blip in the epidemic generated by
factors other than true decline in incidence, time will certainly tell.
Contributors
Dianna J. Magliano drafted the manuscript.
Lei Chen reviewed and edited manuscript.
Meda E. Pavkov reviewed and edited manuscript.
Edward W. Gregg reviewed and edited manuscript.
[10] W.J. Walker, Coronary mortality: what is going on? JAMA 227 (9) (1974)
Jonathan E. Shaw reviewed and edited manuscript.
systematic review, BMJ 366 (2019) l5003.
[5] NCD Risk Factor Collaboration (NCD-RisC), Effects of diabetes definition on global
surveillance of diabetes prevalence and diagnosis: a pooled analysis of 96 popula-
tion-based studies with 331,288 participants, Lancet Diabetes Endocrinol. 3 (8)
(2015) 624–637.
[6] J. Quan, T.K. Li, H. Pang, C.H. Choi, S.C. Siu, S.Y. Tang, N.M.S. Wat, J. Woo,
J.M. Johnston, G.M. Leung, Diabetes incidence and prevalence in Hong Kong, China
during 2006-2014, Diabet. Med. 34 (7) (2017) 902–908.
[7] J.M. Evron, W.H. Herman, L.N. McEwen, Changes in screening practices for pre-
diabetes and diabetes since the recommendation for hemoglobin A1c testing,
Diabetes Care 42 (4) (2019) 576–584.
[8] Y.T. Wu, A.S. Beiser, M.M.B. Breteler, L. Fratiglioni, C. Helmer, H.C. Hendrie,
H. Honda, M.A. Ikram, K.M. Langa, A. Lobo, F.E. Matthews, T. Ohara, K. Peres,
C. Qiu, S. Seshadri, B.M. Sjolund, I. Skoog, C. Brayne, The changing prevalence and
incidence of dementia over time - current evidence, Nat. Rev. Neurol. 13 (6) (2017)
327–339.
[9] D.S. Jones, J.A. Greene, The decline and rise of coronary heart disease: under-
standing public health catastrophism, Am. J. Public Health 103 (7) (2013)
1207–1218.
1045–1046.

Conflict of interest Dianna J. Maglianoa,b,*

a
Baker Heart and Diabetes Institute, Melbourne, Australia
The authors declare that they have no conflict of interest. b
Monash University, School of Public Health and Preventive Medicine,
Melbourne, Australia
Funding E-mail address: Dianna.Magliano@baker.edu.au.

No funding was received for the preparation of this editorial. Lei Chen
Baker Heart and Diabetes Institute, Melbourne, Australia
Provenance and peer review Meda E. Pavkov
Division of Diabetes Translation, Centers for Disease Control and
This article was commissioned and not externally peer reviewed. Prevention, Atlanta, GA, United States

References Edward W. Gregga,b

a
Division of Diabetes Translation, Centers for Disease Control and
[1] L.S. Geiss, J. Wang, Y.J. Cheng, T.J. Thompson, L. Barker, Y. Li, A.L. Albright,
Prevention, Atlanta, GA, United States
b
E.W. Gregg, Prevalence and incidence trends for diagnosed diabetes among adults Department of Epidemiology and Biostatistics, School of Public Health,
aged 20 to 79 years, United States, 1980-2012, JAMA 312 (12) (2014) 1218–1226. Imperial College London, London, UK
[2] T. Karpati, C.J. Cohen-Stavi, M. Leibowitz, M. Hoshen, B.S. Feldman, R.D. Balicer,
Towards a subsiding diabetes epidemic: trends from a large population-based study Jonathan E. Shawa,b,c
in Israel, Popul. Health Metr. 12 (1) (2014) 32. a
Baker Heart and Diabetes Institute, Melbourne, Australia
[3] S.H. Read, J.J. Kerssens, D.A. McAllister, H.M. Colhoun, C.M. Fischbacher, b
R.S. Lindsay, R.J. McCrimmon, J.A. McKnight, J.R. Petrie, N. Sattar, Trends in type Monash University, School of Public Health and Preventive Medicine,
2 diabetes incidence and mortality in Scotland between 2004 and 2013, Melbourne, Australia
Diabetologia 59 (10) (2016) 2106–2113. c
Latrobe University, Bundoora, Australia
[4] D.J. Magliano, R.M. Islam, E.L.M. Barr, E.W. Gregg, M.E. Pavkov, J.L. Harding,
M. Tabesh, D.N. Koye, J.E. Shaw, Trends in incidence of total or type 2 diabetes:

⁎
Corresponding author at: 99 Commercial Road, Melbourne, Vic, 3004, Australia.

64