IDF Diabetes AtlasDiabetes in the young – a global view and worldwide estimates of numbers of children with type 1 diabetes
Introduction
The incidence of childhood onset diabetes is increasing in many countries. There are clear indications of geographic differences in trends but the overall annual increase is estimated at around 3% [1]. Some 79,000 children worldwide are estimated to develop type 1 diabetes annually. There is some indication that incidence is increasing more steeply in some of the low prevalence countries in Europe and that, in relative terms, increases in Europe are greatest in young children [2]. There is also evidence emerging from high-incidence European countries that the increasing incidence trend seems to be levelling off which may give hope for the future [3], [4], [5], [6].
The cause of type 1 diabetes remains unknown. There is clear evidence of a genetic predisposition and strong, but circumstantial, evidence for environmental factors triggering an autoimmune destruction of the beta cells leading to absolute dependence on insulin treatment.
Living with type 1 diabetes remains a challenge for the child and the whole family even in countries with access to multiple daily injections or an insulin pump, glucose monitoring, diabetes education and expert medical care. Poor metabolic control may result in the acute complications of hypoglycaemia and ketoacidosis, poor growth and chronic microvascular and macrovascular complications. Children are more sensitive to a lack of insulin than adults and are at higher risk of a rapid and dramatic development of diabetic ketoacidosis. Episodes of severe hypoglycaemia or ketoacidosis, especially in young children, are risk factors for structural brain abnormalities and impaired cognitive function which may cause schooling difficulties and limit future career choices [7], [8]. Even in developed countries there is still significant excess mortality among children and young adults with type 1 diabetes diagnosed in childhood. A recent study from 10 European countries showed that there were twice as many deaths as expected from national age/sex specific mortality rates [9]. Over a third of the deaths could be directly attributed to diabetes, and these were mainly from metabolic disturbances, diabetic ketoacidosis and hypoglycaemia. Little is known about the mortality of type 1 diabetes in childhood in many developing countries where the prevalence of childhood diabetes is very low. It is suspected that many remain undiagnosed with the deaths attributed to malaria, gastroenteritis or other infections [10], while many that are diagnosed die within a year [11], [12].
A small proportion of children diagnosed with type 1 diabetes have been shown to have monogenic diabetes and not auto-immune mediated diabetes [13]. A correct diagnosis is important as some forms of monogenic diabetes can be successfully transitioned from insulin to oral sulphonylurea medication.
Type 2 diabetes is also increasing in the childhood age group in many parts of world, especially among indigenous populations and in ethnic minorities [14], but few population-based studies are available and therefore will not be considered in detail in this review.
Section snippets
Methodology
Systematic searches of bibliographic databases were performed to identify studies that provided incidence or prevalence rates of type 1 diabetes in children as follows:
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Medline was accessed using OvidSP restricted to human studies published since 1980 and using [exp registries OR exp incidence OR exp prevalence) AND exp diabetes mellitus, insulin-dependent AND exp with the/ep [Epidemiology] sub-heading. If a country was not indexed in Medline then it was included in the search as a text word.
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Worldwide estimates of type 1 diabetes
The following characteristics of the 88 studies reported in the literature which were used to produce the estimates are summarised in Table 1: first author and year of publication, geographical coverage, calendar period, incidence rate (age-standardised if sufficient information provided), number of cases, estimated completeness of ascertainment; and a classification of the source as either A or B using the criteria described in Section 2. The rates in these publications are mapped in Fig. 1
Discussion
The global distribution of childhood type 1 diabetes clearly indicates large area-to-area variations. This variability may partly be due to different distributions of risk genes for the disease as well as different distributions of environmental exposures, but part of the apparent variability both between countries and regions may also be due to methodological problems:
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The available incidence data sometimes covers only one small part of a large country. For example, in India incidence data were
Monogenic diabetes
Monogenic diabetes is caused by a defect in a single gene and can present clinically as either type 1 or type 2 diabetes [116]. At least 10 single gene mutations have been described, involving various transcription factors important for pancreatic development or for islet cell function. Monogenic diabetes which presents in the first 6 months of life is referred to as neonatal diabetes. It can be permanent or transient and it can be isolated or part of a broader syndrome [117]. The majority of
Conclusion
The incidence and prevalence rates for type 1 diabetes in the young appear to be slowly rising in most countries in the world, with the increases being most marked in the very young and in those countries experiencing rapid economic growth. However, much of the data for low- and middle-income countries are either missing, incomplete, non-representative or several decades old. Caution is needed in accepting or interpreting data on the burden of diabetes in the young when data from neighbouring
Conflict of interest
There are no conflicts of interest.
Acknowledgements
The authors would like to acknowledge Jessica Beagley for her contribution to the literature search for this paper.
The 6th edition of 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 Diabetes® initiative, Pfizer, Inc., and Sanofi Diabetes.
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