This cross-sectional study investigates the incidence, mortality, and disability-adjusted life-years of childhood diabetes at the global, national, and regional levels from 1990 to 2019.
Key Points
Question
What is the burden of childhood diabetes as measured by incidence, mortality, and disability-adjusted life-years (DALYs) at the global, national, regional and Sociodemographic Index (SDI) subgroup levels from 1990 to 2019?
Finding
In this cross-sectional analysis that included 1 449 897 children, in 2019, there were 227 580 cases of childhood diabetes globally, resulting in 5390 deaths and 519 117 DALYs; and a 39.4% increase in incident cases since 1990. The childhood diabetes burden has increased in all SDI regions, with the highest increase in low SDI region.
Meaning
Diabetes is a major health issue among children, and accurate estimation of its burden is essential for developing targeted prevention and treatment approaches.
Abstract
Importance
Diabetes in children is a global epidemic that causes various medical conditions associated with an increased incidence of premature death.
Objective
To investigate the trends in diabetes incidence, mortality, and disability-adjusted life-years (DALYs) in children, with risk factors for diabetes-associated death, from 1990 to 2019.
Design, Setting, and Participants
This was a cross-sectional study that used data from the Global Burden of Diseases (GBD) 2019 in 204 countries and territories. Children with diabetes who were aged 0 to 14 years were included in the analysis. Data were analyzed from December 28, 2022, to January 10, 2023.
Exposure
Childhood diabetes from 1990 to 2019.
Main Outcome Measures
Incidence, all-cause and cause-specific deaths, DALYs, and corresponding estimated annual percentage changes (EAPCs). These trends were stratified according to region, country, age, sex, and Sociodemographic Index (SDI).
Results
A total of 1 449 897 children (738 923 male [50.96%]) were included in the analysis. In 2019, there were 227 580 incident cases of childhood diabetes worldwide. Cases of childhood diabetes increased by 39.37% (95% uncertainty interval [UI], 30.99%-45.45%) from 1990 to 2019. Over 3 decades, diabetes-associated deaths decreased from 6719 (95% UI, 4823-8074) to 5390 (95% UI, 4450-6507). The global incidence rate increased from 9.31 (95% UI, 6.56-12.57) to 11.61 (95% UI, 7.98-15.98) per 100 000 population; however, the diabetes-associated death rate decreased from 0.38 (95% UI, 0.27-0.46) to 0.28 (95% UI, 0.23-0.33) per 100 000 population. Among the 5 SDI regions, the low SDI region had the highest childhood diabetes-associated mortality rate in 2019. Regionally, North Africa and the Middle East had the largest increase in incidence (EAPC, 2.06; 95% CI, 1.94-2.17). Among 204 countries, Finland had the highest national incidence of childhood diabetes in 2019 (31.60 per 100 000 population; 95% UI, 22.65-40.36), Bangladesh had the highest diabetes-associated mortality rate (1.16 per 100 000 population; 95% UI, 0.51-1.70), and the United Republic of Tanzania had the highest DALYs rate (100.16 per 100 000 population; 95% UI, 63.01-155.88). Globally, environmental/occupational risk, nonoptimal temperature, high temperature, and low temperature were key risk factors for childhood diabetes-associated mortality in 2019.
Conclusions and Relevance
Childhood diabetes is an increasing global health challenge with rising incidence. Results of this cross-sectional study suggest that despite the global decline in deaths and DALYs, the number of deaths and DALYs remains high among children with diabetes, especially in low SDI regions. Improved understanding of the epidemiology of diabetes in children may facilitate prevention and control.
Introduction
Diabetes is one of the most common endocrine diseases in children worldwide.1 For many years, childhood diabetes generally constituted type 1 diabetes (T1D). Recently, the global epidemic of childhood obesity has led to an increasing prevalence of type 2 diabetes (T2D) in children.1,2,3 The main underlying factors are obesity and poor lifestyle (eg, sedentary living), and most affected children have a parental history of T2D.3,4,5,6 Obesity, the most prominent risk factor for T2D, requires lifestyle modifications (eg, nutrition and exercise) beginning in childhood.3,6 The increasing incidence of T2D has not influenced the incidence of T1D, which steadily increases during childhood and adolescence; it is currently 22.9 new cases per 100 000 people younger than 15 years of age per year.7 Children with T1D require specialized pediatric diabetes treatment and constant medical care. The increasing incidence of diabetes in children leads to prolonged exposure to hyperglycemia and other metabolic abnormalities; early diabetes onset carries an elevated risk of cardiovascular complications.8,9 These disease dynamics, which constitute a heavy burden on patients and their families, have become global public health problems.
According to the Global Burden of Disease (GBD) study, the number of children with diabetes increased by 64 287 from 1990 to 2019.10 Therefore, childhood diabetes is an important target for efforts to reduce the burden of noncommunicable diseases in children. Furthermore, early diagnosis of diabetes in children can facilitate prevention and control, and diabetes epidemiology is influenced by continuing changes in population weight worldwide; thus, regular reassessment of GBD in children with diabetes, including updates to risk estimates, is essential for efforts to prevent long-term complications of diabetes. To our knowledge, no long-term global trends in the epidemiology of childhood diabetes have been reported. Here, we used the GBD database to analyze trends in diabetes incidence, diabetes-associated mortality, and diabetes-associated disability-adjusted life-years (DALYs) in children, with corresponding risk factors, from 1990 to 2019. We hope that this interpretation of GBD 2019 estimates for health care professionals will facilitate the development of new prevention and treatment approaches that can mitigate the health risks of diabetes in children.
Methods
Overview and Data Collection
This cross-sectional study was approved by Weifang Medical University. The ethical board of Weifang Medical University granted a waiver of informed consent as the study only involved data analysis and no identifiable personal information. Available data, standardized disease definitions, and prevalence information were gathered on children aged 0 to 14 years with diabetes using the Global Health Data Exchange query tool created by GBD collaborators.11
The 2019 GBD study assessed the incidence, mortality, and DALYs, with the corresponding rates and uncertainty intervals, for 369 diseases and injuries in 204 countries and territories from 1990 to 2019.11,12 To summarize the age distribution of the burden of diabetes in children, patients were divided into 4 groups: younger than 1 year, 1 to 4 years, 5 to 9 years, and 10 to 14 years. In this study, we collected data regarding the number of cases and incidence of diabetes, diabetes-associated mortality, and number of diabetes-associated DALYs in children, along with their corresponding rates at global, regional, and national levels. Data on the race and ethnicity of the participants are not listed in the GBD database, which does not allocate race and ethnicity for data collection. We computed mean estimated annual percentage changes (EAPCs) using linear regression. We also collected data regarding global risk factors that contribute to diabetes mortality in children.13 This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.
Sociodemographic Index
Sociodemographic Index (SDI) is a measure of a country’s or region’s level of development based on data on fertility rate, education level, and per capita income.11 SDI ranges from 0 to 1; higher levels indicate greater socioeconomic development. The SDI is reportedly associated with disease incidences and mortality rates. In this study, countries and geographic regions were classified into 5 SDI regions (low, low medium, medium, medium high, and high) to explore the association between the burden of childhood diabetes and socioeconomic development.
Statistical Analysis
Numbers of incidence, mortality, DALYs, and their corresponding rates were the main indicators used to describe the burden of childhood diabetes. Each rate is reported per 100 000 population, along with 95% uncertainty interval according to the GBD algorithm.14 The dynamics of childhood diabetes were analyzed by calculating EAPCs to identify temporal trends in the disease burden15; 95% CIs of EAPCs were determined by linear modeling.16 If the upper limit of both EAPC and its 95% CI is negative, its corresponding rate shows a decreasing trend; conversely, if the lower limit of both an EAPC and its 95% CI is positive, its corresponding rate shows an increasing trend. Gaussian curves were used to analyze associations between EAPC and rates and the Human Development Index of diabetes in children. Additionally, risk factors for diabetes in children were assessed. All calculations were performed using R Studio, version 4.1.2 (R Project for Statistical Computing). All P values were 2-sided, and P < .05 was considered statistically significant.
Results
Diabetes in Children: Global Trends
Incidence
A total of 1 449 897 children (738 923 male [50.96%]; 710 974 female [49.04%]) were included in the analysis. In 2019, the global incident cases of diabetes in children were 227 580 (95% uncertainty interval [UI], 156 477-313 145). From 1990 to 2019, the global incident cases of childhood diabetes increased by 39.4% (95% UI, 30.99%-45.45%). The corresponding incidence rate increased accordingly 9.31 (95% UI, 6.56-12.57) in 1990 to 11.61 (95% UI, 7.98-15.98) in 2019; the EAPC was 0.76 (95% CI, 0.73-0.79). From 1990 to 2019, the incidence of diabetes increased in children of all ages. The largest increase (52.06%) occurred in children aged 10 to 14 years. The smallest increase (30.52%) occurred among children aged 1 to 4 years. The incidence of diabetes was highest among children aged 5 to 9 years in both 1990 and 2019 (43.64% and 41.62%, respectively). In 2019, the incidence of diabetes was generally higher in girls than in boys; among children younger than 1 year, the incidence was higher in boys than in girls. The male to female ratio of diabetes incidence among children of different ages exhibited a bimodal distribution, with a peak among children aged 5 to 9 years (Table and Figure 1A).
Table. Incidence of Diabetes in Children Between 1990 and 2019 at the Global and Regional Level.
| Location | Rate per 100 000 (95% UI) | |||||
|---|---|---|---|---|---|---|
| 1990 | 2019 | 1990-2019 | ||||
| Incident cases | Incidence rate | Incident cases | Incidence rate | Cases change | EAPCa | |
| Global | 163 292.99 (115 080.26 to 220 534.04) | 9.31 (6.56 to 12.57) | 227 579.72 (156 476.89 to 313 144.56) | 11.61 (7.98 to 15.98) | 0.39 (0.31 to 0.45) | 0.76 (0.73 to 0.79) |
| SDI | ||||||
| High | 37 355.74 (28 859.76 to 46 594.94) | 21.63 (16.71 to 26.98) | 42 839.6 (31 188.7 to 54 770.49) | 26.24 (19.1 to 33.55) | 0.15 (0.06 to 0.2) | 0.89 (0.78 to 0.99) |
| High middle | 26 207.11 (18 675.37 to 35 530.25) | 8.63 (6.15 to 11.71) | 30 809.49 (21 101.62 to 42 380.26) | 12.56 (8.61 to 17.28) | 0.17 (0.1 to 0.23) | 1.29 (1.24 to 1.33) |
| Middle SDI | 36 194.04 (24 563.7 to 50 428.32) | 6.23 (4.23 to 8.67) | 50 755.4 (34 355.79 to 71 280.13) | 9.17 (6.21 to 12.88) | 0.38 (0.3 to 0.43) | 1.21 (1.15 to 1.28) |
| Low middle | 41 394.02 (27 948.63 to 57 474.09) | 9.13 (6.16 to 12.68) | 55 495.88 (37 448.42 to 78 498.79) | 10.6 (7.15 to 14.99) | 0.32 (0.22 to 0.41) | 0.43 (0.39 to 0.47) |
| Low SDI | 22 078.91 (14 661.85 to 31 043.93) | 9.12 (6.06 to 12.83) | 47 565.76 (31 841.71 to 67 421.59) | 10.06 (6.73 to 14.26) | 1.03 (0.93 to 1.12) | 0.29 (0.25 to 0.34) |
| Regions | ||||||
| Andean Latin America | 1014.06 (686.2 to 1412.08) | 6.74 (4.56 to 9.39) | 1492.48 (1013.73 to 2077.94) | 8.25 (5.6 to 11.49) | 0.47 (0.41 to 0.55) | 0.65 (0.63 to 0.67) |
| Australasia | 864.65 (766.93 to 981.86) | 18.85 (16.72 to 21.4) | 1506.57 (1218.81 to 1843.31) | 27.47 (22.23 to 33.62) | 0.74 (0.53 to 0.96) | 1.18 (1.07 to 1.28) |
| Caribbean | 738.15 (499.98 to 1029.08) | 6.47 (4.38 to 9.02) | 1006.41 (677 to 1402.02) | 8.61 (5.79 to 12) | 0.36 (0.26 to 0.44) | 0.94 (0.92 to 0.96) |
| Central Asia | 2294.54 (1540.37 to 3259.14) | 9.19 (6.17 to 13.06) | 3559.41 (2376.08 to 5035.11) | 13.23 (8.83 to 18.72) | 0.55 (0.5 to 0.62) | 1.08 (0.98 to 1.18) |
| Central Europe | 2761.3 (1959.23 to 3773.61) | 9.54 (6.77 to 13.04) | 2718.97 (1855.72 to 3835.49) | 15.42 (10.52 to 21.75) | −0.02 (−0.09 to 0.05) | 1.58 (1.52 to 1.65) |
| Central Latin America | 3839.05 (2640.16 to 5200.29) | 5.99 (4.12 to 8.11) | 4947.34 (3387.87 to 6734.74) | 7.57 (5.18 to 10.3) | 0.29 (0.24 to 0.34) | 0.77 (0.75 to 0.8) |
| Central Sub-Saharan Africa | 2271.07 (1515.16 to 3230.06) | 8.79 (5.87 to 12.5) | 5453.31 (3639.4 to 7821.29) | 9.56 (6.38 to 13.71) | 1.4 (1.2 to 1.56) | 0.26 (0.23 to 0.29) |
| East Asia | 13 014.98 (8835.28 to 17 990.8) | 3.89 (2.64 to 5.37) | 12 831.16 (8247.28 to 18 076.11) | 5.51 (3.54 to 7.77) | −0.01 (−0.1 to 0.06) | 0.92 (0.77 to 1.08) |
| Eastern Europe | 4967.05 (3374.36 to 7074.08) | 9.65 (6.56 to 13.75) | 5352.99 (3572.14 to 7593.08) | 14.44 (9.64 to 20.49) | 0.08 (0.04 to 0.12) | 1.05 (0.87 to 1.23) |
| Eastern Sub-Saharan Africa | 7815.42 (5183.67 to 11 005.05) | 8.65 (5.74 to 12.18) | 15 958.22 (10 561.01 to 22 585.47) | 9.04 (5.98 to 12.79) | 1.04 (0.96 to 1.1) | 0.14 (0.12 to 0.17) |
| High-income Asia Pacific | 9181.72 (7121 to 11 588.89) | 26.05 (20.21 to 32.88) | 6262.59 (4752.84 to 7968.47) | 26.83 (20.36 to 34.14) | −0.32 (−0.36 to −0.29) | 0.1 (0.07 to 0.14) |
| High-income North America | 17 974.5 (13 245.18 to 22 971.18) | 29.27 (21.57 to 37.41) | 19 380.52 (14 081.78 to 24 574.47) | 29.24 (21.25 to 37.08) | 0.08 (−0.02 to 0.17) | 0.49 (0.3 to 0.67) |
| North Africa and Middle East | 13 158.09 (9028.04 to 18 334.27) | 9.16 (6.28 to 12.76) | 30 977.42 (21 051.8 to 42 961.47) | 17.62 (11.97 to 24.43) | 1.35 (1.2 to 1.5) | 2.06 (1.94 to 2.17) |
| Oceania | 91.58 (59.25 to 127.77) | 3.49 (2.25 to 4.86) | 195.13 (127.66 to 275.91) | 4.04 (2.64 to 5.71) | 1.13 (0.99 to 1.27) | 0.53 (0.51 to 0.55) |
| South Asia | 46 815.42 (31 577.99 to 65 160.11) | 10.66 (7.19 to 14.84) | 59 345.52 (39 927.42 to 84 451.4) | 11.48 (7.73 to 16.34) | 0.27 (0.14 to 0.38) | 0.18 (0.13 to 0.22) |
| Southeast Asia | 6055.21 (3923.79 to 8546.17) | 3.52 (2.28 to 4.96) | 7230.43 (4719.98 to 10293.11) | 4.28 (2.8 to 6.1) | 0.19 (0.16 to 0.24) | 0.66 (0.64 to 0.67) |
| Southern Latin America | 2813.96 (2192.85 to 3662.28) | 18.85 (14.69 to 24.53) | 3409.62 (2463.49 to 4438) | 22.87 (16.53 to 29.77) | 0.21 (0.02 to 0.37) | 0.71 (0.66 to 0.75) |
| Southern Sub-Saharan Africa | 1981.34 (1317.69 to 2815.51) | 9.72 (6.47 to 13.82) | 2437.67 (1602.29 to 3499.35) | 10.32 (6.79 to 14.82) | 0.23 (0.17 to 0.27) | 0.14 (0.1 to 0.18) |
| Tropical Latin America | 6069.42 (4232.32 to 8343.45) | 11.25 (7.85 to 15.47) | 7352.45 (4942.53 to 10 178.67) | 14.79 (9.94 to 20.47) | 0.21 (0.11 to 0.28) | 0.45 (0.16 to 0.75) |
| Western Europe | 12 165.77 (9410.84 to 15 277.02) | 17.12 (13.25 to 21.5) | 18186.41 (12 545.64 to 23 934.55) | 26.43 (18.23 to 34.78) | 0.49 (0.3 to 0.66) | 1.56 (1.39 to 1.74) |
| Western Sub-Saharan Africa | 7405.75 (4918.56 to 10 492.37) | 8.43 (5.6 to 11.95) | 17 975.1 (11 831.41 to 25 881.09) | 9.06 (5.97 to 13.05) | 1.43 (1.32 to 1.52) | 0.25 (0.22 to 0.28) |
Abbreviations: EAPC, estimated annual percentage change; SDI, Sociodemographic Index; UI, uncertainty interval.
EAPC is expressed as 95% CIs.
Figure 1. Trends in Diabetes Incidence, Deaths, and Disability-Adjusted Life-Years (DALYs) Among Children From 1990 to 2019.
A, Trends in incident cases and incidence rate. B, Trends in death cases and death rate. C, Trends in DALYs cases and DALYs rate.
Mortality
Over the past 30 years, the global number of diabetes-associated deaths in children decreased by 20% (6719; 95% UI, 4823-8074) in 1990 vs 5390 (95% UI, 4450-6507) in 2019. Similarly, the diabetes-associated death rate decreased from 0.38 (95% UI, 0.27-0.46) per 100 000 in 1990 to 0.28 (95% UI, 0.23-0.33) per 100 000 in 2019; the EAPC was −1.18 (95% CI, −1.24 to −1.11) (eTable 1 in Supplement 1). With the exception of a small increase (2.16%) among children aged 10 to 14 years, the diabetes-associated mortality rate declined in children of all other ages. The largest decrease in the diabetes-associated mortality rate (31.12%) occurred in children younger than 1 year. The highest numbers of deaths in 1990 and 2019 occurred among children younger than 1 year (2171 and 1495, respectively). In 2019, the diabetes-associated mortality rate among children aged 4 years or younger was higher in boys than in girls (younger than 1 year: boys, 1.34; girls, 0.91; 1-4 years: boys, 0.23; girls, 0.22); among children aged 5 to 14 years, the rate was higher in girls than in boys (5-9 years: boys, 0.16; girls, 0.23; 10-14 years: boys, 0.18; girls, 0.26). In boys, the lowest diabetes-associated mortality rate was observed among children aged 5 to 9 years (0.16); in girls, the lowest rate was observed among children aged 1 to 4 years (0.22) (Figure 1B).
DALYs
The global number of diabetes-associated DALYs in children decreased by 15.40% from 1990 to 2019 (613 585; 95% UI, 450 857-728 317) in 1990 vs 519 117 (95% UI, 431 524-621 792) in 2019; the EAPC was −1 (95% CI, −1.05 to −0.94) (eTable 1 in Supplement 1). From 1990 to 2019, the number of diabetes-associated DALYs decreased in children of all age groups, except for a slight increase (12.04%) among children aged 10 to 14 years. The greatest decrease in the number of diabetes-associated DALYs (31.12%) was observed among children younger than 1 year. The groups with the highest numbers of diabetes-associated DALYs in 1990 and 2019 were children younger than 1 year (192 021) and children aged 10 to 14 years (152 958), respectively. In 2019, the rate of diabetes-associated DALYs among children aged 4 years or younger was higher in boys than in girls (younger than 1 year: boys, 118.57; girls, 80.58; 1-4 years: boys, 20.77; girls, 19.85); among children aged 5 to 14 years, this rate was higher in girls than in boys (5-9 years: boys, 16.69; girls, 21.96; 10-14 years: boys, 20.90; girls, 26.93). In boys, the lowest rate of diabetes-associated DALYs was observed among children aged 5 to 9 years; in girls, the lowest rate was observed among children aged 1 to 4 years (Figure 1C).
Diabetes in Children: SDI Regional Trends
Incidence
The low-middle SDI region had the most cases of childhood diabetes in 2019 (55 496; 95% UI, 37 448-78 499). The incident cases in the low SDI region increased by 103.16% (95% UI, 93.28%-112.41%). The greatest increase in the incidence of childhood diabetes occurred in the high-middle SDI region (EAPC, 1.29; 95% CI, 1.24-1.33) (Table and Figure 2A).
Figure 2. Epidemiologic Trends of Incidence, Death, and Disability-Adjusted Life-Years (DALYs) Rates in 5 Sociodemographic Index (SDI) Regions of Childhood Diabetes From 1990 to 2019.
A, Trends in incidence rate. B, Trends in death rate. C, Trends in DALYs rate.
Mortality
Among the 5 SDI regions, only the low SDI region exhibited an increase (58.11%) in diabetes-associated mortality; the low SDI region also had the highest number of diabetes-associated deaths (2367; 95% UI, 1837-3045). Among the 4 remaining SDI regions, the high-middle SDI region had the greatest decrease (70.74%) in diabetes-associated mortality; the highest SDI region had the lowest number of diabetes-associated deaths in 2019 (89; 95% UI, 75-109). In 2019, the childhood diabetes-associated mortality rate was highest in the low SDI region (0.50; 95% UI, 0.39-0.64); it was lowest in the high SDI region (0.05; 95% UI, 0.05-0.07). The high-middle SDI region had the lowest EAPC in the childhood diabetes-associated mortality rate (−3.86; 95% UI, −4.07 to −3.65) (eTable 1 in Supplement 1 and Figure 2B).
DALYs
In 2019, the low SDI region had the highest number of diabetes-associated DALYs (213 856; 95% UI, 167 696-274 723) with a dramatic increase of 59.92% from 1990 to 2019. The high-middle SDI region had the greatest decrease (60.49%) in the number of diabetes-associated DALYs (eTable 1 in Supplement 1 and Figure 2C).
Diabetes in Children: Geographic Regional Trends
Incidence
Among 21 geographic regions, South Asia had the most cases of childhood diabetes in 2019 (59 346; 95% UI, 39 927-84 451]), whereas Oceania had the fewest (195; 95% UI, 128-276). The incidence of childhood diabetes was highest in high-income North America (29.24; 95% UI, 21.25-37.08). In contrast, the incidence of childhood diabetes was lowest in Oceania (4.04; 95% UI, 2.64-5.71). From 1990 to 2019, North Africa and Middle East had the largest increase in the incidence of childhood diabetes (EAPC, 2.06; 95% CI, 1.94-2.17), whereas the high-income Asia Pacific had the smallest increase (EAPC, 0.10; 95% CI, 0.07-0.14) (Table). In 2019, high-income North America (SDI, 0.86) had the highest incidence of childhood diabetes, whereas Oceania (SDI, 0.45) had the lowest incidence. The global SDI was 0.65 in 2019; 10 regions (eg, high-income North America and Australasia) had higher incidences of childhood diabetes than the global mean, whereas 11 regions (eg, Oceania and Southeast Asia) had lower incidences than the global mean (11.61) (Figure 3A).
Figure 3. Incidence, Death, and Disability-Adjusted Life-Years (DALYs) Rates for Childhood Diabetes From 1990 to 2019.
A, Incidence rate. B, Death rate. C, DALYs rate.
Mortality
In 2019, South Asia had the highest number of childhood diabetes-associated deaths (1502; 95% UI, 1133-1951). Oceania had the highest childhood diabetes-associated mortality rate (0.80; 95% UI, 0.52-1.20). Western Sub-Saharan Africa had the smallest decrease in the childhood diabetes-associated mortality rate (EAPC, −0.09; 95% CI, −0.34 to 0.17), whereas East Asia had the largest decrease (EAPC, −5.30; 95% CI, −5.58 to −5.02). In 2019, Oceania (SDI, 0.45) had the highest childhood diabetes-associated mortality rate, whereas high-income Asia Pacific (SDI, 0.87) had the lowest mortality rate. As noted previously, the global SDI was 0.65 in 2019; 7 regions had higher childhood diabetes-associated mortality rates than the global mean, whereas 14 regions had lower rates than the global mean (0.28) (eTable 1 in Supplement 1 and Figure 3B).
DALYs
In 2019, South Asia had the highest number of childhood diabetes-associated DALYs (139 554; 95% UI, 106 844-176 709]), whereas Australasia had the lowest number (623; 95% UI, 420-890). Oceania had the highest DALYs rate (68.58; 95% UI, 45.28-102.73); East Asia had the lowest DALYs rate (6.92; 95% UI, 5.67-8.55). From 1990 to 2019, Central Asia had the smallest decrease in the DALYs rate (EAPC, −0.01; 95% CI, −0.43 to 0.40); East Asia had the largest decrease (EAPC, −4.67; 95% CI, −4.94 to −4.40). The global SDI was 0.65 in 2019; 7 regions (eg, Oceania) had rates of DALYs that were higher than the global mean, whereas 14 regions (eg, East Asia) had rates that were lower than the global mean (26.49) (eTable 1 in Supplement 1 and Figure 3C).
Diabetes in Children: National Trends
Incidence
In 2019, among 204 countries, India had the most cases of childhood diabetes (43 932; 95% UI, 29 478-62 703); Finland had the highest incidence rate of childhood diabetes (31.60; 95% UI, 22.65-40.36) (Figure 4A and eTable 2 and eFigure 1A in Supplement 1). France (EAPC, 3.37; 95% CI, 3.16-3.57) had the largest increases in childhood diabetes incidence; Israel (EAPC, −1.06; 95% CI, −1.64 to −0.47) had the largest decreases (eTable 2 and eFigure 2A in Supplement 1). In 2019, Finland (SDI, 0.86) had the highest incidence of childhood diabetes, whereas Maldives (SDI, 0.56) had the lowest incidence. The global incidence of childhood diabetes in 2019 was 11.61 (95% UI, 7.98-15.98); the incidences were above the global mean in 90 countries and below the global mean in 114 countries (eFigure 3A in Supplement 1).
Figure 4. Incident, Death, and Disability-Adjusted Life-Years (DALYs) Cases of Diabetes in Children in 204 Countries and Territories.
A, Incident cases. B, Death cases. C, DALYs cases.
Mortality
In 2019, India had the highest number of childhood diabetes-associated deaths (625; 95% UI, 466-825) (eTable 2 in Supplement 1 and Figure 4B). Bangladesh (1.16; 95% CI, 0.51-1.70) had the highest childhood diabetes-associated mortality rate; Monaco (0.02; 95% CI, 0.01-0.02) had the lowest mortality rate (eTable 2 and eFigure 1B in Supplement 1). Zimbabwe (EAPC, 3.15; 95% CI, 2.13-4.17) had the greatest increases in the mortality rate; the Philippines (EAPC, −8.21; 95% CI, −9.36 to −7.05) and Singapore (EAPC, −6.26; 95% CI, −6.49 to −6.02) had the greatest decreases (eTable 2 and eFigure 2B in Supplement 1). In 2019, Bangladesh (SDI, 0.48) had the highest childhood diabetes-associated mortality rate, whereas Monaco (SDI, 0.90) had the lowest mortality rate. The global childhood diabetes-associated mortality rate in 2019 was 0.28 (95% UI, 0.23-0.33); the rates were above the global mean in 76 countries and below the global mean in 128 countries (eFigure 3B in Supplement 1).
DALYs
In 2019, India had the highest number of diabetes-associated childhood DALYs (64 003; 95% UI, 49 515-81 818]). (eTable 2 in Supplement 1 and Figure 4C). United Republic of Tanzania had the highest rate of childhood diabetes-associated DALYs (100.16; 95% UI, 63.01-155.88) (eTable 2 and eFigure 1C in Supplement 1). Zimbabwe (EAPC, 2.90; 95% CI, 1.98-3.82) had the greatest increase in DALYs rate; the Philippines (EAPC, −8.15; 95% CI, −9.30 to −6.98) and Turkey (EAPC, −5.17; 95% CI, −5.50 to −4.84) had the greatest decreases (eTable 2 and eFigure 2C in Supplement 1). Tanzania (SDI, 0.42) had the highest rate of childhood diabetes-associated DALYs; Cuba (SDI, 0.67) had the lowest rate. The global rate of childhood diabetes-associated DALYs in 2019 was 26.49 (95% UI, 22.02-31.73); the rates were above the global mean in 73 countries and below the global mean in 131 countries (eFigure 3C in Supplement 1).
Risk Factors for Diabetes in Children
In addition to metabolic risks (high fasting plasma glucose), the GBD database identifies the following 4 risk factors for childhood diabetes: environmental/occupational risks, nonoptimal temperature, high temperature, and low temperature. Specifically, environmental/occupational risks caused 6% of childhood diabetes-associated deaths (301.93 of 5389.67) worldwide; among 21 geographical regions, the highest proportion was 12% (2.62 of 21.03; eg, Western Europe), and the lowest proportion was 1% (0.47 of 63.42; Caribbean). The proportion of childhood diabetes-associated deaths caused by nonoptimal temperature was similar to the proportion caused by environmental/occupational risks. In 2019, high temperature caused 3% of childhood diabetes-associated deaths (152.86 of 5389.67) worldwide; among 21 geographical regions, the highest proportion was 5% (137.61 of 1950.50; South Asia), and the lowest proportion was 0% (9 regions, including high-income Asia Pacific). Low temperature caused 3% of childhood diabetes-associated deaths (152.50 of 5389.67) worldwide; the highest proportion was 12% (Western Europe, 2.61 of 21.03; Central Europe, 0.71 of 5.75), and the lowest proportion was 0% (Caribbean). Notably, the proportion of childhood diabetes-associated mortality caused by low temperature was below the global mean in 7 regions (eFigure 4 in Supplement 1).
Factors Influencing EAPCs
EAPCs significantly differed from incidence, mortality rate, and number of DALYs in 1990; they significantly differed from SDI in 2019. The incidence in 1990 represents the disease pool at baseline, whereas SDI can be considered an index of the level of medical care. EAPCs were negatively correlated with rate of DALYs (Pearson r = −0.4224; P <.001). The EAPC in incidence was positively correlated with SDI, whereas the EAPC in mortality rate was negatively correlated with SDI (Pearson r = −0.4844; P <.001) (eFigure 5 in Supplement 1).
Discussion
Over the past 30 years, the prevalence of diabetes has increased among children worldwide. Because of its increasing medical and social costs, childhood diabetes has gradually become a major public health problem. Here, we investigated diabetes incidence, diabetes-associated mortality, and diabetes-associated DALYs, with corresponding risk factors, among children aged 0 to 14 years in all GBD regions and countries from 1990 to 2019. Our findings provide insights regarding the burden of diabetes over the past 30 years among children in regions and countries with different income levels. Our results reinforce findings from studies conducted between 1990 and 2019, which indicated that the burden of childhood diabetes is increasing in some regions and countries worldwide. A global assessment of the epidemiologic patterns of childhood diabetes may help policy makers and clinicians to develop appropriate prevention and management strategies.
From 1990 to 2019, the numbers of childhood diabetes-associated deaths and diabetes-associated DALYs have both decreased. However, the global incidence of childhood diabetes increased by 39.37%. Diabetes onset now occurs at a younger age, and the increased incidence in children is mainly associated with obesity and lifestyle changes. Additionally, we found significant negative correlations between SDI and diabetes incidence, diabetes-associated mortality rate, and number of diabetes-associated DALYs. The greatest decrease in the childhood diabetes-associated mortality rate occurred in the high SDI region; this decrease was presumably associated with the availability of better medical services in the high SDI region, which allow earlier diagnosis and better treatment of diabetes in children. For example, countries in the high SDI region (eg, Monaco) have a low diabetes disease burden and the lowest diabetes-associated mortality rate, whereas countries in the low SDI region (eg, India) have a high diabetes disease burden and high diabetes incidence.
Diabetes is a complex, multifactorial disease influenced by multiple genetic, metabolic, and environmental factors.17 The exact role of each factor in childhood diabetes is unknown, requires further exploration, and may vary according to geography. These differences in underlying factors are associated with the regional variability in terms of childhood diabetes incidence and diabetes-associated mortality. Changes in modern dietary patterns have led to rapid increases in the number of people with obesity worldwide, and obesity is considered a leading risk factor for diabetes and its complications.18,19,20 Therefore, aggressive obesity prevention and dietary management can help to mitigate diabetes progression in children; recommended approaches for long-term management of diabetes include controlling caloric intake, maintaining a healthy diet, and following the Mediterranean dietary principles regarding anti-inflammatory and antioxidant food.21 Furthermore, cancer is a health factor that may interact with diabetes22; the current obesity-diabetes pandemic is expected to contribute to increased prevalence of various cancers.23,24 Such an increase would confirm the presence of a 2-way association between cancer and diabetes. In children with cancer and hyperglycemia, blood glucose monitoring may prevent the development of diabetes.
In children with diabetes, signs and symptoms are sometimes nonspecific; delays in diagnosis can have devastating effects on the child’s health.25 Children with diabetes often initially present with hypoglycemia, hyperglycemia, or diabetic ketoacidosis. Notably, diabetic ketoacidosis is the primary cause of death among individuals with diabetes.26 Therefore, failure to identify high-risk patients and provide timely treatment may lead to adverse outcomes and high mortality rate, particularly in low-income countries.27 Such failure may partly explain the lower rate of childhood diabetes-associated mortality in regions with higher SDI than in regions with lower SDI. Additionally, cardiovascular disease contributes to mortality in children with diabetes. For example, long-term hyperglycemia leads to early and progressive atherosclerosis.28,29,30 Moreover, the incidence of cardiovascular disease is positively correlated with the incidence of diabetes, presumably via common risk factors (eg, dyslipidemia, hypertension, and obesity).31
Limitations
This study had some important limitations. First, the analysis heavily relied on the GBD database. The database accuracy is constrained by the availability of national registry data, the large number of undiagnosed cases of childhood diabetes, and the lack of information regarding other risk factors associated with childhood diabetes. Second, no system has been established to classify types of childhood diabetes; future studies of childhood diabetes should include information that could facilitate such classification.
Conclusions
Over the past 30 years, the global burden of diabetes in children has gradually increased along with the obesity epidemic; this burden is expected to continue increasing. Findings of this cross-sectional study suggest that although EAPCs in childhood diabetes-associated mortality rate and rate of childhood diabetes-associated DALYs have demonstrated minimal variation worldwide, the EAPC in diabetes incidence continues to substantially increase. Furthermore, higher rates of childhood diabetes-associated mortality and childhood diabetes-associated DALYs persist in the low SDI region. Thus, there is an urgent need for health care professionals to develop more cost-effective and targeted strategies that can mitigate childhood diabetes-associated morbidity and mortality, reduce the socioeconomic burden, and avoid the corresponding risks.
eFigure 1. The Incidence, Deaths, and DALYs Rates of Diabetes in Children in 204 Countries and Territories
eFigure 2. The National Burden of Diabetes in Children in 204 Countries and Territories
eFigure 3. Incidence, Deaths, and DALYs Rates of Diabetes in Children in 204 Countries by SDI in 2019
eFigure 4. Proportion of Childhood Diabetes Deaths Attributable to Risk Factors
eFigure 5. The Correlation Between EAPC and Childhood Diabetes Incidence Rate, Deaths Rate,
and DALYs Rate in 1990 and HDI in 2019
eTable 1. Deaths and DALYs of Diabetes Mellitus in Children Between 1990 and 2019 at the Global and Regional Levels
eTable 2. Incidence, Deaths, and DALYs of Childhood Diabetes at the National Level
Data Sharing Statement
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eFigure 1. The Incidence, Deaths, and DALYs Rates of Diabetes in Children in 204 Countries and Territories
eFigure 2. The National Burden of Diabetes in Children in 204 Countries and Territories
eFigure 3. Incidence, Deaths, and DALYs Rates of Diabetes in Children in 204 Countries by SDI in 2019
eFigure 4. Proportion of Childhood Diabetes Deaths Attributable to Risk Factors
eFigure 5. The Correlation Between EAPC and Childhood Diabetes Incidence Rate, Deaths Rate,
and DALYs Rate in 1990 and HDI in 2019
eTable 1. Deaths and DALYs of Diabetes Mellitus in Children Between 1990 and 2019 at the Global and Regional Levels
eTable 2. Incidence, Deaths, and DALYs of Childhood Diabetes at the National Level
Data Sharing Statement
