Trends in diabetes incidence from 1992 to 2015 and projections for 2024: A Portuguese General Practitioner's Network study

Pleasecitethisarticleinpressas:M.deSousa-Uva,etal.,Trendsindiabetesincidencefrom1992to2015andprojectionsfor2024:APortuguese ContentslistsavailableatScienceDirect

Primary

Care

Diabetes

journal homepage:http://www.elsevier.com/locate/pcd

Original

research

Trends

in

diabetes

incidence

from

1992

to

2015

and

projections

for

2024:

A

Portuguese

General

Practitioner’s

Network

study

Mafalda

de

Sousa-Uva

_,

_L.

_Antunes

_,

_B.

_Nunes

_,

_A.P.

_Rodrigues

_,

J.A.

Simões

_,

_R.T.

_Ribeiro

_,

_J.M.

_Boavida

_,

_C.

_Matias-Dias

a_{NationalHealthInstituteDoutorRicardoJorge,Lisbon,Portugal}

b_{NationalSchoolofPublicHealth,NewUniversityofLisbon,Lisbon,Portugal} c_{UnidadedeSaúdeFamiliarMarquêsdeMarialva,Cantanhede,Portugal} d_{FacultyofHealthSciences,UniversityofBeiraInterior,Covilhã,Portugal}

e_{APDPDiabetesPortugal,EducationandResearchCenter(APDP-ERC),Lisbon,Portugal} f_{CEDOC,ChronicDiseasesResearchCenter,NOVAMedicalSchool,Lisbon,Portugal} g_{PortugueseDiabetesProgramme,DirectorateGeneralofHealth,Lisbon,Portugal}

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Articlehistory:

Received4February2016 Receivedinrevisedform 26April2016 Accepted13May2016 Availableonlinexxx Keywords: Diabetes Incidence Projections Portugal Epidemiology

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Background:Diabetes isknownasa majorcause ofmorbidityandmortalityworldwide. Portugal isknownastheEuropeancountrywiththehighestprevalenceofthisdisease. WhilediabetesprevalencedataisupdatedannuallyinPortugal,theGeneralPractitioner’s (GP)SentinelNetworkrepresentstheonlydatasourceondiabetesincidence.Thisstudy describesthetrendsinDiabetesincidence,between1992and2015,andestimateprojections forthefutureincidenceratesinPortugaluntil2024.

Methods:Anecologicaltime-seriesstudywasconductedusingdatafromGPSentinel Net-workbetween1992and2015.FamilydoctorsreportedallnewcasesofDiabetesintheir patients’lists.AnnualtrendswereestimatedthroughPoissonregressionmodelsaswellas thefutureincidencerates(until2024),sexandagegroupstratified.Incidencerate projec-tionswereadjustedtothedistributionoftheresidentPortuguesepopulationgivenStatistics Portugalprojections.

Results:TheaverageincreaseinDiabetesincidenceratewasintotal4.29%(CI95%3.80–4.80) peryearunderstudy.Until1998–2000,theannualincidenceratewashigherinwomen,and from1998–2000to2013–2015turnouttobehigherinmen.Theincidencerateprojectedfor 2022–2024was972.77/105_{inhabitantsintotal,and846.74/10}5_{and1114.42/10}5_{,respectively,} inwomenandmen.

Conclusions:ThisisthefirststudyinPortugaltoestimatediabetesincidencerateprojections. Thedisturbingreportedprojectionsseemrealisticifthingscontinueasinthepast.Actually, effectivepublichealthpolicieswillneedtobeundertakentominimizethisalarmingfuture scenario.

©2016PrimaryCareDiabetesEurope.PublishedbyElsevierLtd.Allrightsreserved.

∗ _{Correspondingauthor.}

E-mailaddress:mafalda.uva@insa.min-saude.pt(M.deSousa-Uva).

http://dx.doi.org/10.1016/j.pcd.2016.05.003

Pleasecitethisarticleinpressas:M.deSousa-Uva,etal.,Trendsindiabetesincidencefrom1992to2015andprojectionsfor2024:APortuguese

1.

Introduction

DiabetesMellitus(DM)isachronicdiseasecharacterizedby high levelsofblood glucose, that developseitherfrom the destruction of insulin-producing cells (type 1 diabetes) or whenbodytissuesbecomeresistanttotheactionofinsulin, eveninastateofcirculating hyperinsulinemia(type 2 dia-betes)[1].Type1DMisanauto-immuneconditionthatusually developsinchildhoodoradolescence,whiletype2DM devel-ops in adulthood and is associated with obesity, physical inactivityandunhealthydiet.Thelatterrepresents90%ofthe globalcasesofdiabetes[2,3].

DMisknownasamajorcauseofmorbidityandmortality worldwide,beingoneofthemainresponsiblefortheglobal burdenofdisease[4]._{Itistheleadingcauseofblindness,}

kid-neyfailureandamputationworldwide[5],andisresponsible forcausingcardiovascular problemsthatleadto50–80%of deathsinpeoplewithdiabetes[6].TheprevalenceofDMin Portugalin2014wasestimatedat13.1%(10.8%inwomenand 15.8%inmen)[7]andPortugalisknownastheEuropeanUnion countrywiththehighestprevalenceofthischronicdisease

[8].

While prevalence data is updated annually, based on the 2010PREVADIAB nationwide study [9], and taking into considerationdemographicchanges,diabetesincidencehas garnered less attention as a health indicator.The General Practitioner’s (GP) Sentinel Network (GP Sentinel Network) represents,inPortugal,theonlydatasourceondiabetes inci-dence,since1992tonowadays.

Thus,thisstudyaimedtogaininsightinto theDM inci-dence trends, between 1992 and 2015, in the Portuguese population under observation ofthe GP Sentinel Network, aswellastomakeprojectionsforthefutureincidencerates basedonthisknowledge.

2.

Methods

GP Sentinel Network is a network based on the volunteer workofGeneralPractice/FamilyMedicinedoctorswhose pro-fessionalactivityisdevelopedinprimaryhealthcarecenters of the Portuguese National Health System. These doctors report several health events, agreed each year. Between 1992and 2015(except2001and 2002),family doctorsfrom GP Sentinel Network reported all new cases of DM (both types 1 and 2) in their patients’ lists. Diabetes case def-inition used was based on Directorate-General of Health (DGS) guidelines for clinical practice [10]. From 1992 to 1995 the GP Sentinel Network covered only Portuguese mainland, but since 1996 and 1997 Madeira and Azores (Portugueseislands)began,respectively,participationinthe network.

Anecologicaltime-seriesstudywasconductedusingdata fromtheGPNetworkbetween1992and2015,withexception oftheyears2001and2002.

EveryyearGP’supdatethecompositionoftheirpatients’ lists,takingintoaccountsomeuserscharacteristicssuchas ageandgender,whichrepresentvariablesalsoconsideredin thisstudy.

The annual DM incidence rates were calculated divid-ing the observed number ofnew cases by the population undereffectiveobservationfromtheGPNetworkduringthe years understudy.Thepopulationunder effective observa-tion (PUEO) isthe annual averageofthe GP’s patients’ list weeklysum:PUEO_t=



ofpatientscomposingtheGPmlist;andItmisavariablethat

takesthevalue1ifthedoctormwasactiveinweekt,and0 otherwise.Theywereonlyconsideredthepatients’listsfrom theGP’swhowereactiveoneachweek(whichmeansthose that reported cases, evenif theywere of zero). The popu-lationundereffectiveobservationusedasthedenominator fortheannualincidencerateistheaverageofthe PUEOin the52weeksoftheyear,namely:PUEOyear=



t=1PUEOt/52.

Thepopulation undereffectiveobservationvariedbetween 231,292in1991and 37,363in2015.Theincidencerate esti-matesarepresentedper100,000inhabitants,pertriennium, and disaggregated by sex and age group. The triennium 2001–2003haveonlydatafor2003,sincethenewcasesof dia-beteswerenotreportedbytheGPnetworkintheyears2001 and2002.

Poisson regression models were used to estimate the annualtrendsfrom1992to2015.Theobservedincidencerates were then adjustedforthePortuguesepopulation distribu-tion,accordingtoestimatesfromtheStatisticsPortugal[11]. Theincidencerateprojectionsfrom2015to2024,sexandage groupstratified,werealsoestimatedusingPoissonRegression modelsasproposed byHakulinen andDyba[12].Incidence rateprojectionswerethenadjustedtotheresidentPortuguese population distributiongiventheStatisticsPortugal projec-tions [13]. Prediction intervals forthe projected rates were calculatedbasedontheworkofDybaandHakulinen[14]. Pear-songoodnessoffitstatisticandresidualanalysiswereusedto assessthegoodnessofthefittedmodels.

3.

Results

3.1. Totalandsexstratifiedincidence

In the first triennium under study, 1992–1994, the annual incidenceratewas261.7/105_{inhabitants,andinthelast}

tri-ennium,2013–2015,was630.42/105_{inhabitants(Fig.1).Until}

1998–2000,theannualincidenceratewashigherinwomen, andfrom1998–2000to2013–2015turnouttobehigherinmen (Fig.1).

The average increase in DM incidence rate was 4.29% (CI95% 3.80–4.80) per year understudy.In menthe annual trendwasalsoofincrease(5.16%[CI95% 4.47–5.86])aswell asinwomen,althoughslighter forthelatter(4.29%[CI95% 3.80–4.80]).

3.2. Totalandsexstratifiedprojectedincidence

The incidence rate projected for 2022–2024 was 972.77/105

inhabitants in total (CI95% 864.05/105_{–1081.49/10}5_{), and}

846.74/105 _{(CI95% 707.98/10}5_–985.49/105_{) and 1114.42/10}5

(CI95% 944.13/105_{–1284.72/10}5_{), respectively, in women and}

Pleasecitethisarticleinpressas:M.deSousa-Uva,etal.,Trendsindiabetesincidencefrom1992to2015andprojectionsfor2024:APortuguese

1992-1994 1995-1997 1998-2000 2001-2003 2004-2006 20072009- 20102012- 20132015- 20162018- 20192021- 20222024

-Women CI95% lower 578.64 642.73 707.98

Women 280.89 283.78 318.38 312.73 493.10 514.41 562.34 586.65 696.02 770.67 846.74

Women CI95% upper 813.41 898.61 985.49

Men CI95% lower 747.99 845.85 944.13

Men 240.96 264.58 331.46 415.65 552.74 604.05 741.66 678.87 893.62 1003.851114.42

Men CI95% upper 1039.26 1161.851284.72

Total CI95% lower 696.97 780.11 864.05

Total 261.65 274.53 324.69 362.37 521.80 557.40 647.91 630.42 789.57 880.74 972.77

Total CI95% upper 882.16 981.36 1081.49

0 200 400 600 800 1000 1200 1400 In cid en ce rate p er 10000 0 inhabitants

Diabetes incidence rate between 1992-2015 and projecons unl 2024

Fig.1–DiabetesMellitusannualincidencerateprogressioninthepopulationunderobservationfromGPSentinelNetwork andprojectionsfor2024,sexstratified.

3.3. Agestratifiedincidence

Asexpected,therewereobservedgreaterDMincidencerate estimatesintheoldestagegroups.Generally,inmentheage groupwithagreaterincidenceratewasthe55–64yearsold (Fig. 2)andinwomenitwasthe65–74yearsoldagegroup (Fig.3).

TherewasasignificantannualincreaseinDMincidence ratein theage groups abovethe 55 yearsold. Thegreater increasewasseeninmeninthe75+agegroup(7.05%peryear [IC95%5.52–8.60]).

3.4. Agestratifiedprojectedincidence

The higher incidence rate projected for 2022–2024 was, in women, in the age group 65–74 years old (1730.06/105

inhabitants [CI95% 1430.56–2029.56]) and, in men, in the age group 55–64 years old (2412.22/105 _{inhabitants [CI95%}

1569.47–3254.97])(Figs.2and3).

4.

Discussion

TherewasanincreasingtrendintheDMincidenceinthetime periodunderstudy,from1992to2015.Weproposethatthis increasecanberelatedwiththreemainpossiblereasonsthat couldbeactingjointlyorindividually.Ononehand,itcould beassociatedwithanincreaseintheprevalenceofobesityin Portugal[15],asobesityisknownintheliteratureasoneofthe mainriskfactorsfortype2diabetes[5].Ontheotherhand,it couldalsoberelatedwiththeincreasinglypronounced popu-lationaging,sincetheestimatesoftheDMincidenceinthis studyarehigheratolderagesandthereisevidencethatthe overallDMincreaseswithage[16].Finally,itcouldalsobe asso-ciatedwiththechanginginDiabetesdiagnosiscriteria,in2002, whicheventuallycouldjustifyahighernumberofdiagnosed

casesinrecentyears[17].Followingtheknowndistributionof diabetesnewcasesbyagegroup,weexpectthattype2 dia-betesrepresentthelargestnumberoftheobserveddiabetes casesreportedherebytheGPsentinelnetwork,andthusalso oftheprojectedrates.

Theinversionofdiabetesincidenceestimatesamongmen and women, until 1998–2000 higher in females, and after that time period higher in males, it is as far as we know not described in the national literature, although already describedintheinternationalliterature[18].However,itseems consistent with available prevalence data, where men are moreaffectedbydiabetesthanwomen[7].Suchaneventmay beassociatedwithanincreaseinthediseasediagnosisinmen duetotheincreaseddemandforhealthcareinrecentyearsby thisgroup.Ontheotherhand,maybeduetopositivechanges ineatingbehaviorsmorepronouncedinwomeninthelast years[8,19].Itcouldbeevenbecauseofagreaterfrequencyof obesityinrecentyearsinmen[8].

InwhatconcernsDMincidencerateprojections,basedon themostlikelyscenario,weprojectedthatthenumberofnew casesofindividualswithdiagnoseddiabetesinPortugalwillbe 972.77/105_{habitantsby2022–2024.Thefittedmodelactually}

producedestimateswhichseemedsimilartothoseobserved. Thisisthe firststudy inPortugal thatestimates projec-tionsfordiabetesincidence,sowehavenotermofcomparison nationally.However,ourresultsseemreasonablewhen com-paredtotheUnitedStates(U.S.)populationwhoseincidence projections are from 800/105 _{habitantsin 2008to 1500/10}5

habitantsin2050[20].

Theincreaseindiabetesincidenceprojectedherecouldbe largelyattributabletotwomajordemographicfactors,similar tothosepointedbyBoyleandcolleagues[20]:(1)Portuguese populationaging;and(2)increasingsizeofhigherriskgroups. Furthermore,theprojectionswereportsufferfromseveral limitations,suchasnotbeingabletodiscernbetweentype 1andtype2diabetes.Otherrelevantlimitationsincludenot

Pleasecitethisarticleinpressas:M.deSousa-Uva,etal.,Trendsindiabetesincidencefrom1992to2015andprojectionsfor2024:APortuguese 1992-1994 19951997- 19982000- 20012003- 20042006- 20072009- 20102012- 20132015- 20162018- 20192021- 20222024 -0-14 13.58 12.62 27.74 31.54 16.84 5.12 0.00 67.01 27.01 29.17 31.49 15-24 11.08 19.00 16.59 12.96 34.71 28.04 33.99 35.47 42.90 46.77 50.64 25-34 46.58 29.48 52.93 161.19 79.70 99.14 87.33 91.19 145.93 170.48 199.17 35-44 171.17 176.53 268.89 378.70 460.19 376.48 415.85 225.37 529.06 573.68 618.30 45-54 563.21 576.05 642.20 948.40 995.70 1051.11 991.64 1059.75 1288.48 1383.05 1477.62 55-64 677.39 738.87 830.74 981.79 1375.94 1590.24 2222.99 1530.07 2051.66 2231.94 2412.22 65-74 658.44 723.32 958.80 817.24 1347.43 1467.11 1674.48 1684.86 1922.41 2085.37 2248.33 75+ 337.95 436.90 499.00 478.60 950.94 956.22 1223.82 1273.50 1387.01 1521.92 1656.82 0.00 500.00 1000.00 1500.00 2000.00 2500.00 3000.00 Incidence rate per 10000 0 inhabitants

Diabetes incidence rate between 1992-2015 and projecons unl 2024, in men, per age group

Fig.2–MenDiabetesMellitusannualincidencerateprogressioninthepopulationunderobservationfromGPSentinel Networkandprojectionsfor2024,agegroupstratified.

takingintoconsiderationpossibleeffectsoflocalinitiatives concerningdiabetespreventioninPortugalandthe dropin thepopulationundereffectiveobservationfromtheGP Sen-tinelNetworksince1992tonowadays.Boththeselimitations may,eventually,reducetheprojecteddiabetesincidencerates. Thedropinthepopulationundereffectiveobservationcould beassociatedwithnewtasksattributedtoGPsmedical spe-cialtyinthelastfewyearsinPortugal,whichcouldgavethem lesstimetonotifythenewcasesofdiseaseintheirpatient lists. This is infact the reasonpointed out by the largest number of GPs who left the network. On the other hand, simultaneously,theprimarycaresystemhasbeen recently restructured in Portugal, which could also explain some

dissatisfaction with the working conditions. Additionally, manyofthedoctorswhowerepartoftheGPsnetworkwhen itwascreatedarenowpassingthrougharetirementprocess. Thisdropinthepopulationundereffectiveobservationcould eventuallyberesponsibleforareductionintheprojected dia-betesincidencerates,becausetheGPswhoremainedintheGP SentinelNetworkcouldbethoseparticularlyinterestedinthe reporteddiseases.TheotherGPswholeftthenetwork,could nothavereportedaswellinolderyears,sincetheydidnot havesomuchattentionandinterestinthehealthproblems understudyandintheGPnetwork.Ifthis“lessmotivatedGPs” continuedinthesentinelnetwork,itshouldbeobserved even-tuallylowerincidencerates,whichcouldresultinadecrease

1992-1994 1995-1997 1998-2000 2001-2003 2004-2006 2007-2009 2010-2012 2013-2015 2016-2018 2019-2021 2022-2024 0-14 8.10 18.25 9.49 33.67 10.59 10.79 12.50 27.54 18.75 19.98 21.30 15-24 10.73 15.99 13.22 0.00 44.37 0.00 34.41 0.00 25.87 28.16 30.66 25-34 43.28 45.36 56.37 31.36 57.09 40.69 121.29 71.29 79.91 86.54 93.71 35-44 190.96 171.68 183.58 200.92 270.63 269.31 212.49 169.14 269.97 283.29 297.28 45-54 530.06 436.83 508.45 600.40 762.70 730.57 658.43 745.24 845.91 892.54 939.18 55-64 744.76 677.84 802.06 576.37 1163.40 1156.66 1305.21 1190.29 1384.56 1473.73 1562.90 65-74 714.29 865.82 870.77 856.21 1157.17 1232.73 1391.75 1403.58 1527.53 1628.79 1730.06 75+ 439.50 442.16 493.07 510.79 907.59 1008.85 985.06 1142.75 1247.61 1356.23 1464.85 0 200 400 600 800 1000 1200 1400 1600 1800 2000 Inc id e n ce r at e per 100 0 00 i nh abi ta n ts

Diabetes incidence rate between 1992-2015 and projecons unl 2024, in women, per age group

Fig.3–WomenDiabetesMellitusannualincidencerateprogressioninthepopulationunderobservationfromGPSentinel Networkandprojectionsfor2024,agegroupstratified.

Pleasecitethisarticleinpressas:M.deSousa-Uva,etal.,Trendsindiabetesincidencefrom1992to2015andprojectionsfor2024:APortuguese oftheprojectionsherereported.Quitetheopposite,

unfore-seenincreasesinlifeexpectancy ortheimplementation of furtherdiabetesscreeningactionsmayincreasethenumber ofnewlydiagnoseddiabetescases.Also,changesindiagnostic criteriacouldaffectincidencerates,aswellastheincreased ordecreasedaccesstomedicalcare.

Wehaveassumedalinearincreaseindiabetesincidence likeBoyleetal.,2001[21].However,diabetesincidenceseemed torisedifferentlyuntil2003andafterthistimeperiod.Should theriseindiabetesincidenceratesbenonlinear,our projec-tionsmaybeoverestimated.Nonetheless,wearguethatthe generalizedlinearmodelusedisaconsistentandwidelyused methodusefulforafirstapproachtothissubjectinPortugal givingtheGPsSentinelNetworkdataset[12,14].

Finally,itshouldbenoticedthatthedisturbingreported projectionsseemrealisticifthecircumstancescontinueasin thepast,withnomajorPublicHealthchangesoccurring con-cerningdiabetes. Foraninstance,the projectedincreaseof olderpeoplewithdiabetesunderlinesthe needforabetter supportofsocialandhealthcareservicesinthisagegroup.

EffectivePublicHealthpolicieswillneedtobeundertaken tominimizethisalarmingfuturescenario.Actually,thisstudy couldgivesomesupportforPublicHealthgoalsdesigninorder tominimizetheimpactofdiabetesinthePortuguese popula-tioninfutureyears.

Conflict

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgments

The authors thank the volunteer work of General Prac-tice/FamilyMedicinedoctorsfromtheGP SentinelNetwork whoprovidedinformationaboutincidentcasesofdiabetesin theirpatients’lists.

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