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OPEN Global trend analysis of diabetes

mellitus incidence, mortality,
and mortality‑to‑incidence ratio
from 1990 to 2019
Mohammadreza Balooch Hasankhani 1, Hossein Mirzaei 2,3 & Ali Karamoozian 1,3*
Diabetes Mellitus (DM) is a common chronic disease and a public health challenge worldwide. The
present study aimed to analyze the trend in DM incidence, mortality, and mortality-to-incidence ratio
(MIR) world over 30 years. The age-standardized DM incidence and mortality rates for both genders
and different countries of the world from 1990 to 2019 were extracted from the Global Burden of
Disease (GBD) study and the Human Development Index (HDI) was obtained for all countries from
the United Nations Development Program (UNDP) database. The mean trends for the indicators
for developing countries, developed countries, and all countries were evaluated using Generalized
Estimating Equations (GEE) and the spline model. The estimates showed that the global mean trend
of DM incidence from 1990 to 2019 followed an upward trend with an annual increase of 3.73 cases per
100,000 people. The global mean of DM mortality followed an upward trend with an annual increase
of 0.43 cases until 2005 followed by a downward trend after this year with an annual decrease of 0.14
and the global mean MIR followed a downward trend during the same period with an annual decrease
of 0.001 per 100,000 people. Besides, the mean incidence of DM in developing countries followed an
upward trend similar to the trend in developed countries. Additionally, the mean mortality rate due
to DM in developing countries increased with a slope of 0.62 until 2005 and then decreased with a
slope of 0.02, and the mean MIR trend in the developed and developing countries showed a downward
trend. Thus, developed countries followed a relatively faster decrease in MIR than developing
countries.The data from the present study show the increased incidence of DM has made it one of the
most important health concerns in the world, and if this issue is not addressed, this disease can cause
more concerns for communities in the coming years. This being so, more DM prevention and control
programs need to be put into practice.

Abbreviations
DM Diabetes mellitus
MIR Mortality-to-incidence ratio
GBD Global burden of disease
HDI Human development index
UNDP United nations development program
GEE Generalized estimating equations
WHO World health organization
ADA American diabetes association
IHME Institute for health metrics and evaluation
CEEECA Central Europe, Eastern Europe, and Central Asia
HI High income
LAC Latin America and Caribbean
NAME North Africa and Middle East

1
Modeling in Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical
Sciences, Kerman, Iran. 2HIV/STI Surveillance Research Center, WHO Collaborating Center for HIV Surveillance,
Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran. 3Department
of Biostatistics and Epidemiology, School of Public Health, Kerman University of Medical Sciences, Kerman,
Iran. *email: [email protected]; [email protected]

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SA South Asia
SAEAO Southeast Asia, East Asia, and Oceania
SSA Sub-Saharan Africa

Diabetes mellitus (DM) is a global public health problem that imposes a heavy global burden on public health
and is associated with socio-economic ­consequences1. Various studies have shown that the incidence of DM has
increased in recent d ­ ecades2,3. It is predicted that the number of people with DM will increase from 171 million
in 2000 to 300 million by 2025 and 366 million by 2­ 0304–6. The World Health Organization (WHO) report on
DM mortality showed that the mortality rate due to DM increased by 3% from 2000 to 2­ 0197, and DM is the
leading cause of death of 1.5 million people in 2­ 0198.
DM can lead to complications in different body organs and tissues and aggravate other disorders and com-
plications, leading to a heavy economic burden. The mean medical costs for people with DM are estimated to
be 2.3 times higher than the medical costs of people without DM. The American Diabetes Association (ADA)
reported that the cost of diagnosed DM in 2017 was $327.2 billion. Given the growing economic costs and the
social burden that DM and its complications impose on s­ ocieties9, there is a need for further research on DM
in all countries.
Generally, the increasing incidence of DM in different regions is different due to several factors such as life-
style, eating habits, access to health care, etc. Furthermore, the prevalence of obesity is increasing all over the
­world10 due to high-calorie diets and sedentary lifestyles. Thus, the increased prevalence of obesity along with
population aging is one of the main reasons behind the increased prevalence of ­DM11. Another factor affecting
variations in the prevalence of DM in different countries can be the development rate of the countries. According
to the WHO, the prevalence of DM in low- and middle-income countries has increased at a faster rate than in
high-income ­countries7. Moreover, IDF Diabetes Atlas (2021) reported that three out of every four adults with
DM live in low and middle-income c­ ountries12. The Human Development Index (HDI) is one of the important
measures of mean achievement, living conditions, and human development in different countries. Thus, it is
necessary to compare developing and developed countries in terms of the prevalence of diabetics to help poli-
cymakers in controlling the process of this disease.
Most of the epidemiological studies conducted on the incidence and mortality rate of DM have used descrip-
tive or cross-sectional designs. Furthermore, no study has yet addressed the effects of the development and
geographical location on the incidence, mortality, and MIR of diabetics. For example, in recent years, several
epidemiological studies have investigated the incidence and mortality of DM in different parts of the world. Jinli
Liu et al. reported that the age-standardized incidence of diabetics worldwide increased from 234 in 1990 to 285
cases per 100,000 in ­201713. Xiling Lin et al. also showed that the age-standardized mortality rate worldwide
increased from 15.7 to 17.5 per 100,000 people from 1990 to 2­ 01714. Thus, a suitable statistical technique with
a high degree of accuracy needs to be used to describe and compare this diversity in the incidence of diabetics
in different regions from 1990 to 2019. To this end, using longitudinal data, the present study aimed to examine
the DM incidence and mortality rates worldwide and specify the impact of development on the variations in the
DM incidence and mortality rates in different regions of the world. The insights from this study can be used by
international policymaking support centers active in the field of diabetics to bridge the existing gaps.

Methods
Data sources
In this study, the data on the age-standardized DM incidence and mortality rates per 100,000 people for both
genders and different countries of the world from 1990 to 2019 were extracted from the Global Burden of Dis-
ease (GBD) free online database of the Institute for Health Metrics and Evaluation (IHME) of the University of
­Washington15. Then, the mortality-to-incidence ratio (MIR) was calculated by dividing the age-standardized
mortality rate by the age-standardized incidence rate for both sexes in each year and in different countries. MIR
is a measure of the burden of disease in a specific region or country. This ratio determines whether a country or
region has a higher or lower mortality rate for a specific disease that is normalized to its incidence. MIR is also
a simple and common method to estimate the 5-year relative survival rate of p ­ atients16,17.
Human Development Index (HDI) data were also from the United Nations Development Program (UNDP)
database for each country from 1990 to ­202118. Accordingly, the countries with HDI values less than 0.788 were
considered developing countries, and countries with HDI values of 0.788 or higher were taken as developed
­countries19. Finally, 189 countries with available incidence and mortality rates and HDI data were included in
the study.

Statistical analysis
In this longitudinal study, summary statistics related to DM incidence rate, mortality rate, and MIR were pre-
sented for each IHME region from 1990 to 2019. Then, the annual mean trends of the indicators were graphically
shown based on the region and the development level. In the next step, the marginal modeling approach and
the Generalized Estimating Equation (GEE) method were used to evaluate the longitudinal effect of develop-
ment on the incidence, mortality, and MIR of DM. GEE is a population-level approach that allows researchers
to obtain estimates of model parameters that are averaged over the entire ­population20. To examine the mean
trends in DM burden indices, the marginal model was fitted separately for developed and developing countries
as shown in Eq. (1):
µij = β0 + β1 timeij (1)

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where µij is the mean indexes for country i (i = 1,2,…,189) in year j (j = 1,2,…,30), β0 is the intercept, and β1 is the
slope of the model showing the mean annual changes in the indices. Moreover, for cases where the mean trend
had a non-linear pattern, the spline model (Eq. (2)) was used:
(timeij − t ∗ )+ = 0, timeij ≤ t ∗

µij = β0 + β1 timeij + β2 (timeij − t ∗ )+ (2)
(timeij − t )+ = timeij − t , timeij > t ∗
∗ ∗

where t ∗ is the turning point of the mean trend g­ raph21. All statistical procedures and model fitting were per-
formed in SPSS-26 and STATA-17 software.

Results
A total of 189 countries were included in the study to evaluate the DM incidence, mortality, and MIR from 1990
to 2019. Figure 1 shows the trends of the DM incidence, mortality, and MIR in different regions based on the
IHME data. As can be seen, all regions experienced a significant increase in the incidence of DM during the 30
years (Fig. 1a). The mortality rate for LAC was relatively stable during the period and the HI region experienced
a downward trend in the mortality rate. Moreover, the CEEECA, NAME, SA, SSA, and SAEAO regions showed
an upward trend in the mortality rate due to DM. However, the NAME countries had an upward trend from
1990 to 2006 and a decreasing trend in their DM mortality from 2006 to 2019. In addition, the SAEAO countries
experienced a significant upward trend from 1990 to 2005, but they followed a steady trend from 2005 to 2019.
Likewise, SSA displayed an increasing trend from 1990 to 2004 and followed a stable trend from 2004 to 2019
(Fig. 1b). The trend of diabetes-induced MIR for the CEEECA and SA regions was relatively stable over the
period, while an upward pattern was observed in other regions (Fig. 1c).
Table 1 shows the descriptive statistics for DM incidence, mortality, and MIR in each IHME region and all
countries studied in 5-year intervals and 2019. As shown in the table, the countries in the SAEAO region have
the highest incidence and mortality rates and the countries in the SSA region have the highest MIR from 1990
to 2019. In addition, the maximum incidence and mortality rate were found in the SAEAO region in 2019, and
the maximum MIR was observed in the SSA region in 1990.
Table 2 shows the descriptive statistics for DM indicators by developing and developed countries in the
studied period. As can be seen, developing countries had a lower incidence rate and a higher mortality rate and
MIR in the period in question.
Figure 2 displays the trends of DM incidence, mortality, and MIR for developing countries, developed coun-
tries, and the whole world from 1990 to 2019. As shown in this figure, the mean incidence and MIR for develop-
ing, developed countries, and the whole world seem to follow a linear trend. Thus, the linear GEE model was
used to assess the mean trends. Moreover, as the mean mortality rate for all three regions follows a non-linear
pattern, the spline model (the existence of a peak in 2005) was used to investigate the DM mortality trends.
The estimated coefficients and parameters based on the GEE and spline model are presented in Table 3. The
results in this table suggest that the developed countries had an intercept of about 3 per 100,000 people more
than the developing countries. This means that the mean incidence rate in developed countries was about 3 per
100,000 people higher than the incidence of diabetics in developing countries in 1990. In addition, the mean inci-
dence rates in developed and developing countries follow an upward trend, and the estimated slope of the mean
incidence rates is almost the same (3.65 vs. 3.78), indicating a relatively similar increase in the mean incidence
of diabetics in both developing and developing countries. Moreover, the estimated intercept for the incidence of
DM in all countries was about 213.96 per 100,000 people in 1990 with a positive slope with an annual increase
of 3.73 per 100,000 from 1990 to 2019 for the entire world.
The intercept for the mortality rate in developing countries was about 15 per 100,000 people more than in
developed countries. The mean mortality rate from DM in developing countries increased annually until 2005
with a positive slope of 0.62 per 100,000 people and then followed a downward trend with a slope of 0.02 from
2005 to 2019. The mean trend mortality rate for developed countries was almost constant during the study
period (P > 0.05). The mean mortality rate for all countries shows that the estimated intercept for the mortality

500 100 0.25 CEEECA

Age-standardized incidence rate

Age-standardized mortality rate

HI
Age-standardized MIR rate

400 80 0.2
LAC

300 60 0.15 NAME

SA
200 40 0.1 SAEAO
SSA
100 20 0.05
Global

0 0 0
1990 2000 2010 2020 1990 2000 2010 2020 1990 2000 2010 2020
Year Year Year
(a) (b) (c)
Figure 1.  Mean trends of DM (a) incidence, (b) mortality, and (c) MIR rates per 100,000 individuals by IHME
super regions in the period 1990–2019.

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Year
Super region Index 1990 1995 2000 2005 2010 2015 2019
Incidence 159.6 (48.2)a 173.3 (52.8) 188.7 (54.6) 209 (62.5) 228.6 (69.9) 239.6 (80.4) 252.7 (85.4)
CEEECA (29
Mortality 10.8 (5.2) 13.4 (6.7) 13.7 (8.3) 15.1 (10.4) 15.1 (11.4) 15.9 (12) 15.2 (11.2)
countries)
MIR 0.07 (0.02) 0.08 (0.03) 0.07 (0.04) 0.07 (0.04) 0.06 (0.04) 0.06 (0.04) 0.06 (0.03)
Incidence 190.1 (90.4) 204.1 (97.3) 219.7 (99) 238.3 (104.3) 253.5 (102.4) 263.6 (94.4) 278.1 (89.2)
HI (34 coun-
Mortality 17.9 (19.9) 17.2 (17.3) 17.3 (17.9) 16.5 (17.8) 13.9 (15.4) 12.3 (13.8) 11.9 (12.5)
tries)
MIR 0.09 (0.04) 0.08 (0.04) 0.07 (0.04) 0.07 (0.04) 0.05 (0.03) 0.04 (0.03) 0.04 (0.02)
Incidence 290.8 (87.5) 308.2 (90.6) 327.4 (92.9) 345.7 (91.5) 361 (93.2) 381.5 (94) 398.1 (94.9)
LAC (30
Mortality 47.8 (29.6) 51.5 (29.8) 52.1 (30.1) 51.6 (28) 49.3 (24.8) 48.9 (23.6) 49.7 (24.2)
countries)
MIR 0.16 (0.07) 0.16 (0.06) 0.15 (0.06) 0.14 (0.06) 0.13 (0.05) 0.13 (0.05) 0.12 (0.04)
Incidence 265 (93.8) 295.5 (118.6) 329.2 (140.8) 365.1 (154.8) 399.7 (154.1) 422.7 (153.1) 441.5 (143.4)
NAME (21
Mortality 37.7 (27.6) 37.7 (27.7) 40.1 (33.5) 43.9 (42.2) 43.4 (41.3) 41.3 (36.7) 39.8 (32.9)
countries)
MIR 0.13 (0.06) 0.12 (0.06) 0.11 (0.05) 0.11 (0.06) 0.10 (0.05) 0.09 (0.05) 0.08 (0.04)
Incidence 174.4 (20.6) 185.4 (23.2) 204 (22.3) 224 (29.3) 237.8 (34.3) 255.6 (37.6) 273.3 (38.1)
SA (5 coun-
Mortality 21.6 (6.3) 23.5 (7.7) 26.8 (10) 29.9 (12.6) 30.4 (12.5) 30.9 (12.1) 32.1 (11.7)
tries)
MIR 0.12 (0.03) 0.13 (0.04) 0.13 (0.04) 0.13 (0.05) 0.13 (0.04) 0.12 (0.03) 0.12 (0.04)
Incidence 275.7 (100.7) 302.4 (117.4) 339.1 (139.7) 372.5 (156.3) 397.9 (165.4) 425.2 (168.7) 445 (169.3)
SAEAO (25
Mortality 59.8 (38.8) 67.0 (51.7) 74.9 (62.9) 81.8 (67.5) 80.8 (64.8) 82 (64.2) 82.2 (64.1)
countries)
MIR 0.20 (0.08) 0.20 (0.09) 0.20 (0.09) 0.20 (0.10) 0.18 (0.09) 0.17 (0.09) 0.17 (0.08)
Incidence 174.6 (37.4) 186 (40.5) 200.7 (46.1) 212.8 (51.8) 225.5 (58.7) 233.8 (60.7) 237 (56.5)
SSA (45
Mortality 39.3 (13.7) 41.9 (14.7) 45.9 (18.9) 47.9 (23.7) 47.8 (23.5) 47.2 (22.7) 46.5 (21.3)
countries)
MIR 0.22 (0.05) 0.23 (0.05) 0.23 (0.06) 0.22 (0.06) 0.21 (0.06) 0.20 (0.05) 0.19 (0.05)
Incidence 216.9 (90.7) 234.3 (101.3) 255 (112.6) 276.3 (122.4) 295 (127.8) 310.4 (132.4) 323.6 (133.8)
Global (189
Mortality 34.5 (28.1) 37 (31.5) 39.5 (36.2) 41.4 (39.6) 40.4 (38.5) 39.9 (37.8) 39.6 (37.2)
countries)
MIR 0.15 (0.08) 0.15 (0.08) 0.14 (0.08) 0.14 (0.09) 0.13 (0.08) 0.12 (0.08) 0.12 (0.08)

Table 1.  Mean trend of DM incidence, mortality, and MIR per 100,000 by IHME super region over 1990–
2019. CEEECA Central Europe, Eastern Europe, and Central Asia, HI high income, LAC Latin America and
Caribbean, NAME North Africa and Middle East, SA South Asia, SAEAO Southeast Asia, East Asia, and
Oceania, SSA Sub-Saharan Africa. a Mean (standard deviation).

Year
Countries Index 1990 1995 2000 2005 2010 2015 2019
Incidence 215.9 (85.1)a 233.1 (94.1) 254.6 (105.5) 275.4 (113.7) 294.4 (119.9) 310.6 (126.2) 323.3 (130.7)
Developing (118
Mortality 40.2 (27.3) 43.9 (32.3) 47.7 (37.9) 50.1 (40.5) 49.4 (38.5) 49.9 (38.4) 49.8 (38.2)
countries)
MIR 0.18 (0.08) 0.18 (0.08) 0.18 (0.08) 0.18 (0.08) 0.16 (0.07) 0.16 (0.07) 0.15 (0.07)
Incidence 218.6 (100) 236.3 (113) 255.7 (124.3) 277.7 (136.4) 296.1 (140.7) 310 (143.1) 324.1 (139.8)
Developed (71
Mortality 25 (27) 25.4 (26.6) 25.8 (28.6) 26.9 (33.4) 25.3 (33.6) 23.2 (30.2) 22.5 (28.4)
countries)
MIR 0.10 (0.06) 0.09 (0.05) 0.09 (0.05) 0.08 (0.05) 0.07 (0.05) 0.06 (0.05) 0.06 (0.04)

Table 2.  Mean trend of DM incidence, mortality, and MIR per 100,000 by development factor over 1990–
2019. a Mean (standard deviation).

rate in all countries in 1990 was about 34.40 per 100,000 people and then the annual mean mortality rate for
DM increased with a positive slope of 0.43 per 100,000 people until 2005 and then followed a downward trend
with a slope of 0.14 from 2005 to 2019.
Finally, the mean MIR for developing countries was about 1.8 times that of developed countries in 1990.
Likewise, the estimated slope for the mean MIR in developed countries followed a downward trend and was
twice that of developing countries from 1990 to 2019. Moreover, the mean global MIR decreased significantly
with an annual decrease of about 0.001 units.

Discussion
The results of this study showed that the global mean incidence rate of DM followed an upward trend in both
developed and developing countries from 1990 to 2019. The global mean mortality rate due to DM also fol-
lowed an upward trend in developing countries until 2005, and then a downward trend, but showing no sig-
nificant change in developed countries over time. The mean MIR showed a downward trend in both developed

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400 60

Age-standardized incidence rate

Age-standardized mortality rate

300
45

200
30

100

15
0
1990 2000 2010 2020
Year 0
1990 2000 2010 2020
Year
Developing Developed World

(a) (b)
0.2
Age-standardized MIR rate

0.15

0.1

0.05

0
1990 2000 2010 2020
Year
(c)
Figure 2.  Mean trends of DM (a) incidence, (b) mortality, and (c) MIR rates per 100,000 individuals by
development factor and total world countries in the period 1990–2019.

and developing countries, while developed countries had a relatively faster decrease in MIR than developing
countries.
An analysis of the global incidence rate of diabetics showed that almost all countries experienced a significant
upward trend from 1990 to 2019 with an annual increase of 3.73 per 100,000 people. The upward trend in the
incidence of DM was consistent with some other reports around the world. For example, Lin et al. found that
the incidence of DM increased globally from 1990 to ­201714.
A comparison of the incidence of DM in developed and developing countries from 1990 to 2019 showed no
significant difference in the increase in the incidence rate of diabetics in developed and developing countries
(slope 3.65 vs. 3.78). Moreover, the descriptive analysis indicated the incidence of DM in developed countries
has increased by 48.2% in these 30 years, while this increase in developing countries in the same period has been
slightly higher (49.7%). According to Jinli Liu et al., the incidence of DM has increased in both developing and
developed ­countries13.
The increased incidence of DM can typically be attributed to a higher prevalence of risky behaviors such as
obesity, inactivity, and unhealthy diet. Accordingly, a systematic review study showed that lifestyle interven-
tions such as physical activity and healthy diets can lead to a reduction in ­DM22. Studies have also shown that
the prevalence of o­ besity23 and the ratio of energy received through fat has increased over t­ ime24. In addition,
population aging can also be one of the reasons for the increase in the incidence of DM. Studies have confirmed
that the incidence of non-communicable diseases increases with population ­aging25. Another factor affecting
the increased incidence of DM is the improvement of DM diagnosis methods. With the improvement of DM
screening techniques and improved public awareness, people’s participation in screening programs has increased,
leading to the detection of more diabetic cases. Furthermore, studies have indicated that the percentage of people
with undiagnosed DM has decreased over ­time26. A study showed that the number of people who tested HbA1c
increased over time. The level of public literacy has also increased in ­communities25. In addition to the more
accurate diagnosis methods, measurement and diagnosis methods also adjusted, for example, screening criteria
have changed over time and the cut-off points for DM diagnosis have decreased over t­ ime27.
An analysis of the DM mortality rate for each IHME region indicated that all regions except HI have had an
increasing trend in the DM mortality rate from 1990 to 2019, as confirmed in some other reports around the

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HDI level Index Parameter Estimate Standard error P-value

Intercept 212.67 8.27 < 0.001
Incidence
Time 3.78 0.21 < 0.001
Intercept 40.13 1.67 < 0.001
Developing Mortality (non-linear) Time 0.62 0.15 < 0.001
(Time-16) − 0.64 0.28 0.023
Intercept 0.188 0.0074 < 0.001
MIR
Time − 0.001 0.0001 < 0.001
Intercept 216.10 12.94 < 0.001
Incidence
Time 3.65 0.31 < 0.001
Intercept 24.88 1.77 < 0.001
Developed Mortality (non-linear) Time 0.12 0.16 0.459
(Time-16) − 0.45 0.30 0.135
Intercept 0.103 0.0070 < 0.001
MIR
Time − 0.002 0.0001 < 0.001
Intercept 213.96 7.09 < 0.001
Incidence
Time 3.73 0.18 < 0.001
Intercept 34.40 1.30 < 0.001
Total World Mortality (non-linear) Time 0.43 0.12 < 0.001
(Time-16) − 0.57 0.22 0.010
Intercept 0.16 0.0061 < 0.001
MIR
Time − 0.001 0.0001 < 0.001

Table 3.  Parameter estimates from modeling the mean trend of DM incidence, mortality, and MIR by
development factor between 1990 and 2019. HDI human development index.

world. For example, Lin et al. found that the global trend of mortality due to DM increased from 1990 to 2­ 01714.
Other studies have also reported a downward trend in DM mortality in the countries in the HI region, including
­Canada28, ­Australia29, United Kingdom, and several European c­ ountries30. According to Xiling Lin et al., the
mortality rate of DM in high-income countries decreased from 1990 to ­201714.
The data in the present study also showed the global mean mortality rate due to DM increased by 0.43 per
100,000 people annually until 2005 following a decrease by a factor of 0.14 in each follow-up year. One of the
reasons for the reduction of mortality due to DM can be the reduction of complications due to DM. Accordingly,
Mohammed K Ali et al., found that hospital admissions due to diabetic complications decreased after 2­ 00531.
Our findings also suggested that the DM mortality rate in developing countries has increased by 23.9% in 30
years but decreased by 9.9% in developed countries. In a similar vein, Xiling Lin et al. compared the mortality
rates due to DM between developing and developed countries and reported that the number of death due to
DM increased in developing countries annually until 2005 with a positive slope of 0.62 in every 100,000 people
and then followed a downward trend with a negative slope of 0.02. However, no significant change was observed
in developed countries over time. The decreased mortality rate caused by DM in developing countries can be
attributed to the developments in DM education, continuous monitoring of blood sugar, and widespread use of
insulin and its a­ nalogs32,33. The absence of a significant change in DM mortality in developed countries can be
attributed to improvements in developed countries in previous years. However, the mortality rate has followed a
stable trend since then. In contrast, a study by Lin et al. and the report of the World Health Organization showed
that the mortality rate due to DM has increased in the ­world14. A reason for such contradictory findings is that
previous studies in the literature have used only descriptive statistics, while robust analytical techniques such as
GEE and spline model were used in the present study to assess the linear and non-linear indicators of the DM
incidence, mortality, and MIR.
In the present study, MIR was used as a surrogate index for the five-year survival rate of diabetic patients.
According to our findings, MIR followed a downward trend from 0.15 in 1990 to 0.12 in 2019 with a partial slope
of 0.001 (showing an mean annual decrease). Consistent with the findings of the present study, a meta-analysis
study showed that the mortality proportion among DM patients in the world decreased by 43% from 1970 to
1989, by 53% from 1990 to 1999, and by 74% from 2000 to 2­ 01634. MIR is a measure of the number of patients
who die after developing DM. This index can indicate the improvement of early diagnosis and better control of
the ­disease35. A look at the MIR trend in IHME regions shows that HI countries have had the largest decrease
(from 0.09 to 0.04 with a 54% decrease) in these years, while the countries in the SA region have had the lowest
decrease (from 0.123 to 0.117 with a 5% decrease) in the same period. Moreover, during a 30-year follow-up,
developed countries had a greater reduction in MIR of DM than developing countries. It seems that the survival
rate of patients in the richest region has improved faster compared to other regions. The key reasons for this
increase in survival rates are likely to be more widespread screening programs and early detection of the disease,
the promotion of knowledge, attitudes, and practices of people around the world about DM prevention strategies,
and improved levels of care for diabetic patients.

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The significant association between HDI and MIR shows that in recent years, developed countries have
focused on improving the adoption of a healthy lifestyle as well as access to health care services in the prevention
or control of DM and increasing life expectancy. On the other hand, socioeconomic status is directly associated
with the patient’s survival. Thus, patients with higher socioeconomic status may experience more survival due
to greater and better access to DM related care and s­ ervices36.
The most important limitation in the present study was the unavailability of accurate and reliable data on DM
incidence and mortality rates in some countries, especially in less developed areas, is a significant limitation that
may affect the accuracy of the study’s findings and conclusions. Therefore, future studies should focus on collect-
ing more accurate and reliable data on DM incidence and mortality. However, the main strength of the present
study was the use of longitudinal GBD data with a long follow-up period with 30 repeated measurements and the
use of advanced statistical models that enabled us to obtain more accurate estimates. On the other hand, using
MIR as a proxy for survival is a reliable approach to explain the differences in the age-standardized incidence
and mortality rates due to DM in different geographical areas. To calculate this index, there is no need to con-
duct studies with long-term follow-up, which are potentially time-consuming, expensive, and prone to various
biases. Moreover, to the best of our knowledge, unlike the present study, no study has evaluated the relationship
between development and MIR of DM.

Conclusion
The results in the present study indicated that the increased incidence of DM is one of the most important health
concerns in the world. With the extensive changes in recent years in people’s lifestyles, increasing urbanization,
industrialization, and population aging in developing countries, the incidence and mortality rates of diabet-
ics are somewhat similar to developed countries. If the changes in the risk factors for DM are not taken into
account, this disease can cause more concerns for communities in the coming years. This being so, countries
should implement cost-effective DM prevention and control programs to increase public awareness of DM risk
factors, promote active lifestyles, improve nutrition, and increase access to diagnostic and treatment services.

Data availability
The datasets generated and analysed during the current study are available from the corresponding author upon
reasonable request.

Received: 28 August 2023; Accepted: 6 December 2023

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Acknowledgements
The authors thank the GBD and UNDP team for their free access and comprehensive database.

Author contributions
M.B.H. contributed to the acquisition, analysis, and interpretation of data and writing the manuscript. H.M.
and A.K. have contributed to the conception and design of the work and writing the manuscript. All authors
have approved the final draft.

Competing interests
The authors declare no competing interests.

Additional information
Correspondence and requests for materials should be addressed to A.K.
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