The burden of type 2 diabetes worldwide and in Europe

Worldwide, 10% of the population aged older than 25 years suffer from type 2 diabetes [1]. According to World Health Organization (WHO) [1], approximately 3.5% of noncommunicable disease-related deaths can be attributed to type 2 diabetes. Furthermore, health-related quality of life of type 2 diabetes patients is downgraded due to complications [2].

Health care system costs are also negatively affected, including the use of health services, productivity loss and disability, which can be a considerable burden to the individual, families and society [3]. Thus, prevention strategies to halt the rise of type 2 diabetes are urgently needed. However, any public health initiative for the prevention of type 2 diabetes should take into consideration the disproportionately higher prevalence of type 2 diabetes among certain population groups.

Diabetes is one of the fastest growing global health emergencies of the 21st century.In 2019, it was estimated that 463 million people had diabetes and this number is projected to reach 578 million by 2030, and 700 million by 2045.

IDF Diabetes Atlas 9th edition 2019

The burden of type 2 diabetes is higher among certain population groups

Low socioeconomic status (SES) has been associated with higher prevalence of type 2 diabetes. In particular, 80% of people suffering from type 2 diabetes live in low and middle income countries [4], whereas in high income countries low education level and high percentage of unemployment have been associated with a 45% and a 31% increased risk of type 2 diabetes in comparison to high education level and low percentage of unemployment respectively [5]. Sex- and ethnic-related dissimilarities are also associated with the development of type 2 diabetes [6, 7].

Given the aforementioned variation in the prevalence of type 2 diabetes, a large segment of the population in low- and middle-income countries as well as certain ethnic groups, immigrants and low SES groups in high-income countries could be at risk for developing type 2 diabetes and any public health initiative should primarily focus on those population groups.

Risk factors for T2D, IDF infographic

Risk factors related to type 2 diabetes

Taking into account that age and genetic predisposition are non-modifiable risk factors [8, 9], special emphasis should be laid upon modifiable risk factors related to type 2 diabetes. Overweight and obesity [10, 11], physical inactivity [12] and unhealthy dietary habits [13-16] are among the most important modifiable risk factors related to type 2 diabetes. The prevalence of those risk factors is more common in low and middle income countries as well as in vulnerable populations in high income countries and particularly low SES groups and immigrants [17-19].

Contextual burdens increase type 2 diabetes, independently or synergistically, to risk factors. Family environment plays an important role in determining lifestyle habits, behaviours and health indices for all family members (i.e. parents, children, grandparents or other adults living together). Family members beyond any genetic predisposition, they also share a common environment which is influenced by common determinants, such as the lack of awareness regarding health issues, misperception regarding healthy body weight, lack of motivation to change risk behaviours related to type 2 diabetes, illiteracy and language difficulties as well as restrictive cultural and religious norms [20-22]. Furthermore, the older family members do not only provide children with the food and the opportunity for physical activity or inactivity, but also serve as role models [23, 24].

Apart from family environment, the community and school environment plays an important role in determining family’s lifestyle habits and health indices. The community environment has been associated with risk factors for type 2 diabetes in both adults and children. Limited access to community facilities (e.g. sports halls, parks, pedestrian areas etc.) as well as lower social support and community resources lead to poor adherence to recommendations [21, 22, 25-27]. School environment, via food availability, physical education class, school curriculum, and teacher and peers acting as role models, can also influence children’s and families’ health-related behaviours [28].

The role of contextual circumstances: the family, school and community environment

Since schools are available even in the most deprived areas, they can serve as entry points to the community for the delivery of any intervention aiming to promote a healthy and active lifestyle for the prevention of non-communicable diseases, such as type 2 diabetes [29]. However, the effectiveness of any school-based initiative is greater when combined with the active involvement of the family as a whole and the community, given the strong interaction among child, family, school and neighborhood environment [30, 31]. Furthermore, school can also help identifying families at high risk for type 2 diabetes and, to avoid stigmatization, discretely refer them to community health centres for further evaluation and intervention.


  1. World Health Organization., Global status report on noncommunicable diseases 2010. 2011, Geneva: World Health Organization. ix, 164 p.
  2. Wandell, P.E., Quality of life of patients with diabetes mellitus. An overview of research in primary health care in the Nordic countries. Scand J Prim Health Care, 2005. 23(2): p. 68-74.
  3. International Diabetes Federation. IDF Diabetes Atlas. 2013; Available from:
  4. World Health Organization., Global action plan for the prevention and control of noncommunicable diseases 2013-2020. (in IRIS). 2013, Geneva: World Health Organization. iii, 103 p.
  5. Agardh, E., et al., Type 2 diabetes incidence and socio-economic position: a systematic review and meta-analysis. Int J Epidemiol, 2011. 40(3): p. 804-18.
  6. Meisinger, C., et al., Sex differences in risk factors for incident type 2 diabetes mellitus: the MONICA Augsburg cohort study. Arch Intern Med, 2002. 162(1): p. 82-9.
  7. Prevention., C.f.D.C.a., National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. 2011.
  8. Harrison, T.A., et al., Family history of diabetes as a potential public health tool. Am J Prev Med, 2003. 24(2): p. 152-9.
  9. Group, D.S. and G. on behalf of the European Diabetes Epidemiology, Glucose tolerance and cardiovascular mortality: Comparison of fasting and 2-hour diagnostic criteria. Archives of Internal Medicine, 2001. 161(3): p. 397-405.
  10. Vazquez, G., et al., Comparison of body mass index, waist circumference, and waist/hip ratio in predicting incident diabetes: a meta-analysis. Epidemiol Rev, 2007. 29: p. 115-28.
  11. Meisinger, C., et al., Body fat distribution and risk of type 2 diabetes in the general population: are there differences between men and women? The MONICA/KORA Augsburg cohort study. Am J Clin Nutr, 2006. 84(3): p. 483-9.
  12. Weinstein, A.R., et al., Relationship of physical activity vs body mass index with type 2 diabetes in women. Jama, 2004. 292(10): p. 1188-94.
  13. Tobias, D.K., et al., Healthful dietary patterns and type 2 diabetes mellitus risk among women with a history of gestational diabetes mellitus. Arch Intern Med, 2012. 172(20): p. 1566-72.
  14. Adherence to predefined dietary patterns and incident type 2 diabetes in European populations: EPIC-InterAct Study. Diabetologia, 2014. 57(2): p. 321-33.
  15. Romaguera, D., et al., Mediterranean diet and type 2 diabetes risk in the European Prospective Investigation into Cancer and Nutrition (EPIC) study: the InterAct project. Diabetes Care, 2011. 34(9): p. 1913-8.
  16. Martinez-Gonzalez, M.A., et al., Adherence to Mediterranean diet and risk of developing diabetes: prospective cohort study. Bmj, 2008. 336(7657): p. 1348-51.
  17. Agardh, E.E., et al., Explanations of socioeconomic differences in excess risk of type 2 diabetes in Swedish men and women. Diabetes Care, 2004. 27(3): p. 716-21.
  18. Lantz, P.M., et al., Socioeconomic factors, health behaviors, and mortality: results from a nationally representative prospective study of US adults. Jama, 1998. 279(21): p. 1703-8.
  19. Sacerdote, C., et al., Lower educational level is a predictor of incident type 2 diabetes in European countries: the EPIC-InterAct study. Int J Epidemiol, 2012. 41(4): p. 1162-73.
  20. Tamayo, T., et al., Diabetes in Europe: An update. Diabetes Res Clin Pract, 2014. 103(2): p. 206-17.
  21. Manios, Y., et al., Determinants of childhood obesity and association with maternal perceptions of their children’s weight status: the “GENESIS” study. J Am Diet Assoc, 2010. 110(10): p. 1527-31.
  22. Taylor, J., et al., Identifying risk and preventing progression to Type 2 diabetes in vulnerable and disadvantaged adults: a pragmatic review. Diabet Med, 2013. 30(1): p. 16-25.
  23. Dwyer, G.M., et al., What do parents and preschool staff tell us about young children’s physical activity: a qualitative study. Int J Behav Nutr Phys Act, 2008. 5(1): p. 66.
  24. Sarti, R., Who cares for me? Grandparents, nannies and babysitters caring for children in contemporary Italy. Paedagog Hist, 2010. 46(6): p. 789-802.
  25. Stark, J.H., et al., The Impact of Neighborhood Park Access and Quality on Body Mass Index Among Adults in New York City. Prev Med, 2014.
  26. Oluyomi, A.O., et al., Parental safety concerns and active school commute: correlates across multiple domains in the home-to-school journey. Int J Behav Nutr Phys Act, 2014. 11(1): p. 32.
  27. Brown, A.F., et al., Socioeconomic position and health among persons with diabetes mellitus: a conceptual framework and review of the literature. Epidemiol Rev, 2004. 26: p. 63-77.
  28. Foster, G.D., et al., A school-based intervention for diabetes risk reduction. N Engl J Med, 2010. 363(5): p. 443-53.
  29. Baranowski T, C.K., Nicklas T, Thompson D, Baranowski J., School-based obesity prevention: a blueprint for taming the epidemic. Am J Health Behav, 2002. 26: p. 486-93.
  30. Gonzalez-Suarez C, W.A., Grimmer-Somers K, Dones V, School-Based Interventions on Childhood Obesity. A Meta-Analysis. Am J Prev Med, 2009. 37(5): p. 418–427.
  31. Saraf, D.S., et al., A systematic review of school-based interventions to prevent risk factors associated with noncommunicable diseases. Asia Pac J Public Health, 2012. 24(5): p. 733-52.