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Cited by 1,954Diabetes, Cardiovascular Risks, and LipoproteinsObesity, Physical Activity, DietAdipokines, Inflammation, and Metabolic Diseases

Globalization of Diabetes

Open access
Hu, Frank B.·2011·Diabetes Care
DOI 10.2337/dc11-0442PMC PMC3114340
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Abstract

Type 2 diabetes is a global public health crisis that threatens the economies of all nations, particularly developing countries. Fueled by rapid urbanization, nutrition transition, and increasingly sedentary lifestyles, the epidemic has grown in parallel with the worldwide rise in obesity. Asia's large population and rapid economic development have made it an epicenter of the epidemic. Asian populations tend to develop diabetes at younger ages and lower BMI levels than Caucasians. Several factors contribute to accelerated diabetes epidemic in Asians, including the “normal-weight metabolically obese” phenotype; high prevalence of smoking and heavy alcohol use; high intake of refined carbohydrates (e.g., white rice); and dramatically decreased physical activity levels. Poor nutrition in utero and in early life combined with overnutrition in later life may also play a role in Asia's diabetes epidemic. Recent advances in genome-wide association studies have contributed substantially to our understanding of diabetes pathophysiology, but currently identified genetic loci are insufficient to explain ethnic differences in diabetes risk. Nonetheless, interactions between Westernized diet and lifestyle and genetic background may accelerate the growth of diabetes in the context of rapid nutrition transition. Epidemiologic studies and randomized clinical trials show that type 2 diabetes is largely preventable through diet and lifestyle modifications. Translating these findings into practice, however, requires fundamental changes in public policies, the food and built environments, and health systems. To curb the escalating diabetes epidemic, primary prevention through promotion of a healthy diet and lifestyle should be a global public policy priority.

AI snapshot

Written from the paper’s full text.

TL;DR

This review argues that type 2 diabetes has become a global epidemic driven by urbanization, nutrition transition, and sedentary lifestyles, with Asia now the epicenter because Asian populations develop diabetes at younger ages and lower BMI levels than Caucasians. It concludes that most cases are preventable through diet and lifestyle change, but that this requires public policy shifts in food, built, and social environments.

Key findings

  • Global burden: diabetes affects at least 285 million people worldwide, projected to reach 438 million by 2030, with two-thirds of cases in low- to middle-income countries; impaired glucose tolerance is expected to rise from 344 million (2010) to 472 million (2030). Diabetes accounted for 12% of health expenditures in 2010 (~$376 billion), projected at $490 billion by 2030.
  • Asia accounts for 60% of the world's diabetic population; Chinese adult diabetes prevalence rose from <1% in 1980 to nearly 10% by 2008 (>92 million diabetic, 148 million prediabetic), while urban south India reached nearly 20%.
  • Diet: a 2 serving/day increment in whole-grain intake was associated with 21% lower diabetes risk; highest SSB intake (1–2 servings/day) carried a 26% greater risk (RR 1.26 [95% CI 1.12–1.41]); white rice intake in the Shanghai Women's Health Study showed RR 1.78 (95% CI 1.48–2.15) comparing extreme quintiles.
  • Lifestyle: in the NHS, women in a low-risk group (BMI <25, healthy diet, ≥30 min/day activity, no smoking, ≥half-serving alcohol/day) had RR 0.09 (95% CI 0.05–0.17), with 91% of cases (95% CI 83–95%) attributable to the five factors; trials reduced incidence by 31–58% (Daqing 31/46/42% for diet/exercise/combined; Finnish DPS and U.S. DPP 58%; IDPP 28.5% lifestyle).

Methods

Narrative review synthesizing global burden data (International Diabetes Federation estimates), population-based cross-sectional surveys (e.g., Chinese National Nutrition Survey, Shanghai Women's Health Study), prospective cohorts (Nurses' Health Study, NHS II, Health Professionals' Follow-up Study), meta-analyses, genome-wide association studies, and randomized prevention trials (Daqing, Finnish DPS, U.S. DPP, IDPP). Includes a reduced rank regression analysis in a nested case-control sample of 656 diabetes cases and 694 controls, and a gene–diet interaction analysis using a 10-SNP genetic risk score.

Limitations

The paper is a review and states no formal limitations of its own. Evident from the text: much of the mechanistic and gene–environment evidence comes from a small number of cohorts (largely NHS and U.S. male health professionals), limiting generalizability to Asian and other populations; the author notes that identified genetic loci are insufficient to explain ethnic differences or the rapid rise in prevalence and have limited clinical predictive utility; the thrifty genotype hypothesis is described as lacking identified genes and receiving little support from preliminary analyses, and famine-exposure findings are inconsistent across cohorts (Dutch Famine vs. Leningrad Siege).

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Integrity signals

Registry

Crossref · 10.2337/dc11-0442

Cites

66 of 66 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 37 cited sources checked · 0 supported · 0 flagged

  • Findingcitation

    Individuals in the highest quantile of sugar-sweetened beverage intake (most often 1-2 servings/day) had a 26% greater risk of developing type 2 diabetes than those in the lowest (RR 1.26 [95% CI 1.12-1.41]).

    “Our recent meta-analysis (13) found that individuals in the highest quantile of SSB intake (most often 1–2 servings/day) had a 26% greater risk of developing the disease than those in the lowest (relative risk [RR] 1.26 [95% CI 1.12–1.41]).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [13] Malik, 2010, Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis, Diabetes Care source

      Not checked in the free run.

  • Findingcitation

    In Asian populations, increased risk of diabetes starts at a lower BMI than in Europeans.

    “In Asian populations, increased risk of diabetes starts at a lower BMI than in Europeans (9).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [9] Yoon, 2006, Epidemic obesity and type 2 diabetes in Asia, Lancet source

      Not checked in the free run.

  • Findingcitation

    High intake of foods with a high glycemic index or glycemic load, especially white rice, is associated with increased risk of diabetes (RR comparing highest to lowest quintile of white rice intake: 1.78 [95% CI 1.48-2.15]).

    “Findings from the Shanghai Women's Health Study (SWHS) indicate that high intake of foods with a high GI or GL, especially white rice, is associated with increased risk of diabetes (RR comparing highest to lowest quintile of white rice intake: 1.78 [95% CI 1.48–2.15]) (22).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [22] Villegas, 2007, Prospective study of dietary carbohydrates, glycemic index, glycemic load, and incidence of type 2 diabetes mellitus in middle-aged Chinese women, Arch Intern Med source

      Not checked in the free run.

  • Findingcitation

    In the Nurses' Health Study, the quality of fats and carbohydrates plays an important role in the development of diabetes, independent of BMI and other risk factors.

    “In the Nurses’ Health Study (NHS), we found that the quality of fats and carbohydrates play an important role in the development of diabetes, independent of BMI and other risk factors (11).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [11] Hu, 2001, Diet, lifestyle, and the risk of type 2 diabetes mellitus in women, N Engl J Med source

      Not checked in the free run.

  • Findingcitation

    A meta-analysis of 370,000 individuals with 12 years of follow-up showed a U-shaped relationship, with a 30-40% reduced risk of diabetes among those consuming 1-2 drinks/day compared with heavy drinkers or abstainers.

    “A meta-analysis of 370,000 individuals with 12 years of follow-up showed a U-shaped relationship, with a 30–40% reduced risk of the disease among those consuming 1–2 drinks/day compared with heavy drinkers or abstainers (37).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [37] Koppes, 2005, Moderate alcohol consumption lowers the risk of type 2 diabetes: a meta-analysis of prospective observational studies, Diabetes Care source

      Not checked in the free run.

  • May combine two claims. 17
  • Classified as probably not a substantial claim. 5

  • May combine two claims.

    Findingcitation

    Higher dietary glycemic load and trans fat are associated with increased diabetes risk, whereas greater consumption of cereal fiber and polyunsaturated fat is associated with decreased risk.

    “In particular, higher dietary glycemic load (GL) and trans fat are associated with increased diabetes risk, whereas greater consumption of cereal fiber and polyunsaturated fat is associated with decreased risk (Fig. 2).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [11] Hu, 2001, Diet, lifestyle, and the risk of type 2 diabetes mellitus in women, N Engl J Med source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given

    Asia accounts for 60% of the world's diabetic population.

    “Asia accounts for 60% of the world's diabetic population.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    In 1980, less than 1% of Chinese adults had diabetes; by 2008, prevalence reached nearly 10%.

    “In 1980, less than 1% of Chinese adults had the disease. By 2008, the prevalence had reached nearly 10% (Fig. 1) (4).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [4] Yang, 2010, Prevalence of diabetes among men and women in China, N Engl J Med source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Asian populations tend to develop diabetes at younger ages and lower BMI levels than Caucasians.

    “Asian populations tend to develop diabetes at younger ages and lower BMI levels than Caucasians.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [3] Chan, 2009, Diabetes in Asia: epidemiology, risk factors, and pathophysiology, JAMA source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Compared with Western populations, Asians develop diabetes at younger ages, at lower degrees of obesity, and at much higher rates given the same amount of weight gain.

    “Compared with Western populations, Asians develop diabetes at younger ages, at lower degrees of obesity, and at much higher rates given the same amount of weight gain (3).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [3] Chan, 2009, Diabetes in Asia: epidemiology, risk factors, and pathophysiology, JAMA source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    Compared with the relatively nonexposed cohort, the ORs of hyperglycemia in the fetal-exposed cohort were 7.63 (95% CI 2.41-24.1, P = 0.0005) for those who had an affluent/Western dietary pattern, and 2.34 (95% CI 0.82-6.70, P = 0.112) for those with a traditional dietary pattern.

    “Compared with the relatively nonexposed cohort, the ORs of hyperglycemia in the fetal-exposed cohort were 7.63 (95% CI 2.41–24.1, P = 0.0005) for those who had an affluent/Western dietary pattern, and 2.34 (95% CI 0.82–6.70, P = 0.112) for those with a traditional dietary pattern.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [57] Li, 2010, Exposure to the Chinese famine in early life and the risk of hyperglycemia and type 2 diabetes in adulthood, Diabetes source

      Not checked in the free run.

    • Rests on an assumption: The Chinese National Nutrition and Health Survey data accurately classify famine exposure and hyperglycemia.

  • May combine two claims.

    Findingcitation

    In the Nurses' Health Study, higher consumption of white rice is associated with increased risk of diabetes, whereas consumption of brown rice protects against the disease.

    “Despite relatively low consumption of rice in the U.S. population, in the NHS, we found that higher consumption of white rice is associated with increased risk of diabetes, whereas consumption of brown rice, a whole grain, protects against the disease (23).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [23] Sun, 2010, White rice, brown rice, and risk of type 2 diabetes in US men and women, Arch Intern Med source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Premisenone given

    Type 2 diabetes is a global public health crisis that threatens the economies of all nations, particularly developing countries.

    “Type 2 diabetes is a global public health crisis that threatens the economies of all nations, particularly developing countries.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Currently identified genetic loci are insufficient to explain ethnic differences in diabetes risk.

    “but currently identified genetic loci are insufficient to explain ethnic differences in diabetes risk.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationnone given

    The currently identified genetic susceptibility loci are insufficient to explain differences in diabetes risk across different ethnic groups or the rapid rise in diabetes prevalence over the past several decades.

    “but the currently identified genetic susceptibility loci are insufficient to explain differences in diabetes risk across different ethnic groups or the rapid rise in diabetes prevalence over the past several decades.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The currently identified genetic susceptibility loci are representative of overall genetic susceptibility to type 2 diabetes.

  • May combine two claims.

    Premisecitation

    Numerous epidemiologic studies show that increased physical activity reduces risk of diabetes, whereas sedentary behaviors increase risk.

    “Numerous epidemiologic studies show that increased physical activity reduces risk of diabetes, whereas sedentary behaviors increase risk.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Based on an analysis of 17 type 2 diabetes loci and 13 obesity loci, there is no clear evidence for overrepresentation of derived alleles for obesity or diabetes loci or greater concentration of these loci in a particular ethnic group.

    “Based on an analysis of 17 type 2 diabetes loci and 13 obesity loci, Southam et al. (48) found no clear evidence for overrepresentation of derived alleles (vs. ancestral alleles) for the obesity or diabetes loci or greater concentration of these loci in a particular ethnic group.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [48] Southam, 2009, Is the thrifty genotype hypothesis supported by evidence based on confirmed type 2 diabetes- and obesity-susceptibility variants?, Diabetologia source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationnone given

    Most single nucleotide polymorphisms uncovered may not be the actual causal variants, and pinpointing causal variants requires fine-mapping, sequencing, and functional studies.

    “It should be noted that most of the single nucleotide polymorphisms uncovered may not be the actual causal variants, which need to be pinpointed through fine-mapping, sequencing, and functional studies.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Both fetal undernutrition (low birth weight) and overnutrition (the baby of a diabetic mother) are associated with increased future risk of diabetes.

    “Both fetal undernutrition (LBW) and overnutrition (the baby of a diabetic mother) are associated with increased future risk of diabetes (52).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [52] Yajnik, 2009, Nutrient-mediated teratogenesis and fuel-mediated teratogenesis: two pathways of intrauterine programming of diabetes, Int J Gynaecol Obstet source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationnone given

    The adoption of a healthy diet and lifestyle requires not only individual behavioral changes, but also changes in food, built, and social environments.

    “However, the adoption of a healthy diet and lifestyle requires not only individual behavioral changes, but also changes in our food, built, and social environments.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    These data provide strong epidemiologic evidence linking overall dietary patterns, inflammation, and diabetes risk, suggesting that chronic inflammation may mediate the association between a Western dietary pattern and risk of type 2 diabetes.

    “These data provide strong epidemiologic evidence linking overall dietary patterns, inflammation, and diabetes risk, suggesting that chronic inflammation may mediate the association between a Western dietary pattern and risk of type 2 diabetes.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    In a subsequent 14-year follow-up of the Daqing study, the combined lifestyle intervention group had a 51% lower risk of diabetes during the active intervention period, and a 43% lower risk over a 20-year follow-up, compared with control subjects.

    “Compared with control subjects, individuals in the combined lifestyle intervention group had a 51% lower risk of diabetes during the active intervention period, and a 43% lower risk over a 20-year follow-up.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [59] Li, 2008, The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year follow-up study, Lancet source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In the Indian Diabetes Prevention Program, after 3 years of follow-up, the RR reduction was 28.5% with lifestyle management, 26.4% with metformin, and 28.2% with the combined interventions compared with the control group.

    “In the Indian Diabetes Prevention Program (IDPP) (63), after 3 years of follow-up, the RR reduction was 28.5% with lifestyle management, 26.4% with metformin, and 28.2% with the combined interventions compared with the control group.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [63] Ramachandran, 2006, The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1), Diabetologia source

      Not checked in the free run.

  • May combine two claims.

    Premisenone given

    At least 40 genetic loci have been convincingly associated with type 2 diabetes, but these loci confer only a modest effect size and do not add to the clinical prediction of diabetes beyond traditional risk factors.

    “To date, at least 40 genetic loci have been convincingly associated with type 2 diabetes, but these loci confer only a modest effect size and do not add to the clinical prediction of diabetes beyond traditional risk factors, such as obesity, physical inactivity, unhealthy diet, and family history of diabetes.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Most diabetes susceptibility loci that have been identified are related to impaired β-cell function, whereas only a few are associated with insulin resistance or fasting insulin, which points toward β-cell dysfunction as a primary defect for diabetes pathogenesis.

    “It is intriguing that most diabetes susceptibility loci that have been identified are related to impaired β-cell function, whereas only a few (e.g., peroxisome proliferator–activated receptor-γ, insulin receptor substrate 1, IGF-1, and GCKR) are associated with insulin resistance or fasting insulin, which points toward β-cell dysfunction as a primary defect for diabetes pathogenesis.”
    Quote in the paperSubstantial claim
20 of 20

  • The paper relies on this without support.

    The Western dietary pattern derived from principal component analysis of 40 food groups adequately represents the dietary exposure relevant to type 2 diabetes risk.

    “a Western dietary pattern derived from principle component analysis of 40 food groups”
    “intake of processed meat, red meat, and heme iron, which characterize the Western dietary pattern”

  • The paper relies on this without support.

    The genetic risk score based on 10 established single nucleotide polymorphisms adequately captures genetic susceptibility to type 2 diabetes.

    “a genetic risk score (GRS) of type 2 diabetes susceptibility based on 10 established single nucleotide polymorphisms”

  • The paper relies on this without support.

    The five low-risk variables (BMI, diet, physical activity, smoking, alcohol) are causally related to diabetes risk and their combined effect can be estimated from observational data.

    “we defined a low-risk group according to five variables: 1) BMI <25; 2) a diet high in cereal fiber and polyunsaturated fat and low in trans fat and GL; 3) moderate-to-vigorous physical activity for at least half an hour/day; 4) no current smoking; and 5) an average intake of at least a half-serving of an alcoholic beverage/day.”

  • The paper relies on this without support.

    The Chinese National Nutrition and Health Survey data accurately classify famine exposure and hyperglycemia.

    “we examined the association between famine exposure in fetal life and adult hyperglycemia in the Chinese National Nutrition and Health Survey (57).”

  • The paper relies on this without support.

    The currently identified genetic susceptibility loci are representative of overall genetic susceptibility to type 2 diabetes.

    “the currently identified genetic susceptibility loci”
5 of 5

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  1. Yang, 2011, Tobacco control necessary, China Daily

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Related

Authors
Hu, F. B.
Affiliations
Brigham and Women's Hospital (US)
Corresponding author
Hu, Frank B.
ORCID
Hu, Frank B.
Venue
Diabetes Care
Publisher
American Diabetes Association
Published
2011-05-20
Volume
34
Issue
6
Pages
1249-1257
ISSN
  • 0149-5992 (ISSN-L)
  • 1935-5548
DOI
10.2337/dc11-0442
PMC
PMC3114340
OpenAlex
W2045362322
Semantic Scholar
35afc2c6a88129bb98734dc9095f7dc4294bb562
Cited by
1,954
References
64
Citations by year
2026: 81 · 2025: 91 · 2024: 145 · 2023: 109 · 2022: 129 · 2021: 152 · 2020: 142 · 2019: 133 · 2018: 141 · 2017: 164 · 2016: 187 · 2015: 158 · 2014: 150 · 2013: 97 · 2012: 65
FWCI
83.85
Type
journal article
Language
en
Open access
Licence
cc-by-nc-nd
Locations
  • Diabetes Care (publishedVersion, cc-by-nc-nd)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by-nc-nd)
  • PubMed Central (publishedVersion, cc-by-nc-nd)
  • PubMed (publishedVersion)
  • Digital Access to Scholarship at Harvard (DASH) (Harvard University) (submittedVersion, cc-by)
Funders
  • American Diabetes Association
  • National Institutes of Health
  • National Heart, Lung, and Blood Institute (HL60712, R01HL060712)
  • National Institute of Diabetes and Digestive and Kidney Diseases (R01DK058845, DK58845)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Obesity, Physical Activity, Diet
  • Health Sciences › Medicine › Epidemiology › Adipokines, Inflammation, and Metabolic Diseases
Keywords
type 2 diabetes, diabetes epidemic, Asia, nutrition transition, obesity, smoking, alcohol consumption, white rice consumption, physical inactivity, in utero nutrition, genetic susceptibility, Western diet, lifestyle modification, diabetes prevention, public health policy, built environment, health care system
MeSH terms
Adult, Alcohol Drinking, Asia, Developing Countries, Diabetes Mellitus, Type 2, Diet, Dietary Carbohydrates, Health Promotion, Humans, Inflammation, Insulin Resistance, Life Style, Motor Activity, Smoking, Exercise, Prevalence, Genetic Predisposition to Disease, Asian People, Genetic Association Studies

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