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Diabetes mellitus is a major cause of morbidity and premature mortality worldwide with an estimated 451 million adults affected in 2017, almost half of whom are currently undiagnosed [5]. The number of people with diabetes is forecast to rise to 693 million by 2045. Determining the type of diabetes in large epidemiological studies is difficult, but the vast majority of cases, about 90%, are thought to have type 2 diabetes [6]. Currently, care of people with diabetes accounts for approximately USD 850 billion of global healthcare expenditure [5]. Since 1980, the number of people living with diabetes worldwide has almost quadrupled [7]. This is in part due to population growth and ageing, but also represents a true increase in prevalence. The epidemic of type 2 diabetes is closely linked to the rising prevalence of obesity and is contributed by numerous factors including globalisation and urbanisation, with increasingly sedentary lifestyles and greater caloric intake [8].

The diabetes epidemic has been characterised by substantial variation between geographic locations, ethnicities and cultural groups. Low- and middle-income countries have seen the greatest increases in diabetes prevalence over recent decades and this disparity is predicted to continue (Fig. 2) [5, 7]. This has been attributed to differences in both genetic and environmental factors, with potential interactions between them. There is evidence that the intrauterine environment and foetal nutrition can impact gene expression via epigenetic changes [9]. Thus, maternal health can potentially impact the chronic disease risk of subsequent generations. Such factors are theorised to have contributed to the dramatic increases in prevalence in resource-poor settings.

Fig. 2. Estimated number of people (aged 20–79 years) with diabetes worldwide and per region in 2017 and 2045. With permission from: IDF Diabetes Atlas Eighth Edition 2017. Brussels, International Diabetes Federation, 2017.