1. By Sabada Dube Epidemiology: Diabetes in China. Aging population and rising overweight and obesity are driving diabetes epidemic

2. © Datamonitor Healthcare. All rights reserved. 2 Epidemiology: Diabetes in China Key findings Datamonitor Healthcare's key findings

3. © Datamonitor Healthcare. All rights reserved. 3 Epidemiology: Diabetes in China Datamonitor Healthcare’s key findings Disease overview Diabetes is one of the most common endocrine disorders, and is estimated to affect approximately 347 million people worldwide. 80% of people with diabetes live in low and medium income countries. In China, the prevalence of diabetes has been increasing in line with economic development and societal transformation from traditional to modernized lifestyles. Economic development in China and other developing countries is characterized by increasing levels of obesity and overweight, which are associated with the development of diabetes. Historical trends In China, recent epidemiologic estimates and forecasts suggest an ever increasing prevalence of type 2 diabetes in adults. Between 1996 and 2006, the prevalence of type 2 diabetes increased rapidly in urban China, from 4.58% to 9.7%. Recent studies also suggest an increase in prevalence in adults, with 11.6% of adults estimated to have diabetes in 2010. Forecasting methods Cases include males and females aged 0–14 years for type 1 diabetes and those aged 15 years and above for type 2 diabetes. Datamonitor Healthcare has used multiple, complementary data sources, including national longitudinal survey data, to provide representative and comprehensive estimates for China. Before their inclusion in epidemiologic analyses, all data were rigorously assessed for robustness and validated for accuracy by Datamonitor Healthcare’s experienced team of epidemiologists. Epidemiologic drivers The rising overweight and obesity is the major risk factor for type 2 diabetes, and is the main driver behind the increasing prevalence of diabetes in China, and indeed globally. Sedentary lifestyles are also contributing to an increasing diabetes prevalence in populations. Over the last century, technological advances have led to a reduction in physical activity at work, for transportation, and for household tasks, which in turn increases overweight and obesity and ultimately leads to increased risk of type 2 diabetes.

4. © Datamonitor Healthcare. All rights reserved. 4 Epidemiology: Diabetes in China Diabetes definition and ICD codes Disease overview

5. © Datamonitor Healthcare. All rights reserved. 5 Epidemiology: Diabetes in China Diabetes mellitus definition Diabetes mellitus includes: type 1 diabetes, formerly called independent-dependent diabetes mellitus; type 2 diabetes, historically called non-independent-dependent diabetes mellitus; and gestational diabetes. It is a complex metabolic disorder in which there are persistently elevated concentrations of blood glucose caused by autoimmune destruction of the pancreatic beta cells (type 1 diabetes mellitus) or by insulin resistance coupled with relative insulin deficiency (type 2 diabetes mellitus). Type 1 diabetes is mainly diagnosed in children below the age of 15 years, while type 2 diabetes is mainly diagnosed in adults above 15 years. An estimated 90–95% of diabetes cases are type 2. Since 1999, the World Health Organization (WHO) has defined diabetes as a fasting blood glucose of ≥7.0mmol/l (126mg/dl) or a two-hour blood glucose of ≥11.1mmol/l (200mg/dl).

6. © Datamonitor Healthcare. All rights reserved. 6 Epidemiology: Diabetes in China Diabetes in China forecast Epidemiologic forecast results

7. © Datamonitor Healthcare. All rights reserved. 7 Epidemiology: Diabetes in China In 2012, Datamonitor Healthcare estimates that there were 115.3 million prevalent cases of diabetes in China. Of all the prevalent diabetes cases in 2012, more than half (63.2 million) were in urban populations. In the Tier 1 cities of Beijing, Guangzhou, Shanghai, and Tianjin, there were 6.4 million prevalent cases – 1.8 million cases were in Beijing, 2.3 million in Shanghai, 1.3 million in Guangzhou, and almost 1 million were in Tianjin. Over the forecast period, diabetes prevalence will increase by approximately 41% across China, with cases nearly doubling in urban populations. However, rural cases are forecast to decline due to demographic transition from rural to urban living. The main drivers for the increase in diabetes are increasing urbanization rates, which in turn are associated with increased obesity, and population aging and growth. Catastrophic increase in prevalent population in China Diabetes forecast

8. © Datamonitor Healthcare. All rights reserved. Age distribution of diabetes patients Diabetes prevalent cases are mostly concentrated in the 40–69 year age groups. These age groups will continue to contribute the majority of cases during the forecast period. However, prevalent diabetes cases in the 40–49 year age group will decline over the forecast period, signifying the impact of demographic changes as the Chinese population ages. As a result of the aging population, prevalent cases in the 50–59 and 60–69 year age groups will increase over the forecast period. Prevalent cases in the 20–29 and 30–39 year age groups will remain somewhat constant over the forecast period due to population aging and the low risk of developing diabetes in these age groups. Epidemiology: Diabetes in China 8

9. © Datamonitor Healthcare. All rights reserved. 9 Epidemiology: Diabetes in China Diabetes prevalence is set to sore in China Why is diabetes increasing in China? Between 2012 and 2030, the number of prevalent type 2 cases in China will increase substantially by 41% (to 162.7 million prevalent cases), an average annual percentage change of 2.4%. The main drivers for the increase in type 2 diabetes are increasing urbanization rates (which are in turn associated with increased obesity) and population aging and growth. These updated estimates show a substantial increase from estimates based on Yang et al. (2010) which suggested that China had approximately 90 million people with diabetes. The estimated increase presented in this analysis by Datamonitor Healthcare represents the availability of new and updated epidemiologic data. The increase in estimated diabetes prevalence in China is real and is attested by increasing obesity rates in the country since obesity is the major risk factor of type 2 diabetes. Obesity in China, defined as a body mass index of 27.5 or higher, is described to have increased from approximately 3% to 11% in men and from 5% to 10% in women from 1993 to 2009 (Xi et al., 2012). Furthermore, urbanization in China presents a classical epidemiologic transition where chronic diseases like diabetes become more prevalent than infectious diseases. Population changes, particularly population aging and the increase in urbanization, are major demographic drivers for the diabetes epidemic in China. Moreover, risk factors associated with urbanization also play a major role in driving up diabetes numbers in China. For example, increases in obesity rates and a decline in physical activity due to lifestyle and occupational changes are responsible for increased prevalent cases of type 2 diabetes.

10. © Datamonitor Healthcare. All rights reserved. 10 Epidemiology: Diabetes in China. Conclusions and key takeaways

11. © Datamonitor Healthcare. All rights reserved. Conclusions 11 Diabetes prevalence in China presents a public health time bomb as the disease burden increases at an unbearable pace. Population changes, particularly population aging and the increase in urbanization, are major demographic drivers for the diabetes epidemic in China. Moreover, risk factors associated with urbanization also play a major role in driving up diabetes numbers in China. Escalating obesity rates and a decline in physical activity due to lifestyle and occupational changes are responsible for increased prevalent cases of type 2 diabetes. China is therefore the largest single diabetes market and presents opportunities for growth for anti-diabetic drugs. Epidemiology: Diabetes in China

12. Disclaimer All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publisher, Datamonitor Healthcare. The facts of this report are believed to be correct at the time of publication but cannot be guaranteed. Please note that the findings, conclusions and recommendations that Datamonitor Healthcare delivers will be based on information gathered in good faith from both primary and secondary sources, whose accuracy we are not always in a position to guarantee. As such Datamonitor Healthcare can accept no liability whatever for actions taken based on any information that may subsequently prove to be incorrect. Datamonitor Healthcare is owned and operated by Informa plc (“Informa”) whose registered office is Mortimer House, 37-41 Mortimer Street, London, W1T 3JH. Registered in England and Wales Number 3099067. Bringing you closer to the market