Premature mortality projection for diabetes to 2030: a subnational evaluation towards the Healthy China 2030 Goals

Abstract

The Healthy China 2030 Plan set the goal of reducing premature deaths from diabetes by 30% by 2030. However, there has been a lack of assessment of premature mortality for diabetes since the action plan was issued. This study used data from the Global Burden of Disease Study 2021, calculated the premature deaths for diabetes by sex, provinces, and subtypes from 1990 to 2021. We explored the temporal trend of premature mortality using the average annual percent change (AAPC) for different sexes, provinces, and subtypes from 1990 to 2021. Furthermore, we predicted premature mortality for diabetes through 2030 for China and its provinces according to the average annual change rate from 2010 to 2021. There was a first slow upward trend in premature mortality for diabetes from 0.5% in 1990 to 0.6% in 2004, and then a decline until 2021 with premature mortality of 0.4%. By 2030, only Fujian (30.3%) will achieve the desired level of reduction, with only seven provinces meeting the target for females and none for males. There is a large range in the degree of decline between inland and coastal regions, showing obvious geographic differences, and there should be a focus on balancing medical resources.

Keywords

diabetes / mortality / premature mortality / projection

1 Introduction

As the seventh leading cause of death and disability, diabetes accounted for 78.9 years lived with disability globally, and is associated with a two to three times risk of all-cause mortality compared to the general population [1]. Over the three decades, the prevalence of diabetes in China has shown a steady increase [2–4]. Life expectancy is 4.2 years lower than in the healthy population [5]. By 2021, the number of people with diabetes has reached 140.9 million in China [6]. Particularly, predictions indicate that the prevalence will continue to rise [7]. Diabetes has become a pressing public health issue globally, especially in China, requiring urgent attention and control.

In 2011, United Nations (UN) member states adopted targets to reduce all deaths from chronic non-communicable diseases [8,9], which included a 25% reduction in premature mortality for diabetes by 2025. Meanwhile, the Healthy China 2030 Plan [10], was launched in China in 2016, aiming for a 30% reduction in diabetes-related premature mortality compared to the 2015 levels. In 2017, the State Council released China’s Medium- and Long-Term Plan for the Prevention and Control of Chronic Diseases (2017–2025) [11], which aims to reduce preventable morbidity, mortality, and disability due to diabetes. In 2024, the Chinese government issued the Healthy China Action—Diabetes Prevention and Control Action Implementation Plan (2024–2030) [12]. However, there is significant heterogeneity in diabetes prevalence across different regions of China, with aggregated in North-east and North China according to previous research. It is necessary to evaluate the trends in diabetes prevalence across different regions further to establish more targeted prevention and control goals and strategies for each area.

Utilizing the data from Global Burden of Diseases 2021, we analyzed the trend of premature mortality of diabetes in China from 1990 to 2021 and projected further premature mortality. Furthermore, we compared the projection with the target set by the Healthy China 2030 Plan to identify regional patterns and gaps in progress. This study aims to provide policymakers and public health workers with valuable insights to guide the allocation of healthcare resources and inform policy decisions across China.

2 Materials and methods

In this study, we used data from GBD 2021 as empirical data for projection to predict premature mortality from diabetes at the regional level in China. We extracted province-level data on age- and sex-specific deaths from diabetes and its subcategories between 1990 and 2010. The methods employed by GBD 2021 have been comprehensively detailed in previous publications [13].

2.1 Geographical units and periods

In this study, the estimation processes cover the years from 1990 to 2021, and 33 province-level administrative units in China (Xinjiang Production and Construction Corps is excluded). These province-level units include 21 provinces, five autonomous regions, four municipalities, and two special administrative regions, all of which are collectively referred to as provinces throughout the article. Furthermore, these provinces have been divided into seven geographic subregions [14], which are detailed in the supplementary material.

2.2 Projection of diabetes premature mortality to 2030

First, the yearly non-age-standardized premature mortality and unconditional probability of mortality for diabetes were calculated. Furthermore, the average annual percentage change (AAPC) from diabetes was calculated using the geometrically weighted average of the various annual percentage change values from the regression analysis. Then the annual percentage change was calculated. Lastly, projections of premature mortality for diabetes from 2022 to 2030 were calculated. The annual percentage change was calculated by the following formula:

\begin{array}{rl}& \mathrm{A}\mathrm{v}\mathrm{e}\mathrm{r}\mathrm{a}\mathrm{g}\mathrm{e}\mathrm{a}\mathrm{n}\mathrm{n}\mathrm{u}\mathrm{a}\mathrm{l}\mathrm{r}\mathrm{a}\mathrm{t}\mathrm{e}=\\ & \mathrm{l}\mathrm{n}\left(\frac{{\mathrm{P}\mathrm{r}\mathrm{e}\mathrm{m}\mathrm{a}\mathrm{t}\mathrm{u}\mathrm{r}\mathrm{e}\mathrm{m}\mathrm{o}\mathrm{r}\mathrm{t}\mathrm{a}\mathrm{l}\mathrm{i}\mathrm{t}\mathrm{y}}_{2021}}{{\mathrm{P}\mathrm{r}\mathrm{e}\mathrm{m}\mathrm{a}\mathrm{t}\mathrm{u}\mathrm{r}\mathrm{e}\mathrm{m}\mathrm{o}\mathrm{r}\mathrm{t}\mathrm{a}\mathrm{l}\mathrm{i}\mathrm{t}\mathrm{y}}_{2010}}\right)/(2021-2010).\end{array}

The projections of premature mortality from 2022 to 2030 were calculated by the following formula:

\begin{array}{rl}& \mathrm{P}\mathrm{r}\mathrm{e}\mathrm{m}\mathrm{a}\mathrm{t}\mathrm{u}\mathrm{r}\mathrm{e}\mathrm{m}\mathrm{o}\mathrm{r}\mathrm{t}\mathrm{a}\mathrm{l}\mathrm{i}\mathrm{t}{\mathrm{y}}_{2030}=\mathrm{P}\mathrm{r}\mathrm{e}\mathrm{m}\mathrm{a}\mathrm{t}\mathrm{u}\mathrm{r}\mathrm{e}\mathrm{m}\mathrm{o}\mathrm{r}\mathrm{t}\mathrm{a}\mathrm{l}\mathrm{i}\mathrm{t}{\mathrm{y}}_{2021}\times \\ & \exp \left(\frac{\mathrm{l}\mathrm{n}\left({\displaystyle \frac{{\mathrm{P}\mathrm{r}\mathrm{e}\mathrm{m}\mathrm{a}\mathrm{t}\mathrm{u}\mathrm{r}\mathrm{e}\mathrm{m}\mathrm{o}\mathrm{r}\mathrm{t}\mathrm{a}\mathrm{l}\mathrm{i}\mathrm{t}\mathrm{y}}_{2021}}{{\mathrm{P}\mathrm{r}\mathrm{e}\mathrm{m}\mathrm{a}\mathrm{t}\mathrm{u}\mathrm{r}\mathrm{e}\mathrm{m}\mathrm{o}\mathrm{r}\mathrm{t}\mathrm{a}\mathrm{l}\mathrm{i}\mathrm{t}\mathrm{y}}_{2010}}}\right)}{11}\times 9\right).\end{array}

Since we observed in our results that premature mortality from diabetes showed an increasing and then decreasing trend from 1990 to 2021 and that the rate of decline was more different between the period 2005–2010 and 2010–2021, we used the average annual rate of change from 2010 to 2021 for our projections. Details are shown in the supplementary material [15–17].

2.3 Statistical analysis

In this study, the trend of premature mortality for diabetes from 1990 to 2021 was estimated by the Joinpoint Regression Program. Utilizing the bar chart, premature mortality in 2021 and declines in premature mortality from 1990 to 2021 by province were presented. All data were prepared and analyzed in SAS 9.4, Joinpoint 5.2.0.0, and R 4.4.1.

3 Results

Fig.1 shows the premature mortality for diabetes in each province of China in 1990 and 2021. The top of each bar represents the value of the premature mortality in 1990, and the bottom represents the value in 2021. From this result, we can see that the premature mortality of each province in China in 2021 presents a situation in which the west is higher than the east and the north is higher than the south, and the higher areas are mainly concentrated in the north-western, south-western, and north-eastern parts of China, and the ones that occupy the top of the national premature mortality are Xinjiang (0.7%), Qinghai (0.7%), Liaoning (0.6%), Hainan (0.5%), and Yunnan (0.5%). Additionally, the premature mortality of diabetes in 2021 is illustrated in Tab.1. In diabetes deaths, the number of total deaths was 178.5 thousand, and 66.0 thousand people were premature deaths nationally, with premature mortality at 0.38%. The premature death of diabetes is mainly from the east (16.1, 95% UI 10.9–22.6), central (10.7, 95% UI 7.5–14.9), and south-west (10.6, 95% UI 7.2–5.0), with the minimum in north-western (5.3, 95% UI 3.6–7.5). The distribution of premature mortality was similar to it. Fig.1 also shows the degree of percentage decline in premature mortality from diabetes in each province from 1990 to 2021. The darker the color of the bar, the greater the degree of decline, with the largest declines in Hong Kong (64.7%), Macao (54.9%), and Jiangxi (51.3%), and the smallest declines in Hebei (3.5%), Henan (3.5%), and Qinghai (5.8%), and the nation as a whole shows a higher degree of decline in the south-east than in the north-west inland region.

Furthermore, the premature deaths of females (31.8, 95% UI 24.5–41.1) were lower than that of males (34.2, 95% UI 25.3–45.6). In the east, north-west, south, and south-west regions, males had higher premature mortality than females, the central region had equal rates for males and females, and the north and north-east regions had lower rates for males than females (Tab.1). The highest and lowest rates of premature death in both sexes were found in the north-east (53% for males and 54% for females) and the east (0.3 for males and 0.3 for females), respectively. Compared to 1990, the total number of diabetes deaths in 2021 increased from 72.2 million to 178.5 million. By sex, males increased from 30.3 million to 87.9 million, and females increased from 41.9 million to 90.5 million. The number of premature diabetes deaths nationwide in 2021 increased from 39.2 million to 66.0 million and for males, from 17.3 million to 34.2 million. The national premature mortality from diabetes decreased from 0.5% in 1990 to 0.4% in 2021, with an AAPC of −1.0. In terms of sex, the premature mortality was 0.4% in both 1990 and 2021 in males with an AAPC of −0.4, and it decreased from 0.6% to 0.4% in females with an AAPC of −1.6 (Tab.2).

In terms of type of diabetes, the number of deaths from type 1 diabetes decreased from 0.573 million to 0.4 million and type 2 diabetes increased from 66.5 thousand to 174.5 thousand in 2021 compared to 1990. The number of premature deaths from diabetes in 2021 declined from 0.34 million to 0.26 million for type 1 diabetes, and type 2 rose from 35.8 million to 63.4 million. In terms of subtypes, premature mortality decreased from 0.03% to 0.01% in type 1 diabetes with an AAPC of −2.8, and from 0.5% to 0.4% in type 2 diabetes, with an AAPC of −0.9. Looking at the AAPC by sex and subtype, respectively, the premature mortality for diabetes declined less rapidly for males than for females in both subtypes and more rapidly for type 1 than for type 2 in both sexes (Tab.2).

From 1990 to 2021, premature mortality for diabetes showed a trend of slowly increasing and then decreasing, and it is projected that neither males nor females will reach the expected target value by 2030. Premature mortality for females declined faster than for males, with the gap of premature mortality between males and females decreasing since 2004, and the values for premature mortality for males (0.4%) and females (0.4%) converging by 2012. Since 2013, the premature mortality for females started to be lower than that of males (Fig.2).

In terms of the average annual rate of premature mortality from 2010 to 2021, the highest average annual rate of premature mortality for diabetes from 2010 to 2021 among different sub-provinces was in Fujian (−3.0%), and the lowest was in Yunnan (−0.7%); among males, the highest and the lowest were in Fujian (−2.8%) and Hebei (−0.2%); and among females, the highest was in Beijing (−3.6%). In terms of the predicted value of premature mortality in 2030, among the provinces, the highest is in Xinjiang (0.6%) and the lowest is in Hong Kong (0.1%). In terms of sex, the highest and lowest values among males were found in Qinghai (0.7%) and Hong Kong (0.1%), while the highest and lowest values among females were found in Xinjiang (0.6%) and Hong Kong (0.1%). According to the Healthy China 2030 Goals, premature mortality for diabetes will decrease by 30% by 2030 compared with 2015. According to the projections, the country as a whole could not reach the expected target. Only Fujian, where the overall premature death probability decreased by more than 30%, could reach the Healthy China 2030 target. Inner Mongolia, Heilongjiang, Jiangsu, Guangdong, and Macao had decreases between 25% and 29%. Among males, there are no regions that can reach the target, with a 29.1% decrease in Fujian and a 27.4% decrease in Guangdong. Among females, according to the forecast, there are eight provinces and cities that can reach the target, namely Beijing, Tianjin, Inner Mongolia, Heilongjiang, Shandong, Jiangsu, Fujian, and Guangdong. Jilin has a decrease of 29.8%. Provinces and cities that also fell between 25% and 30% were Anhui, Zhejiang, Hubei, Hong Kong, Macao, and Xizang. It is worth noting that the trend of the overall male probability of premature death from diabetes in Guangxi is an upward trend, contrary to the overall national trend, and the reasons behind this are worth exploring further (Tab.3).

4 Discussion

This study analyzes the current status of premature mortality from diabetes in 2021, changes in premature mortality in China and its provinces from 1990 to 2021 and predicts trends from 2022 to 2030. The study found that the nation’s premature mortality from diabetes has generally shown a downward trend over the past 30 years, while the south-east coastal region has declined at a faster rate than the inland north-west region. Furthermore, female’s premature mortality has declined at a faster rate than male’s. We estimated that only Fujian would meet the target by 2030; on contrast, we expect the premature mortality in Guangxi would increase in the near future. Meanwhile, Fujian, Guangdong, Inner Mongolia, Heilongjiang, Jiangsu, Shandong, and Tianjin meet the target for females. Since this study examines trends in premature mortality at the national level, it has important implications for future policy amendment.

In recent years, there has been a general downward trend in premature mortality for diabetes. Some studies have shown that premature mortality from diabetes in developed countries such as the US and the UK have declined at varying rates [18]. We also observed that our results are similar to the study of Wijnen et al. [19] and present differences with the results of the study from Costa Rica [20]. In the study from Costa Rica, it showed a decreasing trend from 2000 to 2014 and an increasing trend from 2014 to 2020, with a faster increase in males than in females. Due to the differences between other countries and China in terms of ethnicity, geographic location, dietary habits, and level of medical care, it remains to be seen to what extent these differences can be attributed.

There are large differences in premature mortality between different regions of China, with high rates of premature mortality concentrated in inland areas (such as Xinjiang, Qinghai, Yunnan), compared with lower rates in coastal areas (such as Hong Kong, Macao, Zhejiang, and Shandong). This may be related to the level of medical care and economic development of the various regions. Generally speaking, coastal areas are more economically and medically developed than inland areas [21], and higher economic levels are often accompanied by better healthcare infrastructure and public health investments, which can contribute to early diagnosis and effective management of diabetes, as well as making it easier to adopt a healthier diet and lifestyles and gain better environment and social support. In addition, we have observed sex differences in the declining trends in premature mortality. Some studies have confirmed that Chinese males have a higher obesity rate than females, leading to a higher prevalence of diabetes and higher premature mortality, which may be one of the reasons why the rate of decline in premature mortality from diabetes is faster for females than for males [22]. There is a large disparity in the number of people with different subtypes of diabetes in China, with more than 90% of diabetic patients who have type 2 diabetes [13,23,24]. According to the GBD, as of 2021, the number of people with diabetes in China will be 116 million, while type 1 diabetes will account for only 1.4 million people [25]. Due to the different pathogenesis of the two types of diabetes, type 2 diabetes is more effectively prevented and controlled than type 1 diabetes. The large number of people with type 2 diabetes, due to acquired factors such as high BMI, poses a major challenge to the public health system. Type 1 diabetes, despite its low prevalence, still poses a continuous management demand on the healthcare system due to its need for lifetime dependence on insulin therapy.

Overall, it is difficult for the country to realize the Healthy China 2030 Goals. China’s rapid urbanization over the last few decades has created a better environment for obesity [26,27]. Some studies predicted that by 2030, the prevalence of obesity among people aged from seven to 17 years olds in China will show a continuous upward trend [28]. Meanwhile, although the prevalence of hypertension has declined slightly since 2010, the treatment and control rates are still not ideal [29]. The results show that although the premature mortality for diabetes is decreasing at different rates in each province, only a small number of provinces can meet the requirements, and most of these provinces are in areas with high economic and medical levels. This reflects the current unbalanced development of China’s public health program [30]. There may be several potential reasons why goals are not accomplished.

The first point is the difference in dietary structure. In places such as Inner Mongolia, Heilongjiang, and Guangdong, where decreases are close to the target, although the target may not be met as projected. Inner Mongolia and Heilongjiang’s failure to meet the target may be attributed to the problem of traditional diet, which is characterized by a high-calorie, high-fat, and high-sugar diet in these two provinces, especially in Inner Mongolia, which has a predominantly meat- and dairy-based diet, and in Heilongjiang, where the traditional diet also contains a large amount of carbohydrates. Sugar intake is also high in Guangdong and other places, and these dietary structures are prone to obesity, then lead to a high BMI, which is an important risk factor for type 2 diabetes. This is consistent with other studies [31,32]. Therefore, local governments and relevant medical and health organizations should pay more attention to local dietary problems. In accordance with the epidemiological characteristics and prevention and treatment needs of different regions and populations, targeted prevention and treatment goals and strategies will be determined, and effective prevention and control measures will be implemented.

The second point is the difference in the level of economic development. The remaining provinces with low reductions in premature mortality, such as Ningxia, Xinjiang, Xizang and Qinghai, are landlocked and have gaps in economic development and medical care between coastal areas, and the imbalance in medical development may have contributed to their failure to meet the target. Due to differences in economic levels, the western region has problems such as outdated medical facilities and a shortage of professionals compared to the eastern region. Moreover, research has shown that the medical insurance costs of hospitalized diabetes patients in the eastern region are much higher than those in the western region. All of these affect the accessibility and quality of medical services and thus the treatment effect of diabetes [33]. Therefore, there is a greater need to focus on the balance of disparity in medical resources and health care services between regions and improving accessibility to health care. The government can encourage more students to devote themselves to primary medical care, especially in areas with a shortage of talent, by implementing incentive policies such as tuition waivers, and implement targeted training programs to encourage talented people to move to the grassroots [34].

The third point is lifestyle and regional differences in illness. It is worth noting, however, that while premature mortality from diabetes is decreasing nationwide, it is increasing in Guangxi. Through a review of the literature, we learned that a minority of population adheres to the four healthy lifestyles (including nonsmoking, non-alcohol consumption or moderate alcohol consumption, adequate leisure-time physical activity, and healthy diet) [35], the prevalence of hypertension is 19.3% [36], and unhealthy lifestyles may contribute to this phenomenon. We found from the research of the Guangxi Center for Disease Control and Prevention that male smoking and drinking behaviors are widespread in Guangxi. The rates of risky drinking and harmful drinking in rural areas are significantly higher than those in cities. In addition, the medical levels and living habits in rural areas are quite different from those in cities [37]. Therefore, health education, raising health awareness, and encouraging healthy lifestyles are particularly important in Guangxi.

There are several limitations to this study. The first is the lack of analyses by rural-urban regions; there is no way to know the rise and fall of diabetes-specific premature mortality in specific prefectures within each province. The second is that the average annual rate used in this study to make projections is fixed. If the future trend change, it may have an impact on the predicted results. In addition, the average annual rate of change provides a point forecast and cannot reflect the uncertainty of the projected results.

In summary, this study provides insights into the achievement of the premature mortality targets for major chronic diseases in the Healthy China 2030 Plan, which provide the evidence for strategies and policy. Although China’s premature mortality from diabetes has begun to show a downward trend, the country is still far from meeting the diabetes prevention and control goals of the Healthy China 2030 Plan, especially in inland areas and male population.

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