The result of the study shows that the prevalence of Diabetes in Indonesia increased from 9.19% in 2020 (18.69 million cases) to 16.09% in 2045 (40.7 million cases) or an increase of 75.1% over 25 years, or an average of 3% per year. The province with the highest prevalence in 2045 is Jakarta (23.11%) and the lowest is East Nusa Tenggara province (8.91%). The largest number of cases in 2045 is in West Java Province (7,170,569 cases) and the lowest is in North Kalimantan Province (138,038 cases). The results of this study indicate a large increase in the prevalence and number of Diabetes cases in Indonesia, if adequate prevention and control of the NCDs risk factors programs are not carried out. Jakarta Province is an urban area which have higher Diabetes risk factors so that the prevalence is the highest. NTT Province is a rural province with a lower risk of Diabetes, so the prevalence is the lowest. The size of cases corresponds to the magnitude of the prevalence and the number of adult populations. The number of Diabetes cases is according to the prevalence and number of people aged 15 years and over, so provinces with large populations tend to have a larger number of Diabetes cases. West Java Province is the largest province in Indonesia so that the number of cases is the largest, while North Kalimantan province is the province with the smallest population so that the number of Diabetes cases is also the lowest.
The increase in the prevalence of Diabetes in Indonesia is almost the same as the results of other studies. In Indonesia, Nuryati’s research in 201227 shows that the prevalence diabetes among adults in Indonesia 8.04%. This study was a cross sectional study using secondary data from Basic Health Research 2007 with respondents above 18 years using oral glucose tolerance test. Nuryati’s study used the same as this study from Basic Health Research but with different period (2007 and 2018 data) so the prevalence was quite same. But, the projection from this study is higher that projection of Nurhayati16 that by 2020 the prevalence was 8.71% in Indonesia and 9.49% in 2024. Nurhayati’s study used a literature review based on Institute of Health Metric and Evaluation (IHME) data which was based on relative risk modelling using regression analysis. This projection is different from this study which used not only risk factors but also Diabetes programs. It indicates that the programs influence the burden of diabetes in Indonesia.
In Thailand, Mahikul et al.28 reported that Diabetes prevalence is predicted to increase from 6.5% in 2015 to 10.69% in 2035 or an increase of 64.4% over 20 years or 3.2% per year. According to data from the Institute of Health Metric and Evaluation, the prevalence of Diabetes in Indonesia in 2019 is estimated at 3.98% of the entire population or 10.33 million cases1. In China, research of Pan et al.29 in a systematic review 1987–2007 reported that the prevalence of Diabetes in China in 2009 was 3.9% (urban 5.2%, rural 2.9%) and is predicted to increase to 5.4% (urban 6.9%, rural 3.8%) in 2016, or an increase of 38.4% over 7 years or an annual increase of 4.6%. Meanwhile, the number of Diabetes cases is projected to increase from 53.1 million cases in 2009 to 76.1 million cases in 2016. In Sweden, Andersson et al.30 reported that the prevalence of Diabetes increased from 5.8% in 2007 to 6.8% in 2013 (2013) and will rise to 10.4% in 2050 or an increase of 79.3% over 1.8% per year. The number of cases is predicted to increase to 940,000 and every 1% increase in annual incidence will result in an increase of 12.6% prevalence and 1,136 000 cases.
In the United States by Boyle et al.19 where if Diabetes mortality is high, then Diabetes prevalence increases from 14% in 2010 to 21% in 2050 (increase of 50% or 1.25% per year) and to 33% in 2050 (increase of 135%) or 3.3% per year) for 40 years if mortality is low. Rowley et al.18 in the US The prevalence of Diabetes will increase by 54% to more than 54.9 million US population between 2015 and 2030. Diabetes—related annual deaths will rise by 38% to 385,800. Another study by Mainous et al.31 in the United States, projections of Diabetes burden based on individual risk prevalence show that the total burden of Diabetes is estimated at 11.5% (25.4 million) in 2011, 13.5% (32.6 million) in 2021, and 14.5% (37.7 million) in 2031 or an increase of 26% over 20 years with an average increase of 1.3% per year. Wild et al.32 projected that diabetes prevalence is estimated at 2.8% in 2000 and increases to 4.4% by 2030 worldwide, or an increase of 57.1% from the prevalence over 30 years, with an average of 1.9% increase per year. The number of people with diabetes in the world is expected to increase from 171 million cases in 2000 to 366 million cases in 2030.
Based on the scenarios, the results of this study show that the prevalence of Diabetes by 2045 was 16.09% and can be reduced to 15.68%, or reduced by 5.54%, if program intervention namely increase of the coverage of villages with Posbindu and SPM of Diabetes services to 100%. This figure can be lowered again to 9.22% or reduced by 42.69% if the program intervention is added with prevention of risk factors (overweight, obesity, central obesity and consumption of fatty foods). These results show that existing program interventions (Posbindu village and SPM of Diabetes services play a role in reducing the prevalence of Diabetes but not so large. The reduction will be much greater if prevention of the main risk factors for Diabetes are overweight, obesity, central obesity, and consumption of fatty foods.
To reduce Diabetes cases, efforts are needed to control risk factors that positively affect Diabetes projections, namely overweight, obesity, central obesity, and consumption of fatty foods. These control efforts are carried out through increasing education, physical activity, and efforts to change the pattern of consumption of fatty foods into healthy foods (enough fruits and vegetables). Efforts to halt the prevalence rate of these four risk factors can be made through a combination of physical activity and a healthy diet. Intervention targets need to be more specific to at-risk populations. Research by Gregg et al.33 in the United States, shows that by 2030 it is projected that 4.6 million incidences and 3.6 million cases of Diabetes prevalence or reducing the prevalence rate by 14% can be prevented by a combination of prevention strategies. This prevention strategy is developed with structured lifestyle interventions for high-risk (pre-diabetic), moderate-risk, and general populations.
The Ministry of Health of Indonesia needs to make policies and programs to prevent risk factors. The program can be through educational efforts through the Healthy Living Community Movement (GERMAS) and healthy behavior in the community. It is necessary to increase 100% Village with Posbindu. In addition, the achievement of Diabetes health service SPM becomes 100% every year. National Planning Bureau needs to include efforts to control Diabetes risk factors, especially overweight, obesity, central obesity, and unhealthy consumption patterns in health program plans in Indonesia and provide sufficient budget related to Posbindu and Diabetes health service SPM.
The results showed that the projected number of deaths due to Diabetes in Indonesia increased from 433,752 deaths in 2020 to 944,468 in 2045. Stroke deaths in Diabetes increased from 52,397 in 2020 to 114,092 in 2045. Deaths from IHD in Diabetes increased from 35,351 in 2020 to 76,974 in 2045. Meanwhile, deaths from chronic kidney disease in Diabetes increased from 29,061 in 2020 to 63,279 in 2045. The number of deaths from Diabetes and its complications increased by 117% over 25 years or an average of 4.7% per year.
These results indicate that Diabetes is one of the highest causes of death in Indonesia. Based on data from the Institute of Health Metric and Evaluation, deaths from Diabetes in Indonesia in 2019 amounted to 40.98 per 100,000 population or 106,333 deaths. It has the largest increase of all other causes of death for 128.7% from 19901. Meanwhile, based on data from the 2015 Sample Registration System, Diabetes is the third highest cause of death in Indonesia after stroke and ischemic heart disease with a proportion of 7.8%34, an increase from 5.7% in 20072.
In Singapore, research by Tan et al.17 shows that Diabetes complications in 2050 in the form of acute myocardial infarction will increase from 9300 deaths (2019) to 16,400 (2050), the number of stroke increase from 7300 to 12,800, the number of end-stage kidney disease from 1700 to 2700. This number increased by an average of 76.3% over 30 years. In Thailand, Mahikul et al.28 in their study predicted death in undiagnosed Diabetes 10 times greater than undiagnosed Diabetes. The positive screening rate decreased mortality in women aged 15–34 years at 10 years. This indicates the importance of blood sugar screening so that people can be aware of the dangers of diabetes and can make prevention and control efforts independently. Research by Foreman et al.35 shows that deaths from Diabetes in the world amounted to 1,437,000 in 2016 to 2,971,000 in 2040, or an increase of 106.7% over 24 years, with an average increase of 4.4% per year. Deaths from Diabetes -related kidney disease in the world 500,000 in 2016 to 1380 in 2040. Stroke deaths in the world were 5,528,000 in 2016 to 5973 in 2040. The number of ischemic heart disease deaths worldwide was 9,480,000 in 2016 to 10,872,000 in 2040.
Deaths from Diabetes and its complications need to be suppressed with appropriate primary, secondary, and tertiary prevention. Ministry of Health to improve such prevention adequately. On primary prevention to prevent complications in people with diabetes through diet modification and a healthy lifestyle. In secondary prevention, treatment of Diabetes and its complications needs to be provided to all patients using the latest technology. Increased achievement of SPM of Diabetes Health services. In tertiary prevention, rehabilitation for advanced cases such as diabetic foot care needs to be expanded, including home care services.
To reduce the fatality of diabetes due to its complications such as Stroke, Ischemic heart disease, Chronic kidney disease and immediate fatality due to Diabetic Ketoacidosis, interventions of the disease should be enhanced across the regions in Indonesia. Chronic disease management program (Prolanis), number of primary health care facilities providing optimal diabetes services (NCD integrated services), and the participation of healthy life movement (GERMAS) should be strengthened. Meanwhile, achievement of blood glucose targets under Prolanis and the percentage of diabetic patients receiving scheduled screenings and counselling with specialists should be increased.
This study has several limitations in terms of quality and representation of research data. This is due to inconsistent data, missing data, and program coverage data exceeding 100%. For inconsistent data, projections use their mean and standard deviation. For data that exceeds the target of 100%, the data is fulfilled to a maximum of 100%. There are 3.3–34.6% missing data that can reduce data quality in making projections. For these circumstances, the data is filled in using the average province of the district so that the data does not deviate from the actual condition.
Data representation for village with Posbindu, Pandu, and SPM of Diabetes services, and SPM of screening are routine data that is inputted by district government which tends to overestimate, because there is no individual data. However, this data is an official release from the Ministry of Health so it can still be used. The data analyzed in this study is aggregate data at the district level (205 districts/cities out of 514 districts/cities) to estimate the burden of Diabetes at the district, provincial, and national levels. This can cause actual projections to vary more than the results of this study because not all district data are analyzed in the preparation of the model. However, with a provincial MAPE value of 13% that is good at making projections at the provincial level and MAPE at the district / city level, the projection is still quite feasible to estimate conditions in the district/city.
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