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Time trends in diabetes mellitus in Jordan between 1994 and 2017

Article  in  Diabetic Medicine · January 2019

DOI: 10.1111/dme.13894

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 DIABETICMedicine

DOI: 10.1111/dme.13894

Research: Epidemiology
Time trends in diabetes mellitus in Jordan between 1994
and 2017

K. Ajlouni1 , A. Batieha2, H. Jaddou2, Y. Khader2, N. Abdo2, M. El-Khateeb3, D. Hyassat3

and D. Al-Louzi4
1
National Centre (Institute) for Diabetes, Endocrinology and Genetics (NCDEG), University of Jordan, Amman, 2Department of Public Health and Community
Medicine, Jordan University of Science and Technology (JUST), Irbid, 3National Centre (Institute) for Diabetes, Endocrinology and Genetics (NCDEG), University of
Jordan, and 4Jordan Ministry of Health, Amman, Jordan

Accepted 4 January 2019

Abstract
Aim The prevalence of diabetes has been increasing over the past few decades. The objective of this study is to assess the
time trends in diabetes between 1994 and 2017 in Jordan.
Methods Surveys were conducted in 1994, 2004, 2009 and 2017 by the same investigators using generally similar
methods. Fasting blood glucose was measured in all surveys. Variables were obtained using structured questionnaires
designed specifically for the surveys. Crude and age-specific diabetes prevalence rates were derived for each sex, together
with overall, crude and age-standardized prevalence rates.
Results The prevalence of diabetes in men aged ≥ 25 years increased from 14.2% in 1994 to 18.3% in 2004, 26.8% in
2009 and 32.4% in 2017. The corresponding prevalence rates in women were 12.3%, 16.9%, 18.8%, and 18.1%,
respectively. The overall age-standardized prevalence rate increased from 13.0% in 1994 to 17.1% in 2004, 22.2% in
2009 and 23.7% in 2017. Known diabetes in the 2017 survey accounted for 82.6% of people with diabetes. A HbA1c of
< 59 mmol/mol (7.5%) was observed in 41.4% of participants with known diabetes.
Conclusion The results showed a high prevalence of diabetes in Jordan among people aged ≥ 25 years. Prevalence
increased from 1994 to 2009, but slowed thereafter. The increase was greater in men than in women. Previously
diagnosed diabetes accounted for a high percentage of people with diabetes in all surveys and was highest in 2017
survey, suggesting that the national strategy against diabetes has brought some benefits. Efforts should be made to
improve glycaemic control in people with diabetes.
Diabet. Med. 00: 1–7 (2019)

and control of diabetes and other non-communicable dis-

Introduction
Diabetes mellitus is a common systemic disease with serious
consequences. An increasing trend in the prevalence of
diabetes since 1980 has been documented worldwide [1].
The prevalence of diabetes has increased at a faster rate in
low- and middle-income countries than in high-income
countries [1]. This surge in prevalence may be due to an
increase in the incidence of diabetes, better survival, popu-
lation ageing or a combination of these factors. In the USA,
the incidence of diabetes almost doubled between 1970 and
2000 [2]. In Jordan, the prevalence of diabetes showed an
increase between 1994 and 2004 [3]. Halting the rise in age-
standardized prevalence of diabetes at its 2010 level by 2025
is a global target [4]. A national strategy for the prevention
Correspondence to: Kamel M. Ajlouni. E-mail: ajlouni@ju.edu.jo
eases was formally adopted by the government of Jordan in
2010. Assessment of diabetes trends at the national level are
needed to measure progress towards the global target and the
effect of interventions. This study is an effort to assess the
time trend in diabetes mellitus between 1994 and 2017. It
also provides an opportunity to assess the impact of adopting
the national strategy on the prevalence of diabetes.
Methods
Four comprehensive population-based surveys were con-
ducted in Jordan during the years 1994, 2004, 2009 and
2017 [2,5,6]. These surveys were conducted by the same
team of researchers and generally used the same methods.
Details of the surveys from 1994, 2004 and 2009 have been
published previously [2,5,6]; the methods used in the 2017

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DIABETICMedicine
What’s new?
• An increasing trend in diabetes prevalence has been
observed in many countries around the world. High
rates of diabetes mellitus have been observed in Jordan
since 1994.
• This study links data from four population surveys
conducted in Jordan in 1994, 2004, 2009 and 2017 to
document an increasing time trend in diabetes in the
country that slowed after 2009. The four surveys were
conducted by the same team of researchers and gener-
ally used the same methods. To our knowledge, this is
the first study to document such a time trend in the
Middle East.
• The study highlights the need for action to prevent
diabetes. The economic burden of diabetes for this
small, not wealthy country is becoming unbearable. All
concerned parties in Jordan should join forces with
international agencies to curb this escalating problem.
Modifiable factors such as diet, physical activity,
overweight and obesity should be addressed. In partic-
ular, changes in lifestyle and creating an environment
conducive to health are of paramount importance.
survey are detailed below. The survey was multipurpose
covering cardiovascular disease risk factors, vitamin D,
vitamin B12, aspects of health care for non-communicable
diseases and other items.
Sample selection
A multistage technique was used to select a nationally
representative sample from the population of Jordan.
Because the study procedures (drawing blood samples,
anthropometric measures, etc.) required a clinical setting,
we asked the General Health Director of each of the 12
governorates of Jordan to select between one and three
health centres that represented the other health centres in
the governorate. We requested that the selected health
centres be large enough to provide the space for the study
team (25 people) to perform the required procedures. A
total of 17 health centres distributed throughout Jordan
were selected. A team of two (one man and one woman)
went door-to-door in the catchment areas of the health
centres selecting every third to sixth household, depending
on the population density. In total, 200–400 households
were selected in each area. The team invited all those aged
≥ 18 years in the selected households to report to the centre
after explaining the study to them. Participants were asked
to fast and not take their medications on that day, but to
bring their medications to the health centre. Only those
aged ≥ 18 years in each selected household were eligible for
inclusion. To encourage participation, the team worked on
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Time trends in diabetes in Jordan  K. Ajlouni et al.
weekends and holidays, and provided free transportation
for those who requested it.
The response rate was 94% for women and just 40% for
men. The main reason behind the lower response rate in men
was employment, often far from their place of residence. The
unemployment rate in men was just 12% compared with a
much higher rate in women (> 70%), which makes women
more available for participation. The total number of people
sampled was 4056, of whom 3594 were ≥ 25 years of age
and were included in this analysis. People aged < 25 years
were not included in this analysis because we did not have
data on them for all previous surveys. Also, the WHO
Stepwise surveys for non-communicable diseases deals with
people aged ≥ 25 years. So, this permits comparison of our
data with that from these stepwise surveys. This sample size
translates to a margin of error of ~ 1.3% given a prevalence
of 20% and a 95% confidence level (95% CI).
All four surveys were population based. The 2009 survey
was almost identical to the 2017 survey and was conducted
at 31 sites distributed throughout Jordan. The 2003 survey
was conducted at one site only (Al-Sarih), a city in northern
Jordan with a population currently exceeding 60 000. Al-
Sarih was included in all four surveys, mainly because of its
proximity to the university where most of the study inves-
tigators work; the city did not differ from the other sites in
terms of diabetes and other cardiovascular disease risk
factors. The 2004 survey was conducted at six sites, mainly
in northern and eastern Jordan. In all four surveys, the
response rate in women was almost double that in men
(Table S1).
Data collection
The study collected a wide array of data from each
participant as summarized below.
Interview data
A trained interviewer administered a comprehensive struc-
tured questionnaire specifically prepared for the study. The
main data obtained included sociodemographic variables,
diabetes and other cardiovascular disease risk factors, style of
dress and sun exposure, morbidity, quality of life and health
service use, among others.
Anthropometric measurements
Height, weight, waist and hip circumferences, and blood
pressure were measured. All measurements were performed
in a standard way by trained field researchers.
Laboratory tests
Three blood samples drawn from a cannula inserted into the
antecubital vein were used for the different laboratory
measurements. Tubes containing sodium fluoride potassium
oxalate were used for glucose measurements. Samples were
centrifuged within 1 h of collection at the survey site and
 Research article
transferred in separate labelled tubes on ice to the central
laboratory of the National Centre of Diabetes, Endocrinol-
ogy, and Genetics in Amman, Jordan. All biochemical
measurements were performed by the same team of labora-
tory technicians using the same methods throughout. Fasting
plasma glucose was measured by the glucose oxidase
method, using a Cobas Analyser (Roche, Risch-Rotkreuz,
Switzerland). HbA1c was analysed using high-performance
liquid chromatography (Bio-Rad, Marnes-la-Coquette,
France), and was certified by the National Glycohemoglobin
Standardization Program. Unfortunately, HbA1c was not
measured in the 1994 and 2009 surveys, because of cost
restraints.
Data management and statistical analysis
Data were analysed using Statistical Package for Social
Sciences software (SPSS-PC). We performed range and
logical checks for data cleaning. Detected errors were
corrected as appropriate. The four raw data files (1994,
2004, 2009 and 2017) were reanalysed using the same
variable definitions to assess time trends associated with the
prevalence of diabetes. Overall and age-specific prevalence
rates were obtained and reported separately for men and
women. Only participants aged ≥ 25 years of age. To allow
comparison between the different surveys and with studies in
other countries, we derived age-standardized prevalence rates
using the world population as a standard [7]. Ninety-five
per cent confidence intervals were reported for the crude and
standardized rates. We also obtained the percentages of
previously diagnosed diabetes in the four surveys and the
percentages of controlled diabetes in the 2017 survey using
different HbA1c cut-off levels. Diabetes was defined as an
fasting plasma glucose level ≥ 7 mmol/l, a prior diagnosis of
diabetes or receiving hypoglycaemic agents.
Ethical considerations
The study was approved by the ethics committee of the
National Centre for Diabetes, Endocrinology, and Genetics,
Amman, Jordan. A letter of support was obtained from the
minister of health to insure cooperation of the staff of the
health centres. Informed consent was obtained from each
participant. All study procedures were performed free of
charge for participants. Blood samples were drawn by skilled
laboratory technicians and nurses using a standard aseptic
technique. Data were strictly confidential and were used only
for scientific purposes.
Results
The results of this study are based on data obtained from
four population-based surveys conducted in Jordan between
1994 and 2017. The age and gender distribution, as well as
the response rates are summarized in Table S1. Apart from
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DIABETICMedicine
the number of participants aged 25–29 in 1994, there was
little differences in age composition between surveys. The
response rate in men was relatively low in all four surveys.
Age-specific prevalence rates of diabetes
Table 1 shows the age-specific prevalence rates for diabetes
mellitus by gender. As expected, prevalence increased with
age in both genders in the four surveys. However, in men, the
increase was more substantial after age 50 in the 2009 and
2017 surveys, reaching 49.4% and 54%, respectively,
compared with 19.0% in the 1994 survey and 28.2% in
the 2004 survey. A similar pattern was observed in women.
These patterns are further illustrated in Figs 1 and 2.
Time trends in overall prevalence of diabetes
Overall, the crude prevalence of diabetes increased from
12.9% in 1994 to 17.4% in 2004, 20.8% in 2009, and
22.4% in 2017, representing an increase in crude prevalence
of roughly 74% between 1994 and 2017. The age-adjusted
(standardized) prevalence rate of diabetes showed a similar
pattern, increasing from 13.0% in 1994 to 23.7% in 2017
(Table 1 and Fig. 3).
Time trends of diabetes by gender
The prevalence of diabetes in men increased dramatically
from 14.2% in 1994 to 18.3% in 2004, 26.8% in 2009
and 32.4% in 2017; thus, the prevalence of diabetes
more than doubled between 1994 and 2017 (128%
increase).
In women, the increase in the prevalence of diabetes was
more modest than in men, increasing from 12.3% in 1994 to
18.1% in 2017 (44% increase) (Table 1).
Previously diagnosed diabetes
Table 2 shows a shift in the proportion of previously
diagnosed diabetes, with the highest proportion observed in
the 2017 survey (82.6%) and the lowest in the 1994 survey
(58.9%) (Table 2).
Extent of diabetes control
The proportion of people with previously and newly diag-
nosed diabetes in the 2017 survey whose disease was
controlled based on different HbA1c levels is shown in
Table 3. The proportion of people with previously diagnosed
diabetes controlled at an HbA1c level < 59 mmol/mol (7.5%)
was 41.4%, < 53 mmol/mol (7.0%) was 33.0%, and
< 48 mmol/mol (6.5%) was 23.6%. The corresponding
proportions of control among those with newly diagnosed
diabetes in the 2017 survey were 42.9%, 52.8% and 66.5%,
respectively (Table 3).
3
DIABETICMedicine Time trends in diabetes in Jordan  K. Ajlouni et al.

Table 1 Age-specific and age-adjusted prevalence rates of diabetes mellitus by gender during the period 1994–2017 in Jordan, 2018

Prevalence (%)

1994 (N = 3640) 2004 (N = 1121) 2009 (N = 3064) 2017 (N = 3594)

Men n = 1328 n = 394 n = 777 n = 1099

Age (years)
25–29 3.2 0 1.7 3.2
30–39 2.5 4.3 6.1 15.6
40–49 23.5 22.6 22.5 30.3
50–59 24.8 25.4 43.1 35.4
60+ 19.0 28.2 49.4 54.0
Total 14.2 18.3 26.8 32.4
Women n=2,312 n=727 n=2,287 n=2,495
Age (years)
25–29 0.9 2.6 2.1 1.4
30–39 3.7 2.6 4.1 4.7
40–49 13.1 14.2 16.9 17.2
50–59 21.9 31.2 38.3 33.0
60+ 27.7 37.7 45.8 52.4
Total 12.3 16.9 18.8 18.1
Men + women
Age (years)
25–29 0.9 1.9 2.0 1.8
30–39 3.1 3.1 4.5 7.1
40–49 14.8 17.1 18.3 21.0
50–59 23.2 29.5 39.5 33.8
60+ 22.1 33.2 47.2 53.1
Grand total:
Crude (95% CI) 12.9 (10.5 to 15.6) 17.4 (15.2 to 19.7) 20.8 (18.9 to 2.7) 22.4 (20.7 to 24.1)
Age-adjusted 13.0 (10.6 to 15.4) 17.1 (15.0 to 19.1) 22.2 (20.8 to 23.8) 23.7 (21.9 to 25.5)

FIGURE 1 Age-specific diabetes prevalence rats in the four surveys, Jordan 2018

study by the same team of researchers reported on time

Discussion
This study is the first in Jordan to provide estimates of the
prevalence of diabetes over a relatively extended period,
1994 to 2017, making use of population data obtained at
four time points (1994, 2004, 2009 and 2017). A previous
trends over a shorter period (1994 to 2004) [3].
The age-standardized prevalence of diabetes in Jordan
increased from 13.0% in 1994 to 23.7% in 2017, an increase
of ~ 83%. The increase was rapid between 1994 and 2009,
but slowed thereafter. Consistent with this finding, data from

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 Research article DIABETICMedicine

FIGURE 2 Age-specific diabetes prevalence rates in (a) men and (b) women in the four surveys, Jordan 2018

may be due to increased survival and not necessarily

increased incidence, thus negating apparent conflict with
the findings of the Framingham study mentioned earlier [2].
In our study, the increase in diabetes prevalence was huge in
men (more than doubled) but modest in women (< 50%),
resulting in a widening of the gap between men and women
from as little as 2% in 1994 to more than 14% in 2017. This
pattern has been observed by others [1,8]. We have no
explanation for this finding, but we speculate that it may be
the result of a change in lifestyle in men to a more sedentary
pattern with less physical effort demanded by their jobs due
to technological advances. The lower response rate in men
was consistent in the four surveys and the main reason for
non-participation in men was work. The unemployment rate
FIGURE 3 Overall crude and age-adjusted diabetes prevalence rates in in men was 12% compared with more than 70% in women.
the four surveys, Jordan 2018 Non-participation can affect prevalence only if it is depen-
dent on whether people have previously diagnosed diabetes;
it is hard to believe that this occurred in men but not in
Table 2 Proportion of people with previously diagnosed diabetes in the
four surveys, Jordan, 2018 women.
Prevention of diabetes is needed to achieve the global
Previously diagnosed diabetes
target of halting the increased prevalence of this disease [4].
At a population level, encouraging physical exercise and
n % population % participants with diabetes
modifications to the diet are the cornerstones of diabetes
Survey period prevention. However, success in inducing these changes is
1994 276 7.6 58.9 not as easy as it first appears. Development and implemen-
2004 146 13.0 74.7 tation of national strategies and action plans, and coordi-
2009 512 12.4 59.6
2017 762 19.0 82.6 nated efforts by different stakeholders, most of whom are
outside the healthcare sector, are essential to success. Early
identification and management of cases may lead to a
reduction in diabetes complications. A well-developed pri-
the Framingham study showed that the incidence of diabetes mary healthcare system accessible to all is also needed. In
in the past decade remained relatively stable, despite rising 2010, Jordan formally adopted a national strategy and action
obesity rates [7]. A recent worldwide study of trends in plan to prevent and control diabetes. The slower rise in the
diabetes showed that since 1980, age-standardized diabetes prevalence of diabetes observed in this study may be partly
prevalence in adults has increased, or at best remained attributable to this strategy. The very high rate of previously
unchanged, in every country. This increase occurred at a diagnosed diabetes observed in our 2017 survey (82.6%)
faster rate in low- and middle-income countries than in high- supports this notion, indicating increased awareness in the
income countries [1]. The increase in prevalence, however, population as well as better access to diagnostic services.

ª 2019 Diabetes UK 5
DIABETICMedicine
Table 3 Status of control in people with newly diagnosed and
previously diagnosed diabetes in the 2017 survey, Jordan, 2018
HbA1c level
< 48 mmol/mol <53 mmol/mol < 59 mmol/mol
(6.5%) (7.0%) (7.5%)
People with 42.9 52.8 66.5
newly
diagnosed
diabetes
(%)
People with 23.6 33.0 41.5
previously
diagnosed
diabetes
(%)
However, given the multitude of factors responsible for
bringing about such change, a study designed specifically to
evaluate the impact of implementing the national strategy is
needed.
Comparing the rate of previously diagnosed diabetes in
our study with that reported from other countries shows that
our figures are acceptable even when compared with devel-
oped countries such as the USA (89.1%) [9] and Denmark
(35%) [10].
Our study showed that the proportion of previously
diagnosed diabetes controlled to an HbA1c level < 59 mmol/
mol (7.5%) in 2017 is modest (41.4%) and to an HbA1c
level < 53 mmol/mol (7%) is low (33%). Data from the
USA revealed higher rates of control; 55% HbA1c < 53
mmol/mol (7%) during the period 2005–2010 [11]. There
have been many uncertainties regarding use of HbA1c as a
target for optimal diabetes control. The American College
of Physicians’ guidance states that physicians should
personalize goals for glycaemic control in people with Type
2 diabetes based on a discussion of the benefits and harms
of pharmacotherapy, personal preferences, their general
health and life expectancy, treatment burden and costs of
care. HbA1c levels between 53 mmol/mol (7%) and
64 mmol/mol (8%) should be the target in most people
[12]. Physicians should moderate pharmacotherapy if the
HbA1c is < 48 mmol/mol (6.5%), whereas in people with a
life expectancy < 10 years, treatment should be guided by
minimizing the symptoms of hyperglycaemia and not the
HbA1c level [12]. Updated American Diabetes Association
(ADA) standards for medical care in diabetes were pub-
lished in 2018 [13]. These standards emphasize the need to
manage cardiovascular risk factors such as obesity, dyslip-
idaemia and hypertension in people with Type 2 diabetes
[13].
A main limitation of this study is the low response rate in
men, which was consistent across the four surveys. As noted
earlier, the main reason for nonparticipation was work, often
outside the city or town in which the survey was conducted.
6 ª 2019 Diabetes UK
Time trends in diabetes in Jordan  K. Ajlouni et al.
Women had a very high unemployment rate and therefore
were more available for participation. There is no evidence
that nonparticipation was dependent on whether a person
had previously diagnosed diabetes. Therefore, it is unlikely
that our prevalence estimates in men were greatly affected by
such a low response rate. In fact, a low response rate is
expected in most population-based surveys. With regard to
the increasing time-trend observed in this study, it is unlikely
to be explained by the low response rate, as it was the case in
all four surveys, particularly in men.
Differences in the age distribution of participants from one
survey to another may explain differences in the prevalence
of diabetes, because diabetes is more common in older age.
However, in our study, little difference in age existed across
the four surveys. Furthermore, we reported age-adjusted
rates directly using the same standard world population;
thus, the effect of differences in age from one survey to
another has been removed.
In conclusion, this study showed a high prevalence of
diabetes mellitus in Jordan among people aged ≥ 25 years.
The prevalence rate increased at a rapid rate from 1994 to
2009, but slowed thereafter. The increase was much greater
in men than in women. Previously diagnosed diabetes
accounted for a high percentage of all diabetes cases in the
four surveys, and was highest in the 2017 survey, suggesting
that the national strategy against diabetes may be beneficial.
More effort should be made to improve glycaemic control in
people with diabetes. A national study designed specifically
to assess the impact of such a national strategy is highly
recommended.
Funding sources
This research was funded by Scientific Research Support
Fund/The Ministry of Higher Education.
Competing interests
None declared.
Acknowledgements
Many thanks to all of the general practitioner working at
health centres of the Ministry of Health. We acknowledge
the work and guidance of the committee of the National
Strategy and Plan of Action Against Diabetes, Hypertension,
Dyslipidaemia and Obesity in Jordan and the assistance of
the following: D. Al-Louzi (Secretary General of Ministry of
Health, Jordan), A. M. Hyari (Secretary General of Awqaf
Ministry, Jordan), M. Al Akor (Secretary General of the
Ministry of Education, Jordan), W. Al-Otoum (Secretary
General of Ministry of Municipal Affairs, Jordan), F. Al
Shboul (Director General of Jordan News Agency, Petra), M.
Tarawneh, (Director of JRTV), M. El-Zaheri (President of
the Jordanian Society for the Care of Diabetes), R. Nasser
 Research article
(President of the Jordanian Society of Endocrinology, Dia-
betes & Metabolism), A. Sayaydeh (Director of the MOH
Primary Healthcare Administration, Jordan), F. Haddad
(Royal Medical Services, Jordan), F. Ammari (Jordan
University of Science and Technology), M. R. Tarawneh,
Ministry of Health, Jordan), R. Al-Ma’aitah (National
Woman’s Health Care Centre Director, Jordan), M. El-
Khateeb (Vice President of the National Centre for Diabetes,
Endocrinology and Genetics- Jordan), D. Hyassat (National
Centre for Diabetes, Endocrinology and Genetics, Jordan)
and A. Batieha (Jordan University of Science and Technol-
ogy, Jordan).
Authors’ contributions
KA, the main investigator, principle author of the study and
guarantor, was involved in planning, executing and analysing
the data. AB was the main author of the study protocol and
was responsible for the statistical analysis. HJ was co-author
of the structured questionnaire and supervised execution of
the protocol and data collection. YK, together with AB, was
responsible for the statistics and supervised the fieldwork.
NA carried out part of the fieldwork, and helped coordinate
doctors responsible for the work in health centres. ME was
responsible for all laboratory procedures, sample handling,
transport and analysis. DH carried out part of the fieldwork,
and shared responsibility for coordinating doctors responsi-
ble for the work in health centres and data collection. DA
was responsible for liaising between health centres all over
Jordan and the investigation team, was mainly responsible
for liaising between the Ministry of Health and the research
team and participated in planning the study.
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Supporting Information
Additional supporting information may be found online in
the Supporting Information section at the end of the article.
Table S1. Age and gender distribution and response rates
across the four surveys.
7