The diabesity health economic crisis—the size of the crisis in a European island state following a cross-sectional study

The sample population that attended the study (response rate of 49% p?=?0.05) was weighted according to age, gender and locality. This enabled the data to be statistically representative of the whole population of Malta as well as to take in consideration the non-responders. After statistically weighting the sample, the final population dataset was of 3,947 (1998 males, 1949 females). Out of which, 10.39% (95% CI: 9.47–11.38) suffered from diabetes, among which 6.31% (95% CI: 5.59–7.11) were previously known diabetics and 4.08% (CI: 3.50–4.74) were newly diagnosed. 69.77% (95% CI: 68.32–71.18) of the total population was found to be either overweight or obese (Table 1) with a heavy male predominance. The diabetic population was predominantly either overweight or obese (92.20% CI 95%: 89.16–94.45) as seen in Table 1.

*Chi squared between each BMI category against gender

It was noted that younger (55 years) diabetics were predominately (54% CI 95%: 44.30–63.12%) new (unknown) diabetics, while for those aged 55 and over, only 34% (CI 95%: 29.21–39.80) were new diabetics with the vast majority (66% CI 95%: 60.20–70.79) being known diabetics. This finding is in keeping with published data evaluating the degree of diabetes awareness between the 1981 and 2010 examination surveys conducted in Malta [23].

Further subdivision of the diabetic population by age and body weight revealed younger diabetics (55 years) to be predominately obese (50% CI 95%: 40.56–59.44) or overweight (46% CI 95%: 36.88–55.70), with only 4% (CI 95%: 2–8.9) having normal weight. Conversely, a higher proportion of older diabetics (?55 years) were found to belong to the normal weight category (9% CI 95%: 6.37–12.50) with 57% (CI 95%: 51.50–61.61) of these found obese and 34% (CI 95%: 28.59–39.13) found to be overweight (p?=?0.001).

On incorporating the established prevalence rates and their corresponding confidence intervals from this study to the Maltese population, an estimate of the present total population burden of diabetes mellitus and obesity by 10-year age groups and gender was established [14]. Table 2 shows the estimated total Maltese diabetes population by gender and age.

CI???95% Confidence intervals

^a2013 Malta Demographic Report

In the Maltese adult population between 25 and 64 years of age, approximately 20,000 adults suffer from diabetes mellitus type 2. Out of which, approximately 10,000 adults suffer from diabetes and are yet unaware of it, with a male predominance (approx. 6,000). On comparing the Maltese diabetes population to the IDF Atlas (7^th Edition) European diabetes population, the Maltese diabetic population contributes to an approximate 0.03% of diabetes within Europe [2]. This prevalence percentage is an estimate comparison since the adult population age groups for the IDF (20 to 79 years) was different when compared to SAHHTEK study (25 to 64 years).

On the other hand, approximately 82,000 of the 233,136 adults (35% of the adult population) in this age category (25–64 years) in Malta are obese, with a persisting male predominance (approx. 46,000) (Table 3). This ranks the Maltese population as the most obese country in the Mediterranean (Italy – 10.5%; Cyprus – 13.9%; Greece – 16.9%) and in Europe [24].

CI – 95% Confidence intervals

^a2013 Malta Demographic Report

Estimating the cost burden (both direct and indirect) of an undiagnosed diabetic to be approximately €1,052 per person per year (6.67% of the annual mean salary income per person in Malta), the annual burden for the entire population (25 to 64 years) was estimated at €9,755,196 (€7,065,232–€13,582,372), which contributes to 1.22% (0.88–1.70%) of the total health expenditure for Malta [16, 25]. The total health expenditure for Malta (for 2016) is approximately €800,000,000 [25]. The direct medical costs include hospital inpatient costs, physician care, emergency care, outpatients care and prescriptions, while the indirect costs included absence from work, reduced work performance and productivity [16]. Conversely, a known diabetic person’s disease cost burden was approximately €1,887 per person annually (11.96% of the annual mean salary income per person in Malta), attributing to an annual health burden of €19,404,021 (€14,929,944–€25,336,749) for the entire population (25 to 64 years) [17]. This is consistent with 2.43% (1.87–3.17%) of the Maltese total health expenditure. Therefore the global cost burden of diabetes mellitus for the Maltese health system is approximate a total of €29,159,217 (€21,994,676–€38,919,121) annually. The diabetes cost burden contributes to 3.65% (2.79–4.87%) of the total health expenditure (state and private expenditure) for Malta [25]. On the other hand, the attributed cost burden (included inpatient stay, day patient stay, general practitioner and specialist consultations but not medication and surgical procedures) for obesity in Malta (2% compound interest per annum), was estimated to be €23,732,781 (€21,514,972–€26,049,204) for the year 2016 [18]. The obesity cost burden contributes to 2.97% (2.69–3.26%) of the total health expenditure for Malta [25]. Therefore the total ‘diabesity’ cost burden for Malta, in 2016, is an approximate total of €52,891,998 (€43,509,648–€64,968,325) which amounts to 6.61% (5.44–8.12%) of the Malta’s total health expenditure.

The projected EUROSTAT 2050 Maltese population (25 to 64 years) was incorporated within the projected prevalence rates for diabetes and obesity rates as seen in Table 4. On incorporating these projected prevalence rates within the projected cost burden (2% compound interest per annum from the 2016 costs) for diabetes and obesity, we were able to estimate the likely economic burden caused by these diseases for 2050 (Table 5). The total adult population (25 to 64 years) projected for 2050 appears to decrease from the current 2016 adult population. Meanwhile, the diabetes and obese population will increase by approximately 28 and 15% respectively by 2050. The economic burden is expected to increase in association with this disease burden. An exponentiation of 1.2 in the diabetes cost burden and exponentiation of 2 in obese cost burden from the current (2016) is expected to occur by 2050. This contributes to an estimated cost burden of €33,751,487 (€25,458,606–€45,048,473) for diabetes mellitus and €46,532,294 (€42,183,889–€51,074,049) for the obese. Therefore the estimated total cost burden for 2050 for diabetes mellitus type 2 and obesity would amount to one-eight of the current (2016) total health expenditure (€800,000,000).

CI – 95% Confidence interval

^aDemographic Data 2013