Diabetes is a metabolic disease with multifactorial etiology characterized by chronic hyperglycemia caused by impaired insulin secretion or its function [1]. Diabetes is one of the health challenges of recent decades that imposes a tremendous economic burden on society [2]. The World Health Organization (WHO) has declared diabetes a latent epidemic because of the growing number of diabetic people worldwide. It has called on all countries to fight the epidemic since 1993. Based on WHO estimation, the number of people with diabetes will reach from 135 million in 1995 to 300 million in 2025. This increase will be equal to 170% in developing countries and 42% in developed countries [3]. Diabetes is also expected to increase in the elderly in developed countries and people of working age in developing countries [4]. Therefore, although diabetes is considered a problem in developed countries, its impact in reducing life expectancy is greater in developing countries [5]. Experts believe that the recent prevalence of diabetes in society is not explicitly related to changes in the genetic and ethnic characteristics of a society but in the lifestyle and modernization of society. Changing the lifestyle can increase the prevalence of diabetes in people with a similar genetic predisposition to diabetes [6].
‌Three in four (79%) of people with diabetes live in low and middle-income countries [1]. Diabetes is the seventh leading cause of death in the United States and has always been one of the top ten leading causes of death in Iran [7]. In a study in six countries, including Bahrain, South Korea, and Armenia, the death rate from diabetes increased from 1985 to 2010 by an average of 3.2% per year [8]. Besides, the number and causes of death are vital to diagnosing society’s health status, and death data in different age and gender groups can indicate how the economic conditions prevail in society. Also, the effectiveness of health care programs and intervention programs to promote health is known with changes in mortality rates [9]. The use of such data plays an essential role in monitoring health programs, allocating resources, prioritizing intervention programs, setting epidemiological research priorities, establishing health policies, and conducting medical research [10]. Therefore, in this study, we intend to examine the diabetes mortality rate in Iran from 2006 to 2010 and its five-year trend.

This analytic cross-sectional study was performed using mortality data in Iran from 2006 to 2010 published by the Ministry of Health [11]. Data were collected through various sources such as the Civil Registry Office, cemeteries, hospitals, and health houses by the Information and Applied Research Center of the Ministry of Health and Medical Education. In the next step, the data were integrated with the Ministry of Health and Medical Education. In this study, the mortality rate of different types of diabetes was categorized based on the International Coding of Diseases (ICD-10, code E10-E14) in Iran (all provinces) from 2006 to 2010. The number and rate of deaths from diabetes, male to female sex ratio, and death rates in age and sex groups and their residence were calculated and reported using Excel 2016 software. Also, for data analysis, the Chi-square test was performed in SPSS V. 24. P values less than 0.05 were considered statistically significant. Finally, a picture of the changes in diabetes mortality in Iran over five years was obtained.

In this study, the mortality of different types of diabetes from all age groups has been collected from 2006 to 2010. During the study period, 27418 deaths occurred due to various types of diabetes, of whom 54.9% were females and 45.1% males. The lowest death rate of both sexes was 9.42 per 100000 in 2006, and the highest was 10.6 per 100000 in 2010. However, in the whole study period, females’ death rate was higher than males, and the sex ratio of males to females varied from 0.74 in 2008 to 0.88 in 2006. In terms of residence, the death rate from various types of diabetes was much higher in urban areas than in rural areas in all years. The average age of the deceased varied from 66.6 years in 2010 to 69.3 years in 2007 and was 68.1 years in total for five years study period. The mortality rate due to diabetes was significantly different between men and women in all years. Diabetes mortality was significantly higher in women (P‌<0.01). Also, there was a significant difference in the number of deaths from diabetes between the years of study (P‌<0.01). It has increased over the years of study (Table 1 and Figure 1). 







Table 2 presents that the lowest death rate from various types of diabetes belongs to the 5-14 years age group (from 0.14 in 2007 to 0.24 per 100000 population in 2010). In comparison, the highest rate belonged to the age group of over 70 years (from 150.69 in 2006 to 181.31 per 100000 population in 2010). 



The trend of diabetes mortality from 2006 to 2010 by age groups shows that after the age group under 5 years, a relative decrease in death rate was observed in the age group of 5 to 14 and then the trend of diabetes death increased with age and in the age group of 70 years and above has had a vertical ascent (Figure 2). 


Regarding the mortality from diabetes by type, the highest cause of death belonged to non-insulin-dependent diabetes (E11), with 40% of the total number of deaths, followed by other disorders related to diabetes (E12-E14) with 30.8%. The lowest number belonged to insulin-dependent diabetes (E10), with 29.2% of all deaths. Mortality is higher in women in all types of death causes (Table 3). 


 

The present study results in a five-year period show that the death rate due to diabetes increases significantly during the study years. This finding is consistent with the results of previous studies on the increase in deaths due to diabetes in all countries, especially developing countries [4, 12]. The mortality rate due to diabetes in Europe varies from 7.9 per 100,000 people in Greece to 32.2 in Italy. The mortality rate in Iran is higher than in Greece and lower than in Italy. While a declining trend is reported for some non-communicable diseases globally [13], diabetes is an exception. The mortality rate from diabetes is increasing in Europe [14], which is associated with the population’s aging process [15]. A 29% increase in deaths from diabetes in North America, a 12% increase in East Asia, and an 11% increase in West Asia indicate a growing trend of deaths from diabetes [14], which is consistent with the results of the present study. Death from diabetes is mainly due to its complications such as cardiovascular diseases, kidney problems, and the like [16].
In this study, the number of deaths due to diabetes was significantly different between men and women, so that in all study years, deaths due to diabetes in women were significantly higher than in men. This finding is consistent with the findings of Ruiz-Ramos et al. in Spain [17] and Roglic [18]. The higher prevalence of diabetes in women can be one of the causes of high mortality due to diabetes in women [18]. In the study of Farahmand et al. [19], obesity has been reported as a risk factor for diabetes in women more than men, which is considered a risk factor in diabetes [12]. Another cause of obesity in women is related to childbirth [20, 21]. Gharipour study [22] states that people with a BMI above 30 are 9.98 times more likely to develop diabetes, which all justifies the causes of more deaths in women, according to the present study results.
The present study showed that the mortality rate from various types of diabetes in all years in urban areas was much higher than that in rural areas. This finding was inconsistent with the results of a study by Bragg et al. in China, which showed that despite the higher prevalence of diabetes in urban areas, more deaths occur in rural areas. They blamed the lack of diabetes management and its complications in rural areas [23].
Increased urbanization [19, 24], change in lifestyle pattern, a tendency to western life [25], and dietary style and tendency to consume ready-to-eat, fast foods and sedentary [26] during the last two decades, especially in developing countries, are some of the reasons for the higher prevalence of diabetes and consequent death from diabetes in urban areas. Behaviors and lifestyles strongly influence non-communicable diseases. The victims of these diseases share an unhealthy diet with high saturated fat and sugar, low physical activity, and smoking. The high prevalence of diabetes in cities can also be due to low physical activity and high consumption of sugar and fatty foods that are risk factors for diabetes. These foods become synonymous with the urban lifestyle. On the contrary, its prevalence in rural areas has remained low due to limited exposure to risk factors and rural life preservation, and traditional physical activity [27].
In the present study, the lowest death rate from diabetes belonged to the age group of 5-14 years, and the highest rate was seen in people over 70 years. After the age group of under 5 years, a relative decrease in the death rate is observed in the age group 5 to 14 years. Then, the death rate of diabetes has increased with age and has risen vertically in 70 years and above. Bragg et al. reported that the prevalence of diabetes also increased with age [23]. In 2010, nearly 4 million people were estimated to die of diabetes, about 6.5% of the total number of deaths at all ages, and 10% of all deaths between the ages of 20-79 years [18].
This study showed that the highest cause of death was non-insulin-dependent diabetes, with 40% of all deaths. The prevalence of diabetes in Iran is high and is expected to increase in the future, along with increasing life expectancy, urban development, and increasing obesity. Preventive activities in controlling diabetes and thus reducing its mortality can be done in different ways. Before employing any prevention policies, much benefit can be obtained from the effects of increasing awareness about diabetes in the general population. Many studies have reported a lack of knowledge about diabetes and its risk factors in South Asia [28, 29] and even in patients with diabetes [30, 31]. Diabetes has many risk factors that can be changed with lifestyle and by promoting knowledge in this field, adopt a healthy lifestyle. Mohan et al. [32] reported that in an Indian community, creating a public park at one’s own expense significantly increased the physical activity of local residents.
Leaving the traditional food patterns and consuming diets high in saturated fat and refined carbohydrates are essential factors in increasing obesity and diabetes. Consumption of low amounts of fiber and unsaturated fats, as well as high intake of refined carbohydrates, saturated fats, and trans fats, are among the diets that lead to insulin resistance and diabetes [33]. Therefore, policies should focus on informing and educating on these unhealthy eating patterns. Other successful policies in this area include efforts to improve food labels and to train to reduce the incidence of diabetes and obesity.
Today, the aging of the population is observed in developing countries, and especially in these countries, geographical transmission occurs on a larger scale without improving living conditions, social provision, and access to health care. It is predicted that with unhealthy aging due to lack of progress in nutritional status and socio-economic conditions, the disease’s burden will increase in the elderly population. Thus, it is essential to consider both prevention and treatment policy options. Also, in non-communicable diseases, the underlying causes should be considered, and the health system’s capacities to deal with the increasing burden of the disease should be examined.

 From 2006 to 2010, deaths due to diabetes have increased in Iran, and it was higher in women and urban communities. Because of the increase in the elderly population, the growing trend of urbanization, changing diet and lifestyle in Iran, it is necessary to plan, educate, and perform interventions to prevent, diagnose, and early treatment of diabetes.
Ethical Considerations
Compliance with ethical guidelines
In this study, the data published by the Ministry of Health and Medical Education of Iran has been used and publishers have maintained the confidentiality of the data.

This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Investigation, writing – original draft, and writing – review & editing: All Authors; Methodology, data collection and data analysis: Amin Ataey.

The authors declared no conflict of interest.

We would like to thank all the people who helped us in compiling this article. Also, we used the information published by the Deputy Minister of Health of the Ministry of Health. So we appreciate the efforts of these colleagues.
 

References

1. International Diabetes Federation. IDF Diabetes Atlas [Internet]. 2019 [Updated 2019]. Available from: https://www.diabetesatlas.org/en/resources/
2. Maracy MR, Kheirabadi GR, Fakhari N, Zonnari R. [Comparison of night time sleep quality in type 2 diabetics, impaired glucose tolerance cases and non-diabetics (Persian)]. Iranian Journal of Endocrinology and Metabolism. 2011; 13(2):165-72. http://ijem.sbmu.ac.ir/article-1-1099-en.html.
3. Azizi F, Hatami H, Janghorbani M. [Epidemiology and control of common diseases in Iran (Persian)]. 1^th ed. Tehran: Eshtiagh Publicatio; 2007 .
4. Boyle JP, Thompson TJ, Gregg EW, Barker LE, Williamson DF. Projection of the year 2050 burden of diabetes in the US adult population: dynamic modeling of incidence, mortality, and prediabetes prevalence. Population Health Metrics 2010; 8:29. [DOI:10.1186/1478-7954-8-29] [PMID] [PMCID]
5. Roglic G, Unwin N, Bennett PH, Mathers C, Tuomilehto J, Nag S, et al. The burden of mortality attributable to diabetes. Diabetes care. 2005; 28(9):2130-5. [DOI:10.2337/diacare.28.9.2130] [PMID]
6. Joshi SK, Shrestha S. Diabetes mellitus: a review of its associations with different environmental factors. Kathmandu University Medical Journal. 2010; 8(29):109-15 [DOI:10.3126/kumj.v8i1.3233] [PMID]
7. Heron MP. Deaths: leading causes for 2012. National vital statistics reports. 2015; 64(10):1-93. [PMID]
8. malaki Moghadam H, Askarishahi M. [Trend analysis of mortality rate due to diabetes mellitus in seven countries of Asia between 1985-2010: A joinpoint regression analysis (Persian)]. Iranian Journal of Endocrinology and Metabolism. 2017; 18(6):412-9. http://ijem.sbmu.ac.ir/article-1-2111-fa.html
9. Naghavi M, Jafari N. [Mortality in 29 provinces of the country in 2004 (Persian)]. Tehran: Arvij; 2007. http://opac.nlai.ir/opac-prod/bibliographic/1028108
10. Dortag E, Bahrampour A, Haghdost A, Zendedel K, Jaberipour M, Marzeban M. [Completeness of fars province deaths registry on cancer death using capture recaptures method (Persian)]. Journal of North Khorasan University of Medical Sciences. 2011; 3(5):33-44. [DOI:10.29252/jnkums.3.5.S5.33]
11. Khosravi A, Aghamohamadi S, Kazemi E, Pour Malek F, Shariati M. Mortality profile in Iran (29 provinces) over the years 2006 to 2010 . Tehran: Ministry of Health and Medical Education; 2013.
12. Hajer GR, van Haeften TW, Visseren FL. Adipose tissue dysfunction in obesity, diabetes, and vascular diseases. European Heart Journal. 2008; 29(24):2959-71. [DOI:10.1093/eurheartj/ehn387] [PMID]
13. Tunstall-Pedoe H, Kuulasmaa K, Mahonen M, Tolonen H, Ruokokoski E, Amouyel P. Contribution of trends in survival and coronar y-event rates to changes in coronary heart disease mortality: 10-year results from 37 WHO MONICA Project populations. Lancet (London, England). 1999; 353(9164):1547-57. [DOI:10.1016/S0140-6736(99)04021-0]
14. World Diabetes Foundation. Diabetes Atlas, 3^rd edition WDF04-084 [Internet]. 2006 [Updated 2006]. Available from: https://www.worlddiabetesfoundation.org/projects/belgium-wdf04-084
15. Garcia BF, Godoy C, Perez S, Bolumar F. Multiple codification of the causes of death: from dying” of” to dying” from”. Gaceta Sanitaria. 1992; 6(29):53-7. [DOI:10.1016/S0213-9111(92)71092-9]
16. Goldacre MJ. Cause-specific mortality: understanding uncertain tips of the disease iceberg. Journal of Epidemiology and Community Health. 1993; 47(6):491-6. [DOI:10.1136/jech.47.6.491] [PMID] [PMCID]
17. Ruiz-Ramos M, Escolar-Pujolar A, Mayoral-Sanchez E, Corral-San Laureano F, Fernandez-Fernandez I. Diabetes mellitus in Spain: Death rates, prevalence, impact, costs and inequalities. Gaceta Sanitaria. 2006; 20(S1):15-24. [DOI:10.1157/13086022] [PMID]
18. Roglic G, Unwin N. Mortality attributable to diabetes: estimates for the year 2010. Diabetes Research and Clinical Practice. 2010; 87(1):15-9. [DOI:10.1016/j.diabres.2009.10.006] [PMID]
19. Farahmand M, Hejazi N, Akbarzade M, Almasi-Hashiani A. [Prevalence of obesity in urban and rural population of Fars province, national plan of chronic disease risk factor surveillance, (2006-07) (Persian)]. Zahedan Journal of Research in Medical Sciences. 2012; 13(S1):49. https://sites.kowsarpub.com/zjrms/articles/95265.html
20. Hajian K, Hiedari B. [Prevalence of abdominal obesity in a population aged 20 to 70 years in urban Mazandaran (northeran Iran, 2004) (Persian)]. Iranian Journal of Endocrinology and Metabolism. 2006; 8(2):147-56. http://ijem.sbmu.ac.ir/article-1-282-en.html
21. Sarshar N, Khajavi AJ. [The prevalence of obesity in females of 15-65 years of age in Gonabad, Iran (Persian)]. The Horizon of Medical Sciences. 2006; 12(3):38-43. http://hms.gmu.ac.ir/article-1-65-en.html
22. Gharipour M, Mohammadifard N, Asgsri S, Naderi G. [The prevalence of obesity and cardiovascular risk factors in Isfahan (Persian)]. Journal of Inflammatory Disease. 2003; 7(2):53-64. http://journal.qums.ac.ir/article-1-242-en.html
23. Bragg F HM, Iona A, Guo Y, Du H, Chen Y, Bian Z, et al. Association between diabetes and cause-specific mortality in rural and urban areas of China. Jama. 2017; 317(3):280-9. [DOI:10.1001/jama.2016.19720] [PMID] [PMCID]
24. Okosun IS, Chandra KD, Boev A, Boltri JM, Choi ST, Parish DC, et al. Abdominal adiposity in U.S. adults: prevalence and trends, 1960-2000. Preventive Medicine. 2004; 39(1):197-206. [DOI:10.1016/j.ypmed.2004.01.023] [PMID]
25. Ghassemi H, Harrison G, Mohammad K. An accelerated nutrition transition in Iran. Public Health Nutrition. 2002; 5(1a):149-55. [DOI:10.1079/PHN2001287] [PMID]
26. Kelishadi R, Ardalan G, Gheiratmand R, Gouya MM, Razaghi EM, Delavari A, et al. Association of physical activity and dietary behaviours in relation to the body mass index in a national sample of Iranian children and adolescents: CASPIAN Study. Bulletin of the World Health Organization. 2007; 85:19-26. [DOI:10.2471/BLT.06.030783] [PMID] [PMCID]
27. Cheema A, Adeloye D, Sidhu S, Sridhar D, Chan KY. Urbanization and prevalence of type 2 diabetes in Southern Asia: A systematic analysis. Journal of Global Health. 2014; 4(1):010404. [DOI:10.7189/jogh.04.010404] [PMID] [PMCID]
28. Rafique G, Azam S, White F. Diabetes knowledge, beliefs and practices among people with diabetes attending a university hospital in Karachi, Pakistan. Eastern Mediterranean Health Journal. 2006; 12(5):590-8. [PMID]
29. Ulvi OS, Chaudhary RY, Ali T, Alvi RA, Khan M, Khan M, et al. Investigating the awareness level about diabetes mellitus and associated factors in Tarlai (rural Islamabad). Journal of Pakistan Medical Association. 2009; 59(11):798-801. [PMID]
30. Murugesan N, Snehalatha C, Shobhana R, Roglic G, Ramachandran A. Awareness about diabetes and its complications in the general and diabetic population in a city in southern India. Diabetes Research and Clinical Practice. 2007; 77(3):433-7. [DOI:10.1016/j.diabres.2007.01.004] [PMID]
31. Gul N. Knowledge, attitudes and practices of type 2 diabetic patients. Journal of Ayub Medical College Abbottabad. 2010; 22(3):128-31. [PMID]
32. Mohan V, Shanthirani C, Deepa M, Datta M, Williams O, Deepa R. Community Empowerment-a successful model for prevention of non-communicable diseases in India-the Chennai urban population study [CUPS-17]. Journal of the Association of Physicians of India. 2006; 54:858-62. [PMID]
33. Misra A, Khurana L, Isharwal S, Bhardwaj S. South Asian diets and insulin resistance. British Journal of Nutrition. 2008; 101(4):465-73. [DOI:10.1017/S0007114508073649] [PMID]