This study utilizes a systematic analysis framework, defined as the consistent and standardized application of the Global Burden of Disease (GBD) 2023 dataset to track longitudinal epidemiological trends. By employing the GBD’s standardized methodology—which uses rigorous statistical modeling to synthesize data from multiple sources—we ensure that our estimates of prevalence, mortality, and DALYs are both internally consistent and internationally comparable across the MENA region. This framework enables objective identification of health trends from 1990 to 2023, minimizing biases from country-specific reporting. The GBD Study, coordinated by the Institute for Health Metrics and Evaluation at the University of Washington, offers consistent estimates of incidence, prevalence, mortality, and population health for diverse diseases and injuries across demographics and time periods, using data from the GBD 2023 Study through the Global Health Data Exchange Results Tool (https://vizhub.healthdata.org/gbd-results/) [18].

The GBD Study utilizes various data sources, including population surveys, hospital discharge data, administrative claims databases, and systematic literature reviews to standardize the measurement of T2DM disease burdens by year, gender, and geography. It groups MENA countries into sub-regional clusters for better visualization and comparison of epidemiological trends while focusing on the region’s overall burden. Comprehensive methodological details are available in published literature [19–21].

We compiled the data of all available data on the T2DM burden by country and region from 1990 to 2023. Our primary outcomes were prevalence, DALY and mortality due to type 2 DM along with age-standardized rates (ASR) and 95% uncertainty intervals (UI) (Supplementary Table 1). Uncertainty intervals were derived using 1,000 posterior samples drawn during each of the estimation processes/simulations. The 2.5 and 97.5 percentiles represent the distributions we created based on 1,000 posterior samples. For the purposes of data visualization, the countries of the MENA region have been grouped into logical sub-regional clusters (e.g., Turkey, the Levant, North Africa, and the Gulf and adjacent West Asian countries). This sub-regional approach allows for a clearer comparison of heterogeneous epidemiological trajectories while maintaining our overarching focus on the comprehensive MENA burden.

To characterize T2DM, we used the GBD health outcome definition. The GBD Study has created a methodology that applies algorithms to data sources with different case definitions for T2DM to remove inconsistencies between countries and to guarantee comparability between the methods used to provide us with each country’s data regarding T2DM. Data were extracted from the GBD 2023 Study via the Global Health Data Exchange Results Tool. The cause of interest was defined as Diabetes mellitus type 2 (GBD Cause Code: B.8.1.2). Our query parameters were configured to extract Age-standardized rates (per 100,000 population) for Prevalence, Mortality, and DALYs, spanning the years 1990–2023 across both sexes. Hence there is a consistent and comparable dataset for the comparison of T2DM-related cases across countries and overtime.

Data were extracted from the GBD 2023 Results Tool using the following systematic query parameters:

Cause: Type 2 diabetes mellitus (Cause Code: B.8.1.2)

A summary of the custom query used for this study can be accessed via the following GBD Results Tool persistent link: https://vizhub.healthdata.org/gbd-compare/.

The estimates of prevalence, DALYs, as measured by disability adjusted life years for T2DM, and mortality owing to T2DM were obtained directly from the GBD 2023 Study. In this analysis, the burden of T2DM was not determined from the literature because the GBD has provided a novel statistical method for calculating prevalence, mortality, and DALY estimates through Bayesian meta-regression model. Additionally, the use of multi-period and geographically proximate data has been employed in acquiring T2DM prevalence estimates with less instability when primary data is limited. Prevalence estimates are summarized by age, sex, geography, and constructed by region within the world.

To account for the differences in age distribution of populations across countries, all population prevalence, mortality, and DALY rates were adjusted to allow for comparison using direct standardization using the World Standard Population developed by GBD. The reporting of DALY and prevalence rates include DALY rates are presented as the number of DALYs per 100,000 people; prevalence is reported as a percentage of total numbers of prevalent cases, and mortality is reported as number of deaths per 100,000 population. The absolute changes, percentage changes and annual average growth rates for temporal trends are the differences over 33 years from 1990 to 2023.

The GBD 2023 Study utilizes a unique methodological approach for the analysis of missing data. Burden estimates of T2DM were calculated based on multilevel regression models that incorporated temporal and spatial autocorrelation. Imputation in data-limited settings was informed by covariate data from several sources (including: the Socio-demographic Index (SDI), age structure of the countries, indicators of healthcare access, and country-specific epidemiological patterns) [22, 23]. Uncertainty from the input data variability, model specification, and disability weight estimation across all modelling stages has been propagated through posterior sampling [18, 22, 23]. The final uncertainty intervals provide a complete range of potential values around the point estimates.

The total burden estimates the stratification of burden estimates by sex so that differences in T2DM burden can be evaluated by gender, using T2DM -related DALYs and prevalence data. The entire duration of the study from 1990 to 2023 is used to demonstrate trends over a long period and more recently, where they have been stable. Estimates for each country were assessed separately in the MENA region. An analysis of comparative data across countries helps to identify constant high burden countries, rapidly growing burden countries, relatively stable burden countries, and countries experiencing a decline in burden over time.

The current study used GBD-based burden estimates by employing a descriptive epidemiological design methodology. To visualize long-term DALY, mortality, and prevalence trends, time-series plots are created for the countries included in MENA region. For males and females, the overall pattern of burden over time for both groups is also illustrated. All analysis followed the GBD analytical protocols to verify that they will be replicable and comparable with prior studies demonstrating global burden of disease.

Figure 1 illustrates that from 1990–2023, type two diabetes mellitus became an increasingly common health issue in the MENA region. Over the course of three decades, the age-standardized prevalence of type 2 diabetes has more than doubled. In 1990, the prevalence of type 2 diabetes was 5.57% (95% confidence interval: 5.08%–6.05%). Year by year, the prevalence rate increased, reaching 9.29% in 2014, then 10.53% in 2020, and finally 11.51% in 2023 (95% confidence interval: 10.64%–12.45%).

Figure 2 reveals that mortality rates (age-adjusted) attributable to type 2 diabetes have also increased over the same period in the MENA region. In 1990, the age-standardized rate for diabetes-related mortality in the MENA region was 26.13 deaths per 100,000 (95% C.I. 16.89–36.93). By 2014, that figure had climbed to 30.38 deaths per 100,000 (95% C.I. 25.31–36.21). The highest occurrence of diabetes-related mortality within the MENA occurred in 2016 with a rate of 30.79 deaths per 100,000 (95% C.I. 25.87–37.12). Since then, there have been slight decreases and stabilization; by 2023, there were approximately 30.16 deaths per 100,000 (95% C.I. 24.36–36.34) related to type 2 diabetes within the MENA region.

Figure 3 shows a significant increase in the number of age-adjusted disability-adjusted life-years (DALY) per 100,000 population from type 2 diabetes Mellitus between 1990 and 2023 for both men and women in North Africa and the Middle East region; however, the increase was much more substantial for men than women. Males with type 2 diabetes had a DALY of 840.53 (95% UI: 625.03–1,049.52) in 1990 and an increase of 1,518.81 (95% UI: 1,207.31–1,858.03) in 2023, representing an increase of nearly 81%. For female diabetics, the increase was much less, increasing from 1,080.63 (95% UI: 787.86–1,434.10) in 1990 to 1,396.25 (95% UI: 1,066.15–1,752.78) in 2023, about a 29% increase overall. The trends also indicate that, over the years, the sex gap in diabetes-related DALY has narrowed.

As shown in Figure 4, across 1990–2023, DALY rates for type 2 diabetes mellitus grown markedly in Turkey, the Levant, and North Africa, nevertheless with apparent regional patterns. Turkey displayed a long period of relative stability from 1990 to 2015 (1,052.54 per 100,000 to about 1,120 DALYs per 100,000), followed by a sharp acceleration after 2019, reaching its maximum rate in 2023 (1,243.07 per 100,000), representative a recent and marked worsening of diabetes burden.

The Levant region was consistently ranked as the area that exhibited the best overall rate increase for this measure during the entire time period with the highest quantified number of incidents of type 2 diabetes being in Palestine (1800–2000 per 100,000; DALY rates show a steady increase until around 2020, followed by a sharp decline thereafter) and in Jordan (1900 per 100,000; climax was reached at around the same time), both of which decreased relatively steadily throughout the rest of the 2000 to 2020 decade until arriving at what was described by the 2023 data as elevated but stabilized rate(s) (Jordan: 1,537.42 per 100,000; Palestine: 2083.03 per 100,000). Lebanon and Syria also exhibited consistent and steady increases in type 2 diabetes rates throughout the entire period as these countries continue to bear increasing burdens of chronic disease and system stresses as their populations age. The North African region also exhibits consistent upward trends across the individual countries within this area; DALY rates have been increased overall 50%, 80% in North Africa since 1990.

Egypt and Tunisia experienced large absolute increases, while Algeria, Morocco, Libya, and particularly Sudan experienced a similar but somewhat less dramatic increase than their North African counterparts. Taken as a whole, these results clearly demonstrate that all three of these regions exhibit a continuously expanding burden for type 2 diabetes, with the Levant region continuing to carry the highest burden of the chronic disease burden over an extended time period, North Africa represents an area undergoing a continued transition of epidemiologic/conditions of health, and currently Turkey appears to be approaching the beginning of an accelerated phase of increasing burden.

As shown in Figure 5, Within West Asia and the Gulf Region, Saudi Arabia, Qatar, Bahrain, and the UAE had consistently the highest age-standardized DALY rates of T2DM, with Saudi Arabia, and Bahrain showing the highest rates (2,613 and 3436 DALY/100,000 people, respectively) by 2023, which is more than a 100% increase over 1990 levels (1,207 and 2,710.5, respectively). In fact, Saudi Arabia has by far the largest burden of T2DM within the Gulf Region and West Asia. The pre-1990 data for Saudi Arabia is limited but based on available information; it can be expected that Saudi Arabia had an increase in DALY rates (i.e., >1207 DALY per 100,000 people), as reported after 1995; Bahrain has maintained consistently high DALY rates throughout this time period with no clear evidence that this will decrease in the future. Also of note is that just like Saudi Arabia, there has been an overall upward trend in the burden of T2DM in both Qatar and the UAE; Qatar peaked in approximately 2006–2008 at >2400 DALY per 100,000 people, before declining to 1979.46 DALY per 100,000 people by 2023; whereas the UAE has steadily increased from 1985 to 1570 DALY/100,000 people, with acceleration in the increase beginning after 2010.

This study presents several strengths: it utilizes 33 years of standardized burden estimates for analyzing temporal trends, employs age-standardized measures for comparability across diverse demographics, integrates prevalence, mortality, and DALYs for a multidimensional view of diabetes burden, and offers sub-regional data disaggregation that highlights geographic disparities and informs policy priorities.

There are several limitations in the study’s estimates, which are based on modeled data that may be influenced by under-reporting, varying surveillance quality, and differing diagnostic criteria for diabetes across countries. Additionally, data quality issues in low-resource and conflict areas could introduce uncertainty in trend estimates. The estimation of Disability-Adjusted Life Years (DALYs) depends heavily on the assumptions used in the methodology, potentially misrepresenting the burden of diabetes. The reliance on ecological data restricts causal inferences regarding the factors influencing diabetes mortality and DALYs, making the interpretations exploratory and cautionary. Furthermore, while the Global Burden of Disease (GBD) framework allows for standardized comparisons, it may overlook localized data nuances, suggesting that findings should complement rather than replace data from national health surveillance systems.

T2DM is a rapidly expanding and increasingly disabling public health issue within the MENA region. Over the last three decades, the increasing prevalence, continued high rates of mortality, and rapidly increasing burden of DALYs strongly indicate an urgent need for the establishment of coordinated prevention, early detection, and sustainable chronic disease management systems. Given the significant contribution of T2DM to regional mortality and long-term morbidity, it must be prioritized as a major driver of chronic disease burden. If strong policy measures are not taken to address this growing public health crisis, there will likely be escalating pressures on the healthcare system and profound socioeconomic consequences across the MENA region.

The study highlights the importance of comprehensive strategies to combat the increasing prevalence of Type 2 Diabetes Mellitus (T2DM) through initiatives that target obesity reduction, healthy eating, physical activity, and social determinants of metabolic risk. It emphasizes the need for improved early screening and diagnosis programs, access to medications, and long-term follow-up to mitigate complications. The sustained high Disability-Adjusted Life Years (DALY) in Saudi Arabia indicates significant gaps in secondary prevention and diabetes management, calling for a shift to integrated chronic care. The study advocates culturally tailored community health interventions and the incorporation of diabetes prevention into broader public health policies and planning. Lastly, it underscores the need for enhanced health information systems to assess the diabetes burden and evaluate prevention program effectiveness, providing a foundation for future studies on regional risk factors.