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Rising tide: the growing global burden and inequalities of early-onset type 2 diabetes among youths aged 15–34 years (1990–2021)

Diabetology & Metabolic Syndrome volume 17, Article number: 103 (2025) Cite this article

Abstract

Background

Type 2 diabetes mellitus (T2DM) is increasingly affecting people aged 15–34, posing a serious public health challenge due to its faster progression and higher complication risks. This study examines the global, regional, and national burden of early-onset T2DM from 1990 to 2021, emphasizing trends and disparities across different sociodemographic contexts.

Methods

Using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021, we analyzed incidence, prevalence, mortality, disability-adjusted life years (DALYs), years lived with disability (YLDs), and years of life lost (YLLs) in people aged 15–34. Stratifications included age, sex, and the Socio-Demographic Index (SDI). Joinpoint regression significant temporal shifts, and decomposition analysis attributed changes in T2DM burden to factors such as prevalence, population growth, aging, and case fatality rates. Inequality was assessed with the Slope Index of Inequality and Concentration Index.

Results

From 1990 to 2021, early-onset T2DM incidence and prevalence rose significantly worldwide, especially in high-SDI regions. Although global mortality and DALYs appeared relatively stable, low-SDI regions showed worrisome increases. Rising T2DM prevalence was the principal driver of mortality and DALYs, notably in low- and middle-SDI regions. Inequality analyses indicated widening disparities, with higher incidence and prevalence in high-SDI countries and more severe outcomes in low-SDI countries.

Conclusions

The global burden of early-onset T2DM among youths is escalating, with significant disparities across different sociodemographic levels. The findings underscore the urgent need for targeted public health interventions. Future research should focus on the underlying factors driving these trends and explore strategies for effective prevention and management of early-onset T2DM.

Introduction

Diabetes is a rapidly growing global health issue, with its prevalence reaching 537 million in 2021, projected to rise to 783 million by 2045 [1]. T2DM accounts for 90–95% of all diabetes cases [2] and is increasingly affecting younger populations [3]. Epidemiological evidence indicates a concerning rise in early-onset T2DM globally [4,5,6,7]. The Joint Asia Diabetes Evaluation (JADE) cohort study published in 2014 included 41,029 T2DM patients, of whom 7,481 (18%) had early-onset diabetes, with an average diagnosis age of 32.9 years [8].

The duration of diabetes is the most significant risk factor for complications. The UK Prospective Diabetes Study demonstrated a direct relationship between diabetes duration and the incidence of complications [9]. Adolescents diagnosed with T2DM face a lifelong risk of complications due to their longer disease course. A meta-analysis of 26 studies from 30 countries found that For each additional year in the age of diagnosis, the adjusted risks of all-cause mortality, macrovascular, and microvascular diseases decreased by 4%, 3%, and 5%, respectively [10]. Therefore, a younger age at diagnosis is associated with higher mortality and vascular disease risk. Blood glucose control is especially challenging in younger individuals [11], Hsieh et al. found that those diagnosed at a younger age had the poorest glycemic control, regardless of diabetes duration [12].

Understanding the global burden of early-onset T2DM is crucial to allocating healthcare resources effectively. The Global Burden of Disease (GBD) study offers valuable data to assess the health impact of diseases, including diabetes [13]. Globally, the prevalence of diabetes in young populations has surged, and early-onset T2DM now carries greater severity, increasing the burden on individuals, families, and healthcare systems. Consequently, the 2024 ADA guidelines recommend that even individuals without risk factors and with normal weight should begin diabetes screening at age 35, effectively lowering the screening threshold for T2DM [14].

While some studies have explored T2DM’s burden, they often overlook younger populations [15], use outdated data [16], or focus on specific regions [17]. To enhance understanding of the global epidemiology of T2DM among young populations, we used data from the 2021 GBD study to evaluate the burden, trends, and inequalities of T2DM in individuals aged 15–34 years. Our study assesses the impact of population size, aging, disease prevalence, and case fatality rates on T2DM mortality and DALYs across different regions, highlighting cross-country inequalities and providing a comprehensive overview.

Methods

Data Source

This study utilized data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021, which provides a comprehensive assessment of health loss across 371 diseases, injuries, and impairments, along with 87 risk factors, stratified by age and sex for 204 countries and territories. The GBD 2021 employed the most recent epidemiological data, standardized and integrated from various sources, each uniquely identified and cataloged in the Global Health Data Exchange (GHDx). To address gaps across different locations, spatiotemporal Gaussian process regression was applied to smooth the data over age, time, and geographic location. The Meta-Regression with Bayesian priors, Regularization, and Trimming (MR-BRT) method was utilized to correct for biases arising from differences in case definitions and study methodologies across countries. Detailed descriptions of the methodologies used in GBD 2021 have been published elsewhere [18]. GBD accepted data that reported diabetes type 1, juvenile-onset diabetes, and insulin-dependent diabetes among children,then estimates of diabetes mellitus type 2 by subtracting the estimates of diabetes mellitus type 1 from estimates of overall diabetes mellitus for each age, sex, and location from 1990 to 2021. For this analysis, estimates and their 95% uncertainty intervals (UIs) for the incidence, prevalence, mortality, DALYs, YLDs, and YLLs of T2DM in adolescents and young adults aged 15–34 years were extracted, with all rates standardized per 100,000 population. The SDI, a composite measure reflecting income, education, and fertility levels, was used to categorize countries into five SDI quintiles: low, low-middle, middle, high-middle, and high [19].

Descriptive analysis

To gain a thorough understanding of the burden of T2DM among adolescents and young adults aged 15–34 years, a descriptive analysis was conducted at global, regional, and national levels. This analysis included visual representations of the global number of cases, crude rates, and age-standardized rates (ASR) for incidence, prevalence, mortality, DALYs, YLDs, and YLLs, disaggregated by sex from 1990 to 2021. Comparisons were made between the case numbers and ASRs for incidence, prevalence, and DALYs in 1990 and 2021 across global, regional, and national levels, as well as across the five SDI quintiles. This comprehensive approach enabled an in-depth exploration of the evolving global burden of T2DM in adolescents and young adults over the past 32 years.

Trend analysis

Trend analysis was conducted using Joinpoint regression to identify significant changes in T2DM metrics over time across different SDI levels. This analysis calculated the Average Annual Percentage Change (AAPC) for incidence, prevalence, mortality, DALYs, YLDs, and YLLs, highlighting periods of acceleration or deceleration in these trends. Joinpoint software was used to determine significant shifts in trends, reflecting changes in disease dynamics, healthcare interventions, and other influencing factors [20].

Decomposition analysis

To better understand the factors driving changes in the T2DM burden from 1990 to 2021, decomposition analysis was performed. This analysis disaggregated changes in T2DM mortality and DALYs into contributions from population size, population aging, disease prevalence, and case fatality rates. The aim was to quantify the relative impact of demographic changes and epidemiological transitions on the T2DM burden across different SDI levels [21].

Cross-country inequalities analysis

To quantify inequalities in the burden of T2DM among adolescents and young adults aged 15–34 years related to SDI, the Slope Index of Inequality (SI) and Concentration Index (CI) were utilized. The SI was determined by performing regression analysis on the country-level ASR of T2DM against the SDI-associated relative position scale, defined by the midpoint of the cumulative population distribution ranked by SDI. This approach measures absolute inequality across sociodemographic levels. The CI was calculated by fitting a Lorenz concentration curve to the cumulative distribution of the population ranked by SDI against the cumulative distribution of T2DM burden. This dual-method analysis allowed for a detailed examination of how T2DM burden is distributed across countries with varying levels of socioeconomic development and how these disparities have evolved over time [13].

Frontier analysis

Frontier analysis was employed to benchmark the burden of T2DM by comparing regions against those performing at the highest levels. This approach identifies leading regions that set standards and targets for others to aspire to [22]. For each region, the "effective difference" was calculated, representing the gap between the observed and potential T2DM burden, adjusted for SDI. This analysis identifies regions that are closer to or further from optimal performance, providing insights into areas where improvement is needed and where best practices can be adopted.

Results

Descriptive analysis of t2dm burden in adolescents and young adults aged 15–34 years at global, regional, and national levels

From 1990 to 2021, the global burden of T2DM among individuals aged 15 to 34 years showed significant variations across different regions and countries. The analysis revealed marked sex differences, with males generally experiencing higher incidence rates than females. Overall, the incidence and prevalence of T2DM increased steadily over this three-decade period, with notable disparities between regions. High-income countries, particularly in North America and Europe, exhibited a marked increase in both incidence and prevalence rates, with the prevalence per 100,000 population more than doubling from 1990 to 2021. In contrast, several low- and middle-income countries, especially in Sub-Saharan Africa and Southeast Asia, displayed a slower yet significant rise in the T2DM burden. At the national level, the incidence, prevalence, mortality, and DALYs of T2DM varied remarkably worldwide, with the highest age-standardized rates (ASRs) for incidence, prevalence, and DALYs observed in the Marshall Islands, while Kiribati showed the highest ASR for DALYs.

When the data were examined by SDI quintiles, the high SDI quintile recorded the highest ASR for incidence and prevalence, while it also exhibited the greatest ASR for mortality and DALYs in 2021 (Supplement 1). A clear trend was observed: the ASR for incidence and prevalence increased with rising SDI, whereas the ASR for mortality and DALYs showed an inverse pattern, decreasing as SDI rose.

Trends in T2DM burden among adolescents and young adults aged 15–34 years by SDI

The global analysis of T2DM in adolescents and young adults aged 15–34 years from 1990 to 2021, as illustrated by the Average Annual Percentage Change (AAPC) in incidence, prevalence, mortality, and DALYs, revealed significant regional disparities. Incidence and prevalence rates increased across most regions, with the highest AAPC observed in high-income nations such as Greenland and Canada. In contrast, trends in mortality and DALYs exhibited more variability across regions; countries such as Turkmenistan, Lithuania, and Latvia experienced higher increases in these metrics, while countries with more advanced healthcare infrastructures, such as Singapore, showed lower or even negative AAPC in mortality (Fig. 1).

Fig. 1
figure 1

Global and Regional AAPC in Early-Onset T2DM Among Youths Aged 15–34 Years from 1990 to 2021. This figure illustrates the global and regional AAPC from 1990 to 2021 across four key metrics related to early-onset T2DM among youths aged 15–34 years. A AAPC in incidence rates of T2DM. This map highlights regions where the incidence of early-onset T2DM has significantly increased (red) or decreased (blue) over the study period. The most substantial increases are observed in regions such as the Caribbean, parts of Southeast Asia, and Northern Europe. B AAPC in prevalence rates of T2DM. This map shows the changes in prevalence across different regions, with notable increases in Canada, the Persian Gulf, and Southeast Asia. C AAPC in mortality rates due to T2DM. The map indicates the regions with the highest increase in mortality rates, with significant rises observed in South America, Sub-Saharan Africa, and parts of Southeast Asia. D AAPC in Disability-Adjusted Life Years (DALYs) due to T2DM. This map reflects the regions where the burden of T2DM, measured in DALYs, has increased or decreased, with significant increases observed in South America, Sub-Saharan Africa, and the Balkan Peninsula. The color gradient from blue to red represents the AAPC, where blue indicates a decrease and red indicates an increase in the respective metric

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The Joinpoint regression analysis on the burden of T2DM in adolescents and young adults aged 15–34 years from 1990 to 2021 (Fig. 2) revealed significant and varied trends across different SDI levels. While there were generally increasing trends, local trends varied significantly across different time periods. Specifically, the ASR of prevalence showed slight decreases from 1990 to 1995 in middle and high-middle SDI regions. Low and middle SDI countries exhibited a more pronounced increase in incidence starting in the late 1990s (Fig. 2A). Similarly, the ASR of prevalence showed fluctuations, with decreases from 1990 to 1993, followed by increases in subsequent periods in middle and high-middle SDI regions (Fig. 2B). The ASR of mortality remained stable with minor fluctuations in high SDI regions but showed more complex patterns in low and middle SDI regions. For example, a significant decrease in mortality was observed in some middle SDI regions around the mid-2000s, while some low SDI regions exhibited periods of increased mortality (Fig. 2C). High SDI regions showed a consistent increase in DALYs, particularly from the early 2000s, suggesting that while mortality may be stable, the years of life lost due to disability are increasing (Fig. 2D). Additionally, from a 10-year interval perspective, all measures of burden experienced their fastest changes from 2010 to 2021.

Fig. 2
figure 2

Trends in ASR of Early-Onset T2DM Among Youths Aged 15–34 Years by SDI Level, 1990–2021. This figure illustrates trends in ASR for four metrics of early-onset T2DM among youths aged 15–34 years, stratified by SDI levels from 1990 to 2021. A Incidence Rates—Shows rising incidence of early-onset T2DM across all SDI levels, with the steepest increase in high-SDI regions. Joinpoint analysis marks significant trend shifts, indicating periods of acceleration or deceleration. B Prevalence Rates—Depicts increasing prevalence across all SDI levels, with high-SDI regions exhibiting the highest rates. Joinpoint analysis identifies key years of significant trend changes, notably in high- and middle-SDI regions. C Mortality Rates—Presents mortality trends with greater variability. High-SDI regions show stable rates, while lower-SDI regions display fluctuations, with joinpoints highlighting shifts in mortality patterns. D DALYs Rates—Illustrates trends in DALYs, reflecting disease burden. Significant increases occur in high- and middle-SDI regions, with joinpoints noting key changes, especially in high-SDI regions since the late 1990s. Lines are color-coded by SDI level: blue (high-SDI), orange (high-middle SDI), green (middle SDI), red (low-middle SDI), and brown (low-SDI). Each panel includes annotations of significant joinpoints and associated AAPC values, quantifying the rate of change over time. The figure underscores the growing global burden of early-onset T2DM, with distinct patterns across SDI levels, highlighting disparities in incidence, prevalence, mortality, and DALYs

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Decomposition of changes in T2DM Burden by SDI

Figure 3 illustrates the decomposition of the percentage change in T2DM-related mortality and DALYs from 1990 to 2021 across different SDI levels. The analysis highlights that changes in T2DM prevalence were the predominant drivers of the observed increases in both mortality and DALYs across all SDI levels, with this effect being particularly pronounced in low-middle and low SDI regions. Additionally, the contribution of population aging to the increased burden of T2DM was especially significant in high and high-middle SDI regions, reflecting the demographic transitions occurring in these areas. The sex-specific analysis revealed that these trends were consistent across both males and females, with slight variations in the impact of population age and case fatality rates.

Fig. 3
figure 3

Decomposition Analysis of T2DM Mortality and DALYs by SDI, 1990–2021. This figure presents a decomposition analysis of factors influencing changes in mortality and Disability-Adjusted Life Years (DALYs) due to early-onset T2DM among youths aged 15–34 years across SDI levels from 1990 to 2021. A Global and SDI-Level Contributions to Mortality—Displays percentage contributions of changes in population size, population age, prevalence, and case fatality/disease severity to mortality from early-onset T2DM globally and by SDI level. It shows prevalence and case fatality/disease severity as key drivers, especially in low and low-middle SDI regions. B Gender-Specific Contributions to Mortality—Breaks down mortality factor contributions by gender, illustrating percentage changes for females and males. It highlights differences in the roles of population size, population age, and other factors across SDI levels. C Global and SDI-Level Contributions to DALYs—Shows percentage contributions of the same factors to changes in DALYs from early-onset T2DM. Results indicate prevalence increases as the primary driver of DALYs across all SDI levels, with significant impact in low and low-middle SDI regions. D Gender-Specific Contributions to DALYs—Presents gender-specific decomposition of DALYs, detailing contributions of each factor to changes among females and males. Bars in each panel represent percentage changes by factor—population size (purple), population age (green), prevalence (yellow), and case fatality/disease severity (teal)—across SDI levels, with global contributions included. Black dots within bars denote the overall percentage change per factor. The color coding aids in distinguishing contributions, revealing distinct patterns in mortality and DALYs drivers globally and by gender and SDI level

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Trends in inequality for type 2 diabetes mellitus across SDI

Significant inequalities associated with SDI in the burden of T2DM were observed, with these disparities becoming more pronounced over time (Fig. 4). The analysis showed that higher SDI countries generally experienced higher incidence and prevalence rates, with these trends intensifying over time. For example, the Slope Index of Inequality highlighted a difference of −144 (95% CI − 339.0 to 51.4) in prevalence per 100,000 population between the highest and lowest SDI countries in 1990, which further increased to −456 (95% CI − 945.0 to − 32.2) by 2021. The Concentration Index, which measures relative inequality, increased from −0.07 (95% CI − 0.1 to − 0.03) in 1990 to 0.03 (95% CI − 0.01 to 0.08) in 2021. In contrast, mortality and DALYs, reflecting more severe outcomes of T2DM, were inversely related to SDI, with lower SDI countries shouldering a disproportionately higher burden, indicating a growing imbalance in the distribution of T2DM burden across countries with varying levels of socioeconomic development.

Fig. 4
figure 4

Socio-Demographic Inequalities in Early-Onset T2DM (Ages 15–34), 1990 vs. 2021. This figure analyzes socio-demographic inequalities in early-onset Type 2 Diabetes Mellitus (T2DM) across incidence, prevalence, mortality, and DALYs from 1990 to 2021, using relative Sociodemographic Index (SDI) rank and concentration indices. A, B Incidence Rate. A Scatter plot shows age-standardized incidence rates per 100,000 vs. SDI rank for 1990 (blue) and 2021 (yellow). Bubble size reflects population in millions; arrows indicate key countries (e.g., United States, Bangladesh). Incidence rises over time, steeper in high-SDI regions. B Concentration curves compare cumulative T2DM incidence by SDI for 1990 (blue) and 2021 (yellow), with 2021 deviating further from equality, showing increased inequality. C, D Prevalence Rate. C Scatter plot of prevalence rates vs. SDI rank for 1990 and 2021. Prevalence increases significantly in high-SDI countries (e.g., United States). D Concentration curves for prevalence show a widening inequality gap from 1990 to 2021, per concentration index. E and F: Mortality Rate. E Scatter plot of mortality rates vs. SDI rank. Mortality decreases in high-SDI countries, with arrows showing rising inequality from 1990 to 2021. F Concentration curves for mortality shift further from equality in 2021, indicating increased inequality. G, H Disability-Adjusted Life Years (DALYs). G Scatter plot of DALYs vs. SDI rank. DALYs decrease in high-SDI regions, with differences in low-SDI areas. H Concentration curves for DALYs show greater inequality in 2021 vs. 1990. The 1990–2021 comparison reveals rising disparities: high-SDI regions see greater incidence and prevalence; low-SDI regions bear higher mortality and DALYs. Bubble sizes in scatter plots highlight population impact

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Frontier analysis of type 2 diabetes mellitus metrics across SDI

The frontier analysis of T2DM burden, based on SDI and ASRs from 1990 to 2021 across various countries, revealed distinct trends. As SDI values increased from 0.0 to 1.0, there was a noticeable rise in the incidence and prevalence rates of T2DM, particularly in higher SDI regions. This upward trend was marked by a shift in density from lighter to darker shades over the years, indicating a persistent increase in the burden of T2DM in these areas. Visual representations delineated clear distinctions among countries and territories. For incidence and prevalence, the Marshall Islands, American Samoa, and Cook Islands were observed to have significantly higher rates, placing them far from the frontier. In contrast, countries like Somalia, Malawi, and Rwanda were closer to the frontier, suggesting relatively better outcomes given their SDI.

The death rate due to T2DM showed a downward trend with increasing SDI, while DALYs, YLDs, and YLLs followed a similar pattern, indicating that as socio-demographic development progresses, the burden of T2DM tends to diminish. The analysis revealed a crucial inflection point around an SDI value of 0.3; as SDI increased beyond 0.3, incidence and prevalence continued to rise, but there was a noticeable deceleration in mortality and YLLs rates. This decline in mortality and YLLs suggests that despite the rising number of cases, overall health outcomes for T2DM patients improve as countries advance in their socio-demographic development (Fig. 5, Supplement 7).

Fig. 5
figure 5

Frontier Analysis of Early-Onset T2DM Metrics by SDI from 1990 to 2021. This figure illustrates the frontier analysis of early-onset Type 2 Diabetes Mellitus (T2DM) metrics among youths aged 15–34 years across Sociodemographic Index (SDI) levels from 1990 to 2021, focusing on incidence, prevalence, mortality, and Disability-Adjusted Life Years (DALYs). A, B Incidence Rate. A Shows trends in age-standardized incidence rates per 100,000 across SDI levels. Lines, with darker shades for recent years, indicate a steep decline in incidence as SDI decreases. B Scatter plot compares incidence trends, with red (increasing) and blue (decreasing) dots. Countries like Switzerland and South Sudan move further from the frontier, showing worsening incidence. C and D Prevalence Rate. C Displays trends in age-standardized prevalence rates across SDI levels, revealing a sharp decline as SDI decreases, with greater differences over time. D Scatter plot shows prevalence trends, with red (increasing) and blue (decreasing) dots. Switzerland and Republic of Korea exhibit rising prevalence, drifting from the frontier. E, F Mortality Rate. E Illustrates trends in age-standardized mortality rates across SDI levels. Mortality decreases as SDI rises, though disparities persist in lower SDI regions. F Scatter plot highlights mortality trends, with red (increasing) and blue (decreasing) dots. Tuvalu and Vanuatu move closer to the frontier, indicating improved mortality. G, H Disability-Adjusted Life Years (DALYs). G Shows DALY trends across SDI levels, with a steep decline as SDI decreases. Higher SDI countries have lower DALYs, reflecting better outcomes. H Scatter plot shows DALY trends, with red (increasing) and blue (decreasing) dots. Switzerland and Republic of Korea worsen, while Somalia and Papua New Guinea improve. The frontier analysis reveals disparities in T2DM burden across SDI levels, showing how countries perform relative to the optimal frontier for each metric

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Discussion

This study provides an updated global assessment of early-onset T2DM among youths aged 15–34 years from 1990 to 2021, examining multiple metrics—incidence, prevalence, mortality, and DALYs—across 204 countries and territories. By leveraging the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021, we elucidate epidemiological patterns, highlight disparities between SDI levels, and underscore the rising challenges posed by early T2DM onset.

Our study observed that from 1990 to 2021, the incidence, prevalence, DALYs, and YLDs of T2DM among the 15–34 age group increased significantly, while mortality and YLLs remained relatively stable. This trend suggests an overall upward trajectory in the disease burden, indicating that T2DM among young populations is becoming more prevalent over time. Both males and females showed increasing ASRs for T2DM during this period, with men consistently exhibiting higher incidence, prevalence, mortality, DALYs, YLDs, and YLLs compared to women. These findings highlight the need for continued gender-specific research to refine prevention and treatment strategies. Previous studies have established that males are at higher risk for early-onset type 2 diabetes mellitus [1]. This disparity may stem from biological factors: androgens promote visceral fat accumulation and insulin resistance [23, 24], while estrogen enhances insulin sensitivity in premenopausal women [ \* MERGEFORMAT 24]. Under equivalent BMI, males disproportionately store abdominal visceral fat, which releases pro-inflammatory cytokines and free fatty acids, impairing β-cell function [25]. Behavioral factors further contribute: males demonstrate higher rates of smoking, alcohol use, and sedentary lifestyles [26], coupled with lower health-seeking behavior [27]. These findings underscore the necessity for gender-tailored prevention strategies.

Income critically shapes population health through structural inequalities [28]. Our analysis identifies disproportionately concentrated and widening T2DM burdens in high-SDI countries, reflecting economic development-driven lifestyle shifts that elevate diabetes risks—including poor diets, sedentary behaviors, and obesity epidemics [29]. Early-onset T2DM strongly correlates with youth obesity epidemics [30], with > 80% of early-onset cases versus < 50% in late-onset cases presenting obesity [31, 32]. Childhood obesity before puberty particularly elevates T2DM susceptibility, though weight normalization during this period may mitigate risk [32]. Obesity-driven elevations in free fatty acids (FFAs) induce pancreatic β-cell dysfunction through lipotoxicity mechanisms, including impaired insulin secretion and cellular apoptosis [33]. Palmitic acid specifically triggers endoplasmic reticulum stress and oxidative damage [34], while chronic FFA exposure disrupts mitochondrial function and glucose regulation [35]. Adipose tissue expansion and endocrine dysregulation in obesity drive insulin resistance through chronic inflammation and oxidative stress [36, 37]. Young people in high-SDI countries are more likely to experience high-stress environments, contributing to mental health disorders, which are linked to metabolic disturbances and increased diabetes risk [38,39,40].In high-SDI settings, psychosocial stressors activate hypothalamic–pituitary–adrenal axis overactivity, elevating cortisol and catecholamines that antagonize insulin function [41, 42]. Family history amplifies risk, with Chinese data showing 60% of early-onset patients having diabetic parents [43]. Additionally, High-SDI regions benefit from advanced healthcare systems, better access to medical services, and greater health awareness, resulting in higher detection and reported incidence of T2DM [44]. Conversely, the lower reported T2DM rates in low-SDI countries likely reflect limited epidemiological data, diagnostic facilities, and healthcare resources [45].

While T2DM incidence and prevalence have risen sharply in high-SDI regions, similar trends are now evident globally. Urbanization and dietary changes—shifting from traditional high-fiber, low-fat diets to those rich in refined grains, sugars, fats, and animal products—have driven increases in obesity and T2DM in low-SDI countries [46]. Poverty and food insecurity in these regions further exacerbate the problem, as low-cost, calorie-dense diets increase diabetes risk [47]. Aggressive marketing of unhealthy foods by multinational corporations disproportionately impacts low-income populations, worsening diet quality [48]. Additionally, rising smoking and alcohol consumption among youths in low-SDI countries further elevate early-onset T2DM risk [49].

Our analysis reveals a concerning rise in T2DM-related mortality and YLLs in low-SDI regions, driven by limited healthcare access and worsening case fatality rates. Early-onset T2DM is linked to severe metabolic disruptions, faster progression of complications, and greater mortality risk. Patients diagnosed between ages 15–30 face threefold higher mortality compared to the general population, with risks declining at older ages [50]. In young patients, the risk of cardiovascular disease and end-stage renal disease is 30–50% higher than in older patients [51]. Despite this, awareness, treatment, and control rates remain low in low-SDI countries due to inadequate healthcare infrastructure, limited resources, and poor socioeconomic conditions [52, 53]. Limited health literacy and education in low-SDI countries hinder chronic disease prevention and management efforts. Coupled with insufficient public health investment, this leaves many unaware of diabetes risks and unable to access timely interventions, perpetuating poor outcomes [10, 54]. Low-SDI countries face limited healthcare resources, low health literacy, and inadequate access to preventive care, leading to higher T2DM mortality and YLLs. While high-SDI countries are better equipped to manage the disease despite rising cases, low-SDI regions suffer more severe outcomes due to weaker healthcare systems.

Our decomposition analysis aligns with previous studies in demonstrating the significant role of population growth and aging in the global rise of early-onset T2DM, particularly in low and low-middle SDI regions, where these demographic trends drive increased mortality and DALYs [55, 56]. eductions in case fatality and disease severity in high and middle SDI regions, as highlighted in our analysis, are consistent with studies showing improved diabetes management and healthcare access in these settings [57].However, our findings differ from prior research in key areas: earlier studies suggested uniform declines in case fatality rates across regions [58], but we observe limited progress in low SDI regions, highlighting healthcare disparities. Additionally, unlike Khan et al. [ \* MERGEFORMAT 56], who identified prevalence increases as the primary driver globally, we find that prevalence changes are more significant in middle and high SDI regions, while demographic factors dominate in low SDI regions. These differences underscore the need for region-specific strategies to tackle the rising burden of early-onset T2DM.

Our frontier analysis (1990–2021) shows that higher SDI levels correlate with reduced severe outcomes, such as mortality and DALYs, especially beyond an SDI threshold of 0.3. High-SDI countries benefit from better healthcare infrastructure, medical technologies, and public health strategies [59]. However, disparities remain: countries like Switzerland, South Korea, and the UK exhibit rising incidence and prevalence, moving further from the ideal frontier. Meanwhile, low-SDI nations like Somalia and Sudan perform relatively better in mortality and DALYs, positioning them closer to optimal outcomes, despite socio-economic challenges. These findings highlight the influence of non-SDI factors, such as healthcare access, cultural practices, and genetic predispositions, on T2DM outcomes [29]. Community-based interventions or traditional practices may help mitigate severe impacts in such regions. Addressing the global T2DM burden requires nuanced, context-specific strategies that balance socio-demographic factors with broader determinants of health.

Early-onset T2DM has become a significant global public health challenge, with its burden rising sharply over the past three decades, particularly in high-SDI regions. However, low- and middle-SDI regions face more severe health outcomes but lack sufficient healthcare and public health resources. Effective prevention, early screening, and self-management strategies are essential to address this growing burden. For newly diagnosed youth, lifestyle and dietary interventions can restore pancreatic β-cell function and slow disease progression [60, 61]. However, young people often struggle with self-management due to stress from educational, work, and personal responsibilities, mild symptoms, or a lack of disease awareness. Governments should integrate diabetes prevention into school curricula, promote healthy lifestyles, and enhance education and self-management programs to support disease comprehension, stress management, and long-term health.

Our findings call for tailored strategies based on SDI levels: high-SDI regions should focus on strengthening preventive measures, while low- and middle-SDI regions should prioritize expanding basic healthcare infrastructure, diabetes education, and diagnostic capabilities. Reducing global health disparities requires international collaboration, such as the WHO Diabetes Network, to share best practices and enhance support for resource-limited regions. Technological advancements, including AI for personalized care and precision medicine targeting genetic predispositions, offer promising tools for improving early detection and treatment. AI can predict complications more accurately, especially in resource-strained settings, while precision medicine could revolutionize diabetes management. Further research is needed to explore socioeconomic and behavioral drivers of early-onset T2DM, particularly in low- and middle-income settings, where urbanization, dietary shifts, physical inactivity, poverty, and health system limitations intersect to elevate risk. Optimism remains, as new interventions, including the 2024 ADA guidelines lowering the diabetes screening age to 35 years [14], GLP-1 receptor agonists to improve metabolic health in young obese patients [62], and AI innovations [63], are expected to significantly reduce the disease burden.

This study provides the most comprehensive analysis of the global burden of T2DM among individuals aged 15–34 years over the past 32 years, covering 204 countries and territories. However, several limitations should be noted. First, reliance on GBD Study data may introduce biases due to variability in data sources, case definitions, and reporting standards across countries, potentially impacting the accuracy of estimates for incidence, prevalence, mortality, and DALYs [64]. Additionally, the GBD methodology estimates type 2 diabetes by subtracting type 1 diabetes from overall diabetes cases, potentially overlooking conditions like MODY. Even in clinical practice, the misdiagnosis of MODY remains highly prevalent [65, 66], and similar issues have been identified in other GBD database studies [18]. Future updates to the GBD database could benefit from including more granular diabetes subtypes. Second, the time span of the research (1990 onward) may be influenced by changing diagnostic criteria and advancements in medical technology over the decades. Lastly, the study did not account for emerging risk factors, such as the COVID-19 pandemic, which may have affected recent trends in T2DM burden. Despite these limitations, this study offers critical insights by employing joinpoint regression, decomposition analysis, and frontier analysis to identify trends and disparities in the global burden of T2DM. These robust methods provide a strong foundation for informing global public health policies and optimizing healthcare resource allocation.

Conclusions

The growing burden of early-onset T2DM among youths aged 15–34 years presents a significant global health challenge that requires urgent attention. The increasing prevalence and associated health complications of this condition underscore the need for comprehensive public health strategies aimed at prevention, early detection, and effective management, particularly in vulnerable populations. Future research should focus on understanding the underlying drivers of this trend, including the role of socioeconomic factors, lifestyle changes, and genetic predispositions. Moreover, there is a pressing need for studies that evaluate the effectiveness of targeted interventions, such as those recommended in the 2024 ADA guidelines, in reducing the incidence and severity of early-onset T2DM. Additionally, the disparities in T2DM burden across different sociodemographic development levels highlight the importance of tailored approaches that address the specific needs of low- and middle-SDI regions. Moving forward, leveraging emerging technologies like artificial intelligence for personalized diabetes care and enhancing global collaboration to share best practices will be crucial in mitigating the rising tide of early-onset T2DM and improving health outcomes for young populations worldwide.

Availability of data and materials

No datasets were generated or analysed during the current study.

Abbreviations

T2DM:

Type 2 diabetes mellitus

GBD:

Global Burden of Diseases

DALYs:

Disability-adjusted life years

YLDs:

Years lived with disability

YLLs:

Years of life lost

SDI:

Socio-Demographic Index

ASR:

Age-standardized rates

AAPC:

Average Annual Percentage Change

FFAs:

Free fatty acids

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Acknowledgements

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Funding

This work was supported by National Natural Scientific Foundation of China (No. 82174354) and National Key R&D Program of China (No. 2024ZD0523500).

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  1. Yang Zhou, Yupeng Chen, and Yiting Tang are co-first authors and have contributed equally to this work.

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  1. Department of Endocrinology, Guang’Anmen Hospital of China Academy of Chinese Medical Sciences, Guang’anmen Hospital, Beixiange 5, Xicheng District, Beijing, 100053, China

    Yang Zhou, Yupeng Chen, Shan Zhang, Zifan Zhuang & Qing Ni

  2. Beijing University of Chinese Medicine, Beijing, China

    Yang Zhou & Yiting Tang

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Yang Zhou, Yupeng Chen, and Yiting Tang contributed equally to this work. Yang Zhou, Yupeng Chen, and Yiting Tang were involved in the study's conceptualization, data analysis, and manuscript drafting. Shan Zhang contributed to the data collection, statistical analysis, and interpretation of the results. Zifan Zhuang assisted with the literature review and manuscript revision. Qing Ni, as the corresponding author, supervised the entire project, provided critical feedback throughout the study, and oversaw the final manuscript preparation and submission. All authors reviewed and approved the final manuscript.

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Zhou, Y., Chen, Y., Tang, Y. et al. Rising tide: the growing global burden and inequalities of early-onset type 2 diabetes among youths aged 15–34 years (1990–2021). Diabetol Metab Syndr 17, 103 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13098-025-01673-0

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Keywords

Diabetology & Metabolic Syndrome

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