Age-sex-income triad disparities in diet-attributable diabetes: a GBD 2023 analysis reveals East Asia and Pacific region’s decoupling phenomenon and cost-effective solutions

Objectives Despite the East Asia and Pacific region (EAPR) accounting for 22.7% of global diabetes deaths amid rapid nutrition transition and ageing, it remains unclear how diet-attributable type 2 diabetes (T2D) burden varies across age, sex and income strata, a critical knowledge gap for region-specific policies. This study aims to quantify diet-attributable T2D burden, project 2035 trends and evaluate preventable burden under dietary interventions.Methods We analysed data from the Global Burden of Disease (GBD) 2023 study for 33 countries/regions in EAPR. Key outcomes included age-standardised mortality rates (ASMR), age-standardised disability-adjusted life year rates (ASDR) and population-attributable fractions (PAF). Temporal trends were quantified using estimated annual percentage change with 95% uncertainty intervals. Future burden was projected via Auto-Regressive Integrated Moving Average (ARIMA) models and carefully validated. Scenario-based dietary intervention analyses were further conducted to estimate the preventable fraction of future T2D burden under feasible reductions in major modifiable dietary risk factors.Results A ‘mortality-disability decoupling’ phenomenon was observed: ASMR declined slightly, while ASDR rose consistently. Pronounced disparities were observed in ASDR: adults aged ≥75 years had a 6.3-fold higher burden than those aged 15–49 years and males had a 1.4-fold higher rate than females. The PAF of diet-attributable T2D mortality was 3.4-fold higher in high-income countries (HICs) than low-income countries (LICs). Meanwhile, high processed meat intake was the top risk in HICs, low fruit intake in LICs and low whole-grain intake across the region. ARIMA projections indicated ASDR would rise to 167.02/100 000 by 2035 without interventions, but combined dietary interventions reduce this to 158.38/100 000.Conclusions These findings suggest that stratified dietary risk reduction approaches may help address the growing diet-attributable T2D burden in the EAPR. However, specific policy interventions were not evaluated in this study. The results align with the goals of the WHO Global Diabetes Compact.