EpiCom Interview with Gilaad G. Kaplan and Siew C. Ng, co-leaders of the GIVES-21 Research Group

Our study charts the remarkable transformation of IBD from a rare condition in Western countries a century ago to a global health issue affecting millions today. As part of the GIVES-21 initiative, we analysed data from over 500 population-based studies spanning more than 80 regions and 100 years.

We discovered that IBD spreads in a predictable, four-stage pattern. In stage 1, IBD is rare, with only isolated cases—similar to what we see in parts of Africa today. Stage 2 is marked by a rapid increase in new diagnoses each year, although prevalence remains low, as seen in newly industrialised regions such as Hong Kong. Stage 3 occurs when incidence stabilises but the number of people living with IBD continues to rise sharply; Western countries, including Canada, are in this stage. Finally, stage 4 is defined by the stabilisation of prevalence as the population with IBD ages.

By defining this framework, we provide governments, healthcare systems and patient communities with a roadmap to anticipate and prepare for the rising burden of IBD worldwide—particularly in regions currently entering the rapid-growth stage.

Early industrialised regions are in stage 3 of the IBD evolution framework—what we call compounding prevalence. In this stage, incidence (the number of new diagnoses each year) has stabilised, but prevalence (the total number of people living with the disease) continues to rise sharply. This happens because IBD is a chronic, incurable condition that is often diagnosed in young adults and has low mortality. As a result, gastroenterology clinics continually add new patients but rarely remove them from their registries. As long as new diagnoses outnumber deaths, prevalence will keep increasing.

An important consequence of compounding prevalence is that the IBD population is aging. Seniors are now the fastest-growing demographic with IBD. This is happening for two reasons: first, gastroenterologists are diagnosing new cases in older adults—including those over 60; second, people diagnosed decades ago are living longer with the disease. For example, someone diagnosed with Crohn’s Disease in their 30s in the 1990s will be in their 70s by 2030. An aging IBD population faces additional challenges, such as cancer, cardiovascular disease and other age-related comorbidities, which make management more complex and costly.

Our work aims to highlight not only the rising prevalence of IBD but also its changing demographics, so that health systems and providers can prepare for the future burden of caring for an older, more medically complex IBD population.

Our Nature paper shows that while IBD was once concentrated in Western countries, it began spreading globally in the early 2000s. Since then, rates have been rising in Asia, Latin America, the Middle East and parts of Africa. This spread follows a predictable pattern, often linked to rapid industrialisation and urbanisation. Environmental changes that accompany modernisation, such as dietary shifts, reduced microbial exposure in early life, increased antibiotic use and pollution, are likely key drivers. At the same time, economic growth brings stronger healthcare infrastructure, leading to greater awareness, better diagnostic tools and more cases being detected. Our four-stage framework provides a roadmap to help countries anticipate and prepare for the growing burden of IBD as part of the broader impact of modernisation:

• Developing countries (stage 1): Developing countries, such as most nations in Africa, are currently in stage 1 of the IBD evolution framework, where only low rates of the disease are detected. However, with economic growth, expanding healthcare infrastructure and the westernisation of diets and lifestyles, incidence is expected to rise steadily throughout the 21st century. The key challenges in these regions will be timely recognition of IBD, training of healthcare professionals and strengthening of healthcare systems to meet the needs of a growing patient population. ECCO now has a unique opportunity to form partnerships with stage 1 developing countries to help prepare for, and mitigate, the expanding burden of IBD anticipated in these regions.
• Newly industrialised countries (stage 2): Regions in Asia and Latin America are experiencing a rapid rise in incidence, while prevalence remains low. If they follow Western patterns, they will transition into stage 3 within the next decade, leading to a sharp increase in prevalence.
• Western countries (stage 3, moving toward stage 4): Incidence has stabilised, but prevalence remains at record highs due to the chronic nature of IBD and low mortality. The IBD population is aging rapidly, which will eventually stabilise prevalence, but gastroenterologists will need to contend with managing the complexities of older adults with comorbidities such as cancer and cardiovascular disease.

The key lesson from our study is that IBD follows a predictable epidemiologic path, and knowing where a country sits within the four-stage framework gives governments and healthcare systems a critical head start. This knowledge can guide tailored strategies, whether that’s building diagnostic capacity in regions where IBD is emerging, training specialists in places where incidence is climbing rapidly or developing care models for older adults in countries with long-established disease.

Looking ahead, two priorities stand out. First, we need greater investment in prevention-focused research to better understand the environmental and lifestyle factors driving IBD, so that we can modify these risks and slow the spread of the disease globally. Second, we must strengthen healthcare systems—from infrastructure and workforce development to ensuring equitable access to effective treatments—so that every person with IBD, regardless of where they live, can receive timely and high-quality care.