Type 2 diabetes mellitus (T2DM) and pre-diabetes (pre-DM) are significant health concerns in Pakistan. This systematic review and meta-analysis estimate the prevalence of T2DM and pre-DM, assessing regional, gender, and urban-rural differences. We searched PubMed, Scopus, Cochrane, and PakMediNet databases, identifying 3478 articles. After screening, 17 studies from 1995 to 2018 were included. The pooled prevalence of T2DM and pre-DM in Pakistan was found to be 10.0 % and 11.0 %, respectively. This equates to approximately 24 million individuals with T2DM and 26 million with pre-DM, totaling 50 million affected. Rural areas showed higher T2DM prevalence post-2000, with an odds ratio (OR) of 1.25 (95 % CI: 0.73 to 2.14). Gender analysis revealed a slightly higher, though statistically insignificant, prevalence of T2DM in females and a significantly higher prevalence of pre-DM in males (OR: 0.79, 95 % CI: 0.63 to 0.98). Regionally, Punjab had the highest T2DM prevalence (16 %), followed by Baluchistan (15 %), Sindh (14 %), and Khyber Pakhtunkhwa (KPK) (11 %). There is a substantial burden of T2DM and pre-DM in Pakistan, with significant regional and gender differences. Targeted interventions and resource allocation are needed to address the rising prevalence of diabetes, focusing on early detection and lifestyle modifications.