Sunday April 9, 2006
Sweet, sweet Asia
BY MANGAI BALASEGARAM
The recent international summit on Asia’s growing diabetes crisis held by the World Diabetes Foundation (WDF) in Hanoi, Vietnam, saw many diabetes experts expressing the view that the disease is set to be one of the 21st century’s biggest health challenges
THERE was a time when type 2 diabetes was considered a rather humdrum disease of the old. It was a disease of rich nations, associated with obesity. It was not the kind of disease that kept public health experts up at night.
Not any more. Today, the risk factors for diabetes have changed. “It is no longer a disease of the rich,” said Dr Viswanathan Mohan, a leading Indian diabetes expert. “The majority of cases are among the middle income [group] and poor.”
Diabetes is also increasingly an Asian problem. And while still closely associated with bulging waistlines, the disease is now appearing in Asians who are hardly obese, so-called “lean diabetics”.
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Footcare is critical for diabetic patients, who carry a risk of lower limb amputation that may be 25 times greater than non-diabetics. - Photo by JESPER WESTLEY, World Diabetes Foundation |
“They may be the first generation of children that die before their parents,” said Prof Paul Zimmet, Director of the International Diabetes Institute, in Victoria, Australia. “The age of onset has moved down 30 years. The old books of medicine talked about diabetes in people more than 60 [years].”
With diabetes appearing across a wider range of age, weight and area than ever before, alongside the obesity epidemic, it is set to be one of the 21st century’s biggest health challenges.
Bigger than bird flu
Already in the United States, an epidemic of type 2 diabetes has assumed gargantuan proportions. The epidemic has burgeoned alongside an expanding obesity problem, rising faster than heart disease and certain cancers. The future looks yet more gloomy. One in three Americans born in the last five years will develop diabetes.
The figures from the International Diabetes Federation’s Diabetes Atlas are numbing. Globally, the number of diabetics is expected to double in the next 20 years to 333 million. Yet it is in the Asia-Pacific region where the pace and scale of the global epidemic is most alarming.
In terms of prevalence, the Pacific island of Nauru has the world’s highest rate, with roughly a third of adults affected. Singapore’s prevalence is also one of the highest, with one in eight adults affected – a figure forecasted to rise to one in five adults by 2025.
In terms of sheer numbers, Asia is home to four of the five countries with the largest diabetic populations globally – India, China, Pakistan and Japan. India alone has some 33 million diabetics – and that number is set to double in 20 years.
It is numbers like these that worry public health experts. “Diabetes, not bird flu, is Asia’s biggest health threat,” said Prof Zimmet, adding this was a “ diabetes tsunami”.
Prof Zimmet was one of many renowned diabetes experts attending a recent international summit on Asia’s growing diabetes crisis held by the World Diabetes Foundation (WDF) in Hanoi, Vietnam.
The summit is the first of a series of initiatives bringing national and international experts together with academics and World Health Organization (WHO) experts on the issue.
The need for a regional focus is evident. Diabetes is a problem even in the cities of less developed Asian nations, with rates double that of Western nations. The prevalence in urban Cambodia, at 7%, is roughly the same as in Australia.
In Malaysia, the proliferation of kidney dialysis centres in urban areas is evidence of the increasing damage wreaked by diabetes. “The situation is alarming,” said Dr Zainal Ariffin Omar, Deputy Director of the Disease Control Division and Head of Non-Communicable Diseases in the Health Ministry.
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Dr Galea: 'Five years ago, very little was being done on diabetes in the region' - Photo by JESPER WESTLEY, World Diabetes Foundation |
Motorisation and ‘colanisation’
Why has the disease become so prevalent across Asia? Rapid development has brought on dietary changes as well as reduced physical activity. Smoking, alcohol and rest are also factors.
“Environmental factors are important,” said Dr Gauden Galea, Regional Advisor for Non Communicable Diseases for WHO’s Western Pacific Region. Urbanisation – and specifically motorisation – has led to reduced physical activity.
“In the past decade in Hanoi, where people have switched from bicycles to motorbikes, diabetes has doubled,” he said, speaking at WDF’s summit.
In addition, today’s diets are higher in calories. Preparation and processing determine the health value of foods. Comparing rice, he said red rice was healthy while briyani was unhealthy. Refined foods usually have a higher glycaemic index. “Polished white rice is almost like eating sugar,” said WDF Vice-Chairman Dr Kapur.
The “coca-colanisation” of societies, as Prof Zimmet describes the spread of Western junk food, is also a problem. But even traditional meals eaten out often have more calories than when prepared at home. One study in Vietnam showed how chicken noodle soup (pho ga) had 23% more calories when prepared in restaurants.
Thus, the average officer worker in Hanoi who rides a motorbike and eats out now faces a double whammy in less exercise, yet a higher calorie intake, Dr Galea said.
It is this situation that has led to a growing obesity epidemic. Today, one in six children in New Delhi is fat. There is a similar statistic in major Chinese cities. Malaysia has the higher number of overweight people, with one in four tipping the scales.
Furthermore, Asians seem to be more prone to diabetes and develop it at a lower body mass index (a height by weight ratio) than Caucasians.
Research has found that Indians carry genes that increase their susceptibility to diabetes as well as lack genes that provide protection, said Dr Mohan, the director of the Madras Diabetes Research Foundation in India.
Other studies show poor nutrition in pregnant women can lead to diabetes in mother and child years later. If the mother has gestational diabetes, this also can increase the likelihood of disease in later life. A study of 3,000-plus pregnant women in Chennai found a 15% prevalence of gestational diabetes.
Asians are also developing the disease at younger ages, when they are economically productive, which places a greater burden on families.
Crippling costs
Most Asian nations are ill prepared to cope with this crisis. Put frankly, a diabetes epidemic is too costly and burdensome for many countries – and families – to bear. “Health systems [in India] are already feeling the pinch. They are struggling to cope,” said Dr Mohan. Families too are under strain; in low-income Indian families, as much as 25% of the family income goes to treating diabetes, studies show.
It has been estimated that by 2025, the healthcare bill for diabetes worldwide will be as much as US$400bil (RM1,480bil).
The reason why diabetes is so costly and debilitating is because it affects every single organ of the body. In many countries, diabetes is now a leading cause of blindness, kidney failure, heart problems and amputation of the foot or even leg. It also affects the heart; indeed many diabetics eventually die of heart attack/failure.
Yet early diagnosis and effective management can prevent many of these complications.
There is thus an urgent need for preventive action. “Now is the time to make a lot of noise about diabetes. We need to send the right messages about diet and exercise. Otherwise, in 10 to 15 years, we will see millions of people needing bypasses, kidney dialysis and laser treatment,” said Dr Mohan. He added that many of his patients came from Malaysia and awareness among them was inadequate.
Many Asian nations are only slowly waking up to the crisis. “Five years ago, there was very little [going on]. Many countries did not have diabetes plans. Now, they do,” said Dr Galea.
But much more needs to be done. In many countries, half the people with diabetes are not even diagnosed. There is a need for better testing and awareness.
Prof Zimmet said that aside from Japan and Singapore, most governments in Asia were not taking enough action.
Dr Zainal said Malaysia’s current programme followed that from the United States and was considered a good model. It is currently being restructured. The healthy lifestyle programme will be intensified.
He said diabetes management at clinics had improved considerably. “We have a diabetes registry now. We started HbA1c monitoring three years ago. We also check for complications. We do regular eye checks and foot care.”
Clearly, all effort must be made to tackle this “disease of development”, which, if uncontrolled, will place a very heavy social and economic burden on the country.
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