Year : 2018 | Volume
: 9 | Issue : 3 | Page : 69--72
Diabetes in Asia: Special challenges and solutions
NORD University, Department of Health Sciences, Norway; Federal University of Cera, Department of Endocrinology, Brazil; Diabetes in Asia Study Group; Centre for Global Health, Bangladesh Diabetes Association, Bangladesh
Prof. Akhtar Hussain
Department of Health Science, Po. box. 1490, 8049 Bodø
|How to cite this article:|
Hussain A. Diabetes in Asia: Special challenges and solutions.J Diabetol 2018;9:69-72
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Hussain A. Diabetes in Asia: Special challenges and solutions. J Diabetol [serial online] 2018 [cited 2020 Mar 31 ];9:69-72
Available from: http://www.journalofdiabetology.org/text.asp?2018/9/3/69/239562
Diabetes was first recognised around 1500 BC by the ancient Egyptians. Indian physicians around the same time identified the disease and called it as 'madhumeha' which literally means honey in the urine which was diagnosed by the fact that the urine attracted ants. Type 2 diabetes (T2D) is the most common form of diabetes. It affects 80%–90% of all people living with diabetes. While its prevalence varies with age, sex and population, the global age-standardised adult diabetes prevalence is around 9.2%, and an estimated 425 million adults currently have diabetes which is projected to rise to 629 million by 2045.
The past three decades have witnessed an epidemic of diabetes (especially T2D) and more than 80% of the people with diabetes currently live in the developing countries. The expected rise of T2D in South Asia is estimated to be more than 150% between 2000 and 2035. Indeed, more than 60% of the people with diabetes now live in Asia and the Western Pacific Region.
Asia: The epicenter of the diabetes epidemic
The number of people with diabetes in Southeast Asia in 2017 is 80 million and this is expected to increase to 151 million by the year 2045. According to the World Health Organization, almost 10% of all adults in China (about 110 million people) currently have diabetes compared to <5% in 1980. In urban India, diabetes rates increased from 3% in 1970 to 12% in 2000 and in urban South India from 13.9% in 2000 to 18.6% in 2006. In rural Bangladesh, the prevalence of diabetes increased from 2.3% to 6.8% between 1999 and 2004, and in 2009, it was 7. 9%. In a national survey done in 2001, 8% of Korean adults had diabetes, with little difference between urban and rural areas. In a nationwide survey in Singapore in 1998, Indians had the highest prevalence of diabetes (12.8%), followed by Malays (11.3%) and Chinese (8.4%). Other Asian countries including Japan, Sri Lanka, Indonesia, Thailand and Vietnam also have experienced a marked increase in the prevalence of diabetes. While some Asian countries such as China and India have a very large number of patients with diabetes, the prevalence of diabetes can be as high as 40% in some Pacific island populations.
There could be a number of reasons for the diabetes epidemic in Asia. Initially, due to a better climate and food, human migration shifted towards Asia. This was followed by Arabian, Portuguese and British invasion for wealth, resulting in multiculturalism, multiracial and religious variations. Earlier many Asian countries had experienced extensive poverty during wartime or civil unrest or famine. However, in recent times, most Asian countries are experiencing an economic upsurge resulting in a rapid change of lifestyles including choice of foods, especially in China and India. This has resulted in better chances of survival of the newborn leading to improved longevity which is one of the causes of the diabetes epidemic.
Risk for diabetes in Asian participants
Both the thrifty genotype and thrifty phenotype hypotheses appear to have etiological roles in the development of diabetes in the Asian populations. The phenotype of T2D in Asians is characterised by young age of the onset, predisposition to beta-cell failure and visceral adiposity. Data from Asia suggest that Asians have an increased risk of diabetes even if they do not reach the body mass index (BMI) used to define overweight or obesity in non-Asian populations.
South Asians have been characterised by the Asian Indian phenotype. At similar BMI levels, diabetes prevalence has been identified as higher in Asians compared with caucasians. Asians are prone to visceral adiposity, which is more closely associated with insulin resistance and T2D than overall adiposity. Asians (especially South Asians) appear to have less muscle and more abdominal fat, which increases insulin resistance. Indian newborns have a lower average body weight but higher levels of body fat and insulin compared to white newborns. It has been shown that Asians with a 'healthy' BMI have more fat around abdominal organs for example, liver and pancreas than Europeans with the same BMI. All these have been collectively termed as the Asian Indian or South Asian phenotype, where in spite of lower BMI, there is more abdominal fat, greater insulin resistance, dyslipidaemia and increased susceptibility to T2D and coronary artery disease.
In a sample of Chinese patients with T2D, 50% were of normal weight, with low BMI correlating with low levels of fasting plasma C-peptide (a marker of decreased insulin secretion) and high glycated haemoglobin levels. In a prospective survey of Japanese Americans, visceral fat area and reduced incremental insulin response were independent predictors for diabetes. Taken together, in some Asian populations, inadequate beta-cell response to increasing insulin resistance results in loss of glycaemic control and increased risk of diabetes, even with relatively little weight gain. In India, thinness in infancy and overweight at age 12 years were associated with increased risk of developing impaired glucose tolerance (IGT) or diabetes in young adulthood.
Genetic factors do have a role in the aetiopathogenesis of diabetes. Some genetic variants have been identified to be associated with diabetes through genome-wide association studies and sequencing. However, studies have also shown that other factors such as epigenetic changes, unhealthy diet and lifestyle possibly have a predominant role in controlling whether a genetically predisposed individual progresses to overt T2D. However, genetic studies are needed to make personalised prevention and/or treatment approach for diabetes, but until now, only monogenic type of diabetes such as maturity-onset diabetes of the young offers such opportunities.
Pregnancy and diabetes in Asian participants
Intrauterine period is critical as stresses during the intrauterine period can cause changes in structure, metabolism and physiology through altered expression of the genome without changes in the DNA codes, a process called epigenetics. Low birth weight and exposure to undernutrition in utero are also widespread in some Asian populations, especially in India, where 30% of infants are underweight. Evidence suggest that these early life changes influence later susceptibility to diabetes, the metabolic syndrome and cardiorenal diseases. Prospective studies from India have shown the impact of foetal undernutrition as well as overnutrition on the future risk of diabetes. However, further studies are required to substantiate the findings as the sample from India may have higher prevalence of Vitamin B12 deficiency attributable to the vegetarian (including lacto-vegetarian) diet in this population. As one recent study from Pakistan showed the high prevalence of Vitamin B12 deficiency even in a non-vegetarian population. Moreover, low birth weight babies were equally delivered by the mothers who were undernourished or overnourished.
The prevalence of gestational diabetes (GDM) is very high in South Asian women., This can also increase the risk of diabetes and cardiovascular disease (CVD) in the offspring. A systematic review and meta-analysis study has shown that approximately one in ten pregnant women in the Eastern and Southeastern Asia had GDM. The prevalence of GDM was highest in Vietnam and Singapore (20.06% and 18.93%, respectively) followed by mainland China and Malaysia (11.91% and 11.83%, respectively) and was <8% in Japan, Korea, Taiwan and Thailand. The heterogeneity in the prevalence of GDM could be due to differences in the screening procedures, diagnostic criteria, population characteristics and other socioenvironmental factors.
Type 2 diabetes in lean people
Much has been published on the characteristics of T2D and its association with the epidemic of obesity. However, relatively little is known about the incidence of lean diabetes, progression of disease and natural history of such patients. The pathophysiology and its distinction from classic T2D in those with low BMI (BMI <18.5 kg/m2) are still unclear and a subject of much debate. The key feature in these thin individuals appears to be a defect in insulin secretory capacity as opposed to peripheral insulin resistance as noted in classical diabetes associated with obesity.
Adult-onset diabetes with low BMI was initially placed under the category of 'malnutrition-related diabetes mellitus' in a subcategory termed 'protein-deficient pancreatic diabetes'. Later, this syndrome was noted to be similar to that originally described as 'Jamaica type diabetes', a term used to represent around 5% of Caribbean diabetics. Similar clinical syndromes were subsequently described in the regions of South Asia and Africa and had acquired various names such as 'tropical diabetes, mixed onset type diabetes, phasic insulin-dependent diabetes, J-type diabetes, Z-type diabetes, M-type, type 3 diabetes or ketosis-resistant growth onset type diabetes. A study from India on around 10,000 individuals with T2D revealed that around 3.5% of patients were lean with a BMI <18.5, with the larger share of around 63% of patients having ideal body weight at the diagnosis. This study also highlighted the fact that HbA1c, fasting and post-prandial blood glucose levels were higher among the lean group. Microvascular complications of diabetes such as retinopathy, nephropathy and neuropathy were more common, presumed to be related to the higher plasma glucose and HbA1c levels.
Prevention of diabetes
Till date, the best evidence for prevention of T2D comes from randomised controlled trials of lifestyle interventions (e.g., to modify diet and physical activity and achieve weight loss) delivered to individuals at the high risk, usually those with IGT or prediabetes. Randomised clinical trials have shown that T2D can be prevented or at least postponed by rather modest lifestyle changes. In the Finnish study, the effect of lifestyle intervention in decreasing diabetes incidence was found to be 58%. The Diabetes Prevention Programme lifestyle intervention also demonstrated a 58% decrease in the incidence of T2D among overweight adults of diverse race/ethnicity at the high risk of developing T2D. These two studies laid the foundation for lifestyle intervention as an effective approach to prevent the occurrence of diabetes in the first place. This was documented further in a number of studies across the globe with varying effectivity. However, the effectivity of lifestyle in decreasing the incidence of T2D in Indians with IGT was found to be only 28% and the same 28% reduction was observed in Pakistani individuals with IGT. The Diabetes Community Lifestyle Improvement Program showed that stepwise diabetes prevention in people with prediabetes can effectively reduce diabetes incidence by a third in community settings; however, different population may require different interventions. Further, it was evidenced from a 5-year follow-up study from Bangladesh that in nutritionally marginalised participants (BMI <22), there was an increase in the risk of diabetes, if they lose their body weight. It was also shown that South Asians develop diabetes 5–10 years earlier in the UK, and different approaches are suggested to prevent diabetes in South Asians compared to the white Europeans.
Differences in South Asian phenotype ([high percentage of body fat and high proportion of deep subcutaneous and visceral fat] and skeletal muscle [low percentage of lean mass and low cardiorespiratory fitness]) are likely to contribute to the differences in the effectivity of lifestyle interventions in Asians. The European and the American participants were also older and had high level of adiposity defined by BMI compared to the participants studied in India and Pakistan. Further studies are needed to recognise the reason for the differences observed so that we can develop a proper intervention strategy for the prevention of diabetes in South Asian participants.
The way forward
Risk factors for diabetes show substantial racial and geographical variations in expression and intensity. The escalating prevalence of diabetes and CVDs in developing countries is mostly related to environmental changes. Asian populations have several important characteristics with respect to biological and environmental risk factors for diabetes and CVD. Growing scientific evidences suggest that there can be no single treatment guideline for all the population in the world. In Asia, the rapid modernisation from an energy-scarce to energy-rich environment has led to high rates of metabolic syndrome and diabetes. While we cannot obviously reverse the economic prosperity in Asia, we can definitely limit the impact of rapid lifestyle changes associated with economic growth of the countries in this region. South Asians need to be encouraged and helped – by various culturally appropriate methods – to maintain a high physical activity level and ideal body weight across the life course to prevent diabetes. Policy initiatives by the governments that would encourage healthy eating and public–private partnerships to make a conducive environment for increased physical activity shall also help prevent diabetes.
It is obvious that the diabetes in South Asia needs to be studied in greater detail with respect to the diagnostic criteria both for diabetes and GDM mellitus, risk factor definitions and their threshold values, prevention modalities and also appropriate treatment guidelines. There are a number of specific questions to be addressed based on the scientific evidence such as BMI categories and central adiposity including body fat percentage for South Asians. This includes issues such as what is the normal weight gain during pregnancy and the normal birth weight for Asians. Further, it is known that the Asians tolerate lower amount of pharmaceutical products, and therefore, all drugs need to undergo clinical trials for the safety and efficacy in Asian participants. However, it needs to be emphasised that even Asia is not one homogeneous entity. There may be diversity even within Asian participants, and thus, ethnic-based guidelines may be needed in the future.
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