Articles

Newsletter Winter 2019 The Silent Epidemic of Diabetes in china

The Silent Epidemic of Diabetes in China

By

Thomas G. Hedberg, MSc, PhD

Clinical Development, Kinexum

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BACKGROUND

There are frequently heavy prices to pay for cultures embracing the lifestyle of Western nations, particularly of the US. China’s rapid economic and social expansion during the past 30 years has led to unwanted and heretofore unknown health consequences. The first epidemiological investigation of diabetes in China in 1980 showed a diabetes prevalence of 1%. By 2009, however, that prevalence had grown to 10%, and diabetes has since become the third largest chronic disease in China after cancer and cardiovascular pathologies.1 According to the International Diabetes Federation, while diabetes is skyrocketing in China, the nation is still largely unprepared for the expected increase in diabetes-related comorbidities and complications. Fortunately, these complications have not yet become as widespread as the core disorder.

 

According to the CND-MDSG (China National Diabetes and Metabolic Disorders Study Group), in a 2010 NEJM article titled “Prevalence of Diabetes among Men and Women in China,” 92.4 million Chinese adults have diabetes and 148.2 million may be classified as pre-diabetic.2 As of 2017, the number of diagnosed cases has jumped to 113.9 million.3 These numbers will continue to grow as the population further embraces the fundamental changes that accompany economic development and urbanization. Among these, perhaps the most unhealthful is the adoption of a considerably more sedentary lifestyle and a fast-food driven diet. According to the Chinese Diabetes Society, the incidence of diabetes will grow substantially over the next 10-20 years to a point where approximately 50 million Chinese with undiagnosed diabetes will begin seeking medical care.4 With Chinese diabetics currently constituting nearly a third of all cases worldwide, the World Health Organization (WHO) projects that diabetes will be the seventh-leading cause of death in China by 2030. An ongoing JAMA study, conducted in collaboration with the Chinese Society of Diabetes (CDS) and the International Diabetes Federation (IDF), has determined that the annual cost to the Chinese national health service for treating diabetes was 173.4 billion Renminbi ($28.5 billion US), or ~13% of the total national expenditure for health services.5 The growth rate of pediatric diabetes in particular was recently heralded by an alarming declaration recently made by Novo Nordisk: “…increasing childhood obesity in China is to diabetes and chronic diseases what melting glaciers are to climate change: a warning signal of times to come…” Clearly, the problem is epidemic and calls for an early, comprehensive, and definitive therapeutic approach.

 

RECOGNITION AND CHALLENGES

The Chinese Ministry of Health has made diabetes prevention and treatment a priority. In October 2010, it announced the launch of a 3-year program to train 100,000 community-level doctors across China in both pediatric and adult diabetes prevention and treatment. Unfortunately, international assessment of these programs has shown them to be insufficient, limited in scope, and not regularly updated.

 

 

 

There is also the challenge of patient education, which is key to any preventative measure. Wang et al. (2017) suggest that approximately 50% of the Chinese population may be pre-diabetic and just over 30% of those with either type 1 or type 2 diabetes remain unaware of their condition. Regional treatment and disease recognition are equally challenging. Recently, the Chinese Diabetes Education Status Survey Group surveyed some 6000 type 2 diabetic patients in 50 regional medical centers and found that only 32.1% had reached acceptable HbA1c levels (<7%) despite the purported availability of treatment. This was compared to data from the US, which showed that 50.1% had HbA1c levels below 7%.6 A 2012 study by Li Ming-Zi et al. provided data from 6 tertiary Beijing hospitals, which surveyed 1,151 type 2 diabetics and found only 37.8% were maintaining their HbA1c levels below 7%.7   

 

Another layer of complexity arises from the fact that the overall problem is complicated by genetics. As a general rule, East Asian peoples have repeatedly been shown to have considerably less physiological tolerance to excess adipose tissue than other populations. Ten extra pounds on a pre-teen Asian child is considerably more dangerous than the same excess weight on a European or African child of equivalent age and build. 

 

There is also considerable ethnic diversity in China. Although the Han Chinese constitute the majority of the country’s population (~91%), they are markedly in the minority in areas populated by other ethnic groups, such as the Hui, Tibetan, and Uyghur peoples. Through a combination of genetic factors and lifestyle, the incidence of diabetes in non-Han populations tends to be significantly less. For example, Tibetan peoples had the lowest prevalence of diabetes and prediabetes (4.3% and 31.3%, respectively) in the country.8 Accordingly, anti-diabetes programs need to be keyed to the ethnic composition of the regions where they are implemented. 

 

Finally, an important factor not generally recognized in the West is the persistent role of traditional Chinese herbalism in treating many disorders, including diabetes. This past January, there was a remarkable flurry of interest in Tianqi, a mixture of 10 herbs that was touted as effective in preventing pre-diabetics from developing clinical disease.

 

Overall, the key challenges remain: 1) A dearth of knowledge about and implementation of prophylaxis to stem the tide of juvenile obesity, 2) Low and late diagnosis and treatment of diabetic patients, 3) Poor glycemic control and compliance among diagnosed patients, 4) The absence of effective recognition and diagnosis of the disease in a huge pre-diabetes population, and 5) The coming increase in diabetes-related complications.

 

APPROACHES TO INTERVENTION

Popular publications, as well as medical journals, almost unanimously stress the exceptional need for supplemental medical education for both physicians and the lay population. Research undertaken by the BMS Foundation cites a continuing shortage of well-trained healthcare professionals with training in either juvenile or adult diabetes. Moreover, as recently as 2016, physicians were found to spend less than 6 hours with each diagnosed diabetes patient per year. Accordingly, increasing awareness of and access to appropriate diabetes treatment will not be sufficient.

 

Attempts at interventional success will also be complicated by the lack of the millions of trained nursing home employees needed to care for a rapidly growing elderly population, which in China, as elsewhere will be more heavily impacted by diabetes and its complications.

 

In addition, perhaps the most glaring problem in achieving an effective plan for diabetes prevention and treatment in China is the imbalance of resources in the healthcare system, which nationwide, favors urban over rural populations.

 

While the government of China is introducing reforms and education to tackle the diabetes epidemic, there are certain legislative barriers that handicap the effectiveness of proposed solutions. For example, the direct advertising of prescription drugs is prohibited. Thus, both patients and healthcare professionals are obliged to look elsewhere for information, a situation which favors any media that provides information. 

 

Despite the huge number of social media users in China, this route has been relatively underexploited.  In recognition of this, a consortium of healthcare professionals from Johns Hopkins Medical School, the International Medical Crisis Response Alliance (IMCRA), and the DaiAi Shenzhen Diabetes Initiative (DSDI) has undertaken the development of a series of online patient/physician forums. This program, launched in 2016 at 2nd People’s Hospital in Shenzhen, China uses social media-accessed targeted streaming video modules to satisfy the largely unmet need for education, support, and interactivity with Chinese-speaking medical experts. The effort has focused largely on diabetes prevention and recognition of the threat of obesity and worsening nutritional practices effecting Chinese children. While this type of media approach has been highly effective in pilot urban centers, such as Shenzhen and Guangzhou, its critically important impact in establishing a platform for reaching rural communities is increasing. As recognized in a recent report by Sanofi, access to programs like the IMCRA-DSDI initiative through use of a digital information portals accessible through smartphones may drive a breakthrough. To quote Sanofi directly: “…the use of apps which allow for remote management and consultation…is an important area of development.”

 

As of November 2018, the essential IMCRA-DSDI-Johns Hopkins program has utilized the following approach in designing dual HCP and patient-targeted systems:

·         Selection of well-published and well-known Chinese-fluent faculty and advisors who would be seen as KOLs by healthcare professionals and the targeted populations

·         Establish a focus on why diabetes has become epidemic in East Asian countries like China, Indonesia, and Vietnam (e.g., Westernization of diet and physical activity levels)

·         Query those faculty and advisors who have experience in China as to practice gaps, target locales and most serious problems as they see them.

 

The video modules recorded to date have focused on the following topics:

·         Why has diabetes become epidemic in China and certain other East Asian nations?

·         Diabetes risks and prevention in childhood

·         Impact of pathological HbA1c levels on economic health and the general well-being of population

·         Prevention: lifestyle and eating habits

·         Managing the pre-diabetic patient

·         Initial approach and treatment options for type 2 diabetes

·         Managing comorbidities

·         When to use insulin and other drugs

·         Cultural and psychosocial issues in endocrinology practice

·         Utilizing the interactivity components of the IMCRA-DaiAI system

 

 

 

System initiation outcomes have been assessed using the following parameters:

·         Metrics on system use and uptake

·         Metrics on interactivity and response to monitoring questions

·         Personal assessments of system impact on users practice

·         Before/After evaluations of program effectiveness by virtue of patient outcomes and impact on practice, clinic and hospital standing

·         Assessment of program expansion appropriate to need

 

IMCRA-DSDI-Johns Hopkins Program Links

·         Juvenile Obesity and Diabetes – Mathiodakis Video Module

·         Juvenile Obesity and Diabetes – Mathiodakis PPT

·         Diabetes Therapy and Injection Technique – Li Video Module

·         IMCRA-DSDI System Introduction – Yan Video Module

·         IMCRA-DSDI Interactive App – Hedberg

·         IMCRA-DSDI Team Meeting in Shenzhen

·         IMCRA-DSDI Team

·         IMCRA-DSDI Live Class In Progress

·         Gestational Diabetes Module

·         A Mother’s Thanks!

BIBLIOGRAPHY

1.       Yang W-Y. Achieve Great Success, and Blaze Trail: Review of Clinical and Basic Research Progress of Chinese Diabetes in the 21st Century. Chinese Medical Journal 2009; 122(21):2525-2529.

2.       Yang W-Y, et al. Prevalence of Diabetes among Men and Women in China. N Engl J Med 2010; 362(12):1090-101

3.       Wang L, et al. Prevalence and Ethnic Pattern of Diabetes and Prediabetes in China. JAMA 2017; 317(24):2515-2523.

4.       International Diabetes Federation (2010). New Diabetes Figures in China: IDF Press Statement.

5.       International Diabetes Federation (2010). China Spends RMB 173.4 Billion (US$25 Billion) a Year on Diabetes Treatment.

6.       Chinese Diabetes Education Status Survey Group. A Nationwide Survey of Diabetes Education, Self-management and Glycemic Control in Patients with Type 2 Diabetes in China. Chinese Medical Journal 2012; 125(23):4175-4180.

7.       Li M-Z. Management Status of Type 2 Diabetes Mellitus in Tertiary Hospitals in Beijing: Gap between Guideline and Reality. Chinese Medical Journal 2012; 125(23):4185-4189.

8.       Hu C and Jia W. Diabetes in China: Epidemiology and Genetic Risk Factors and Their Clinical Utility in Personalized Medication. Diabetes 2018; 67:3-11.