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      Diabetes in China: The challenge now

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      Journal of Diabetes Investigation

      Blackwell Publishing Ltd

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          Abstract

          China has made astonishing strides in economic development and has emerged as a strong global partner during the past 30 years. However, the rapid improvement of the standard of living has also exposed the Chinese to new risks that was once thought to be the preserve of the west. New estimates from a population‐based national study carried out in 2008–2009 reported 92.4 million people with diabetes and 148.2 million people with pre‐diabetes 1 . China, ahead of India now, has become the country with the largest number of people with diabetes in the world (Figure 1). When looking back over the past 15 years, we can see a leap in the prevalence of diabetes in China, in which it increased markedly from 2.0% in 1995 to 5.5% in 2001 and to 9.7% in 2009. The rate of increase is much faster than the USA, India, Japan and the UK (Figure 2). Figure 1  Number of persons with diabetes in China, Japan, India, the USA and the UK from 1995 to 2010 (Source: Global burden of diabetes, 1995–2025: Prevalence, numerical estimates, and projections. Diabetes Care 1998, 21: 1414–1431. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2003. Diabetes Care 2004, 27: 1047–1053. Prevalence of diabetes and impaired fasting glucose in the Chinese adult population: International Collaborative Study of Cardiovascular Disease in Asia (InterASIA). Diabetologia 2003, 46: 1190–1198. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract 2010, 87: 4–14). image Figure 2  The prevalence of persons with diabetes in China, Japan, India, the USA and the UK from 1995 to 2010 (Source: Global burden of diabetes, 1995–2025: Prevalence, numerical estimates, and projections. Diabetes Care 1998, 21: 1414–1431. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2003. Diabetes Care 2004, 27: 1047–1053. Prevalence of diabetes and impaired fasting glucose in the Chinese adult population: International Collaborative Study of Cardiovascular Disease in Asia (InterASIA). Diabetologia, 2003, 46: 1190–1198. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract 2010, 87: 4–14). image It is, actually, not entirely surprising. The rate of chronic ailments, such as high blood pressure and heart disease – the health problems linked to growing prosperity, has also been steadily climbing in China. Diabetes is a major risk for stroke, heart attack and kidney disease, and the costs incurred by diabetes mobility are far greater than the costs of preventing the disease. It stands that China faces a heavy health care burden and expenditure attributable to diabetes. The estimated national direct medical costs for diabetes and its complications, based on the estimated case numbers of 23.46 million, are reported to be $26 billion a year or 18.2% of China’s total health expenditure in 2007 2 . The latest figures will mean health care expenditure on diabetes in 2010 will increase dramatically. Given the disproportionately high ratio of pre‐diabetes to diabetes, health expenditure will increase substantially in coming decades. Like many other developing counties, China has experienced dramatic socioeconomic and cultural transitions. The aging of the population, nutritional changes and increasingly sedentary lifestyles, with a consequent epidemic of obesity, have contributed to the national diabetes epidemic. It has something to do with urbanization, but it is also part of a cultural shift away from traditional lifestyles, centered on food rich in fiber and physical activity, to Western modern lifestyles, centered on fatty food and lack of exercise. These have had a particularly large impact in China, but these are modifiable factors. That eating a healthy diet and becoming physically more active can prevent diabetes has been convincingly proven by China’s Daqing Impaired Glucose Tolerance and Diabetes Study 3 . These findings underline that developing education models calling for the general public to adopt healthy lifestyles is significant for reducing the diabetes epidemic in the future. However, this is a big challenge, because the fast‐food cultural model is now as deeply rooted in Chinese daily life as in Europe and the USA. We are caring for a huge population with diagnosed diabetes; we are also concerned about the number of people with undiagnosed diabetes. Studies have shown that there is a period of asymptomatic or latent diabetes before clinical recognition; many patients at the time of diagnosis already have diabetic complications. New figures reported that 60.7% of people with diabetes are undiagnosed, among which nearly half of the undiagnosed diabetes met the criteria of elevated 2‐h plasma glucose levels, but not the criteria for fasting glucose levels. A previous study also found that nearly half of inpatients with hyperglycemia had undiagnosed diabetes before admission to a tertiary hospital of Guangdong Province. It is likely to result from public unawareness, but it is also likely to be a result of limited medical resources. Incomplete coverage, uneven access, mixed quality and the escalating cost is China’s main health challenge. Developing early detection and diagnosis strategies by appropriate screening methods, especially in subjects with a high risk for diabetes, is significant. However, as shown by International Diabetes Federation (IDF), this needs to be backed up with sufficient resources to manage and treat larger numbers of people with diabetes. Diagnosing more cases without being able to increase the amount of care available will do little to improve the lives of people with diabetes. As we know, ethnic differences in insulin sensitivity and β‐cell function in type 2 diabetes exist among ethnically diverse populations. Despite lower body mass index, China has a similar or even higher prevalence of diabetes than Western countries. In the 1980s, Japanese researchers first discovered that early insulin response was an independent predictor to diabetes. Similar to that in Japanese patients, inadequate β‐cell response to increasing insulin resistance results in loss of glycemic control and increased risk of diabetes, even with relatively little weight gain, and seems to be the main defect to the progression of the disease in Chinese patients. Our recent study comparing intensive insulin therapy with oral hypoglycemic agents in newly diagnosed type 2 diabetes provided some further evidence 4 . A greater proportion of patients with intensive insulin therapy, in which treatment was withdrawn after 2 weeks of normoglycemia, achieved glycemic remission compared with oral agents by the end of 1 year. Of note, in the oral agent group, acute insulin response at 1 year declined significantly compared with immediate post‐treatment, but it was maintained in the insulin treatment groups. This suggests that the improvement of β‐cell function is crucial to maintain glycemic control in Chinese type 2 diabetics. Additionally, new drugs including glucagon‐like peptide‐1 (GLP‐1) analogs are available in China; whether β‐cell protection could benefit in terms of long‐term glycemic control is currently being clinically trialed. Given that many patients prefer to combine traditional Chinese medicine and Western treatments, more research also needs to investigate the possible interactions or the net effect on the overall efficacy, safety and tolerability. To the general diabetes population, good glycemic control is known to reduce the risk of long‐term complications. However, a study reported that over 73% of Chinese type 2 diabetics did not reach the target of HbAlc ≤ 6.5% in 2006. The Chinese Diabetes Society developed new diabetes treatment guidelines proposing an early and effectively combination approach. National Health Plan Promotion of Diabetes Management programs targeting providers as well as patients with diabetes have also been promoted. Notwithstanding national and local efforts, widespread implementation of education has remained an elusive goal for many medical centers. A recent investigation, carried out in Jiangsu Province last year, showed that 60% of type 2 diabetics did not reach the target of HbAlc < 6.5%. Fewer patients from secondary and primary hospitals achieved glycemic control compared with those from tertiary hospitals, in which poor education programs might be a major contributor 5 . We need to develop state‐of‐the‐art education strategies that involve teaching people about preventing and managing disease. The lack of primary health care staff and community health centers throughout the country is also an obstacle to improving the situation. As IDF pointed out, the prevalence of diabetes in China is a wake‐up call for the government and policy‐makers to take action on diabetes. However, like many countries facing complex health care challenges, multiple institutional and attitudinal obstacles still exist to improving health care, and these barriers have created a substantial and growing gap between what we know and what we actually do. The highest priority is to develop strategies assisting more primary health care providers to recognize and treat diabetes; this is an important basis for national education of disease prevention and treatment. Further, institutional collaborations between Chinese and international scientists are believed to be making an impact by promoting diabetes research and wider educational activities.

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          Most cited references 5

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          Prevalence of diabetes among men and women in China.

          Because of the rapid change in lifestyle in China, there is concern that diabetes may become epidemic. We conducted a national study from June 2007 through May 2008 to estimate the prevalence of diabetes among Chinese adults. A nationally representative sample of 46,239 adults, 20 years of age or older, from 14 provinces and municipalities participated in the study. After an overnight fast, participants underwent an oral glucose-tolerance test, and fasting and 2-hour glucose levels were measured to identify undiagnosed diabetes and prediabetes (i.e., impaired fasting glucose or impaired glucose tolerance). Previously diagnosed diabetes was determined on the basis of self-report. The age-standardized prevalences of total diabetes (which included both previously diagnosed diabetes and previously undiagnosed diabetes) and prediabetes were 9.7% (10.6% among men and 8.8% among women) and 15.5% (16.1% among men and 14.9% among women), respectively, accounting for 92.4 million adults with diabetes (50.2 million men and 42.2 million women) and 148.2 million adults with prediabetes (76.1 million men and 72.1 million women). The prevalence of diabetes increased with increasing age (3.2%, 11.5%, and 20.4% among persons who were 20 to 39, 40 to 59, and > or = 60 years of age, respectively) and with increasing weight (4.5%, 7.6%, 12.8%, and 18.5% among persons with a body-mass index [the weight in kilograms divided by the square of the height in meters] of or = 30.0, respectively). The prevalence of diabetes was higher among urban residents than among rural residents (11.4% vs. 8.2%). The prevalence of isolated impaired glucose tolerance was higher than that of isolated impaired fasting glucose (11.0% vs. 3.2% among men and 10.9% vs. 2.2% among women). These results indicate that diabetes has become a major public health problem in China and that strategies aimed at the prevention and treatment of diabetes are needed. 2010 Massachusetts Medical Society
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            The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year follow-up study.

            Intensive lifestyle interventions can reduce the incidence of type 2 diabetes in people with impaired glucose tolerance, but how long these benefits extend beyond the period of active intervention, and whether such interventions reduce the risk of cardiovascular disease (CVD) and mortality, is unclear. We aimed to assess whether intensive lifestyle interventions have a long-term effect on the risk of diabetes, diabetes-related macrovascular and microvascular complications, and mortality. In 1986, 577 adults with impaired glucose tolerance from 33 clinics in China were randomly assigned to either the control group or to one of three lifestyle intervention groups (diet, exercise, or diet plus exercise). Active intervention took place over 6 years until 1992. In 2006, study participants were followed-up to assess the long-term effect of the interventions. The primary outcomes were diabetes incidence, CVD incidence and mortality, and all-cause mortality. Compared with control participants, those in the combined lifestyle intervention groups had a 51% lower incidence of diabetes (hazard rate ratio [HRR] 0.49; 95% CI 0.33-0.73) during the active intervention period and a 43% lower incidence (0.57; 0.41-0.81) over the 20 year period, controlled for age and clustering by clinic. The average annual incidence of diabetes was 7% for intervention participants versus 11% in control participants, with 20-year cumulative incidence of 80% in the intervention groups and 93% in the control group. Participants in the intervention group spent an average of 3.6 fewer years with diabetes than those in the control group. There was no significant difference between the intervention and control groups in the rate of first CVD events (HRR 0.98; 95% CI 0.71-1.37), CVD mortality (0.83; 0.48-1.40), and all-cause mortality (0.96; 0.65-1.41), but our study had limited statistical power to detect differences for these outcomes. Group-based lifestyle interventions over 6 years can prevent or delay diabetes for up to 14 years after the active intervention. However, whether lifestyle intervention also leads to reduced CVD and mortality remains unclear.
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              Effect of intensive insulin therapy on beta-cell function and glycaemic control in patients with newly diagnosed type 2 diabetes: a multicentre randomised parallel-group trial.

              Early intensive insulin therapy in patients with newly diagnosed type 2 diabetes might improve beta-cell function and result in extended glycaemic remissions. We did a multicentre, randomised trial to compare the effects of transient intensive insulin therapy (continuous subcutaneous insulin infusion [CSII] or multiple daily insulin injections [MDI]) with oral hypoglycaemic agents on beta-cell function and diabetes remission rate. 382 patients, aged 25-70 years, were enrolled from nine centres in China between September, 2004, and October, 2006. The patients, with fasting plasma glucose of 7.0-16.7 mmol/L, were randomly assigned to therapy with insulin (CSII or MDI) or oral hypoglycaemic agents for initial rapid correction of hyperglycaemia. Treatment was stopped after normoglycaemia was maintained for 2 weeks. Patients were then followed-up on diet and exercise alone. Intravenous glucose tolerance tests were done and blood glucose, insulin, and proinsulin were measured before and after therapy withdrawal and at 1-year follow-up. Primary endpoint was time of glycaemic remission and remission rate at 1 year after short-term intensive therapy. Analysis was per protocol. This study was registered with ClinicalTrials.gov, number NCT00147836. More patients achieved target glycaemic control in the insulin groups (97.1% [133 of 137] in CSII and 95.2% [118 of 124] in MDI) in less time (4.0 days [SD 2.5] in CSII and 5.6 days [SD 3.8] in MDI) than those treated with oral hypoglycaemic agents (83.5% [101 of 121] and 9.3 days [SD 5.3]). Remission rates after 1 year were significantly higher in the insulin groups (51.1% in CSII and 44.9% in MDI) than in the oral hypoglycaemic agents group (26.7%; p=0.0012). beta-cell function represented by HOMA B and acute insulin response improved significantly after intensive interventions. The increase in acute insulin response was sustained in the insulin groups but significantly declined in the oral hypoglycaemic agents group at 1 year in all patients in the remission group. Early intensive insulin therapy in patients with newly diagnosed type 2 diabetes has favourable outcomes on recovery and maintenance of beta-cell function and protracted glycaemic remission compared with treatment with oral hypoglycaemic agents.
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                Author and article information

                Affiliations
                [ 1 ]Department of Endocrinology, The Third Affiliated Hospital of Sun Yat‐sen University, Guangzhou, China
                Author notes
                [* ]Corresponding author. Jianping Weng Tel.: +86‐20‐85252107 Fax: +86‐20‐85252107 E‐mail address: wjianp@ 123456mail.sysu.edu.cn
                Journal
                J Diabetes Investig
                J Diabetes Investig
                10.1111/(ISSN)2040-1124
                JDI
                ST
                Journal of Diabetes Investigation
                Blackwell Publishing Ltd (Oxford, UK )
                2040-1116
                2040-1124
                27 July 2010
                19 October 2010
                : 1
                : 5 ( doiID: 10.1111/jdi.2010.1.issue-5 )
                : 170-171
                JDI53
                10.1111/j.2040-1124.2010.00053.x
                4020717
                © 2010 Asian Association for the Study of Diabetes and Blackwell Publishing Asia Pty Ltd
                Counts
                Figures: 2, Tables: 0, Pages: 2
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                2.0
                October 2010
                Converter:WILEY_ML3GV2_TO_NLM version:3.9.3 mode:remove_FC converted:04.02.2014

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