Diabetes Is a Major Public-Health Crisis in China

Veronica Hackethal, MD

September 18, 2014

Type 2 diabetes in China has become a "major public-health crisis," with rates soaring over the past 3 decades, according to a new 3-part series dedicated to diabetes in China and published online in Lancet Diabetes & Endocrinology on September 11.

The number of people in China now living with diabetes — over 100 million — is greater than any other country in the world. As of 2013, 1 in 4 people with diabetes worldwide lived in China. Eleven percent of adults in China have diabetes, while 50% have prediabetes, putting them at risk for major health problems such as cardiovascular disease, chronic kidney disease, and cancer.

Moreover, many people with diabetes remain undiagnosed, untreated, or poorly controlled.

Diabetes also poses a large economic threat to China. National healthcare expenses for diabetes rose from 1.96% of national healthcare expenditure in 1983 to 18.2% in 2007.

Overview of Epidemic: More than 1 in 10 Has Diabetes

The first paper in the series, by Juliana Chan, MD, professor of medicine at the Chinese University of Hong Kong, and colleagues, provides an overview of the epidemic. The prevalence of diabetes in China has risen rapidly, the authors write, from 0.9% in 1980 to 11.6% in 2010, and parallels trends in increased wealth over recent decades.

Rapid societal change and urbanization has created an "obesogenic environment," they explain. Food abundance, decreased physical activity, social disparity, psychosocial stresses, low-grade infection, environmental pollution, tobacco, care fragmentation, health illiteracy, suboptimal self-care, and inadequate community support all play roles.

China has developed long-term strategies to stem the tide of the epidemic through the China National Plan for Non-Communicable Disease Prevention and Treatment (2012–2015), but whether or not this program can make a difference remains to be seen, they say.

Measures to improve the situation include better health infrastructure, tobacco control, targeted diabetes screening, education, outreach and prevention programs, national registries, community-based care-coordination centers, and adopting an emphasis on primary care (still in its infancy in China).

Integrating care through private–public-community partnerships will also be needed to improve accessibility, the authors suggest.

"How we deliver diabetes care needs to change. Administrators need to provide infrastructure and equipment. Career paths need to be encouraged that are conducive to the training and implementation of preventive and holistic care," Dr. Chan emphasized.

"Most importantly, potential payers — government, corporations, insurers — must develop funding schemes and processes to ensure that these high-risk patients have access to education, periodic monitoring, laboratory tests, and essential medications."

Epidemic Caused by "Mismatch" Between Biology and Environment

The second paper takes a closer look at the causes of the diabetes epidemic in China.

"The roughly 10-fold increase in prevalence of type 2 diabetes over the past 3 decades among Chinese adults suggests that the epidemic is driven primarily by unhealthy diet and lifestyle, along with industrialization, urbanization, and increased aging populations," said coauthor Xu Lin, MD, PhD, professor and assistant director at the Institute for Nutritional Sciences, Shanghai Institutes for Biological Sciences.

Increases in the standard of living and a shift away from a more traditional Chinese lifestyle have resulted in a "mismatch" between biology and environment, Dr. Lin and colleagues write. Rapid urbanization — about half of the Chinese population now lives in cities and towns compared with 20% in the late 1970s — combined with reduced physical activity and changes in diet have helped fuel the epidemic.

And both the Western diet, characterized by food abundance, increased consumption of fat, foods from animal sources, and sugar-sweetened beverages, and the traditional Chinese diet, heavily laden with rice and salt, may tip the balance toward the development of diabetes.

Other contributing factors include psychosocial stress, very high rates of smoking (China has over 300 million smokers), exposure to endocrine disruptors like bisphenol A from environmental pollution, and social stratification. In addition, both maternal malnutrition and gestational diabetes (which has also increased in China) could predispose offspring to diabetes.

Genetic heritability of type 2 diabetes likely also plays a large role, but studies have yet to pinpoint specific genetic factors that can explain some of the ethnic differences seen between the epidemic in China and Western countries.

"Overall, China still has a long way to control the epidemic trend of obesity and type 2 diabetes," Dr. Lin emphasized. "Government, public and private enterprises, nutritional and medical researchers, and doctors need to work together, not only to have a better understanding about the key factors contributing to this epidemic, but also to provide better foods, nutrition recommendations and policies, effective public education, intervention strategies, and a friendly environment for healthy living."

Treatment Strategies: Chinese with Diabetes Differ From Westerners

The final paper by Wenying Yang, MD, of China-Japan Friendship Hospital in Beijing, and Jianping Wen, PhD, of Sun Yat-Sen University in Guangzhou, addresses treatment strategies for Chinese patients with diabetes.

Compared with people of European descent, Chinese people have more serious beta-cell dysfunction earlier in the course of the disease. They also develop diabetes at a lower body mass index (BMI) and have a tendency to store visceral fat, which can predispose them to the development of diabetes.

"Chinese patients have clinical characteristics specific to them, and treatment needs to be tailored to these rather than following treatment guidelines in Europe and North America," the authors write.

Key strategies for diabetes management in Chinese patients include preserving beta-cell function and controlling postprandial hyperglycemia, which tends to be more pronounced in Chinese patients.

As in the West, metformin remains first-line therapy according to the Chinese Diabetes Society guidelines. Alternative first-line therapies include insulin secretagogues and alpha-glucosidase inhibitors, with evidence suggesting that the latter, in particular, can be beneficial in Chinese patients. Incretin-based drugs are recommended as second-line therapy, although there is little clinical experience with them in Chinese patients.

In contrast to guidelines in Europe and the United States, Chinese guidelines recommend short-term intensive insulin for those with severe hyperglycemia at diagnosis, in order to preserve beta-cell function.

The authors note that studies in the Chinese population have mostly been short term, and evidence specific to this population is scarce. Longer-term studies are needed to assess the safety and efficacy of antidiabetic agents in Chinese people, they point out.

A linked editorial sums things up:

"In a country that has gone from economic strength to strength, the diabetes epidemic can now be viewed as a measurable hurdle to achievement of further growth and stability….Strategies to prevent and treat diabetes cannot necessarily be imported from other countries — they must take into account the physiological, cultural, and societal features of Chinese patients. Prevention programs, awareness campaigns, and public-health policies uniquely designed for modern-day China will be essential."

Dr. Chan serves as pro bono chief executive officer of the Asia Diabetes Foundation and director of the nonprofit Yao Chung Kit Diabetes Assessment Center. The coauthors have reported no relevant financial relationships. Dr. Lin and coauthors and Drs. Yang and Wen have reported no relevant financial relationships.

 

Lancet Diabetes Endocrinol. Published online on September 11, 2014.Chan abstract, Lin abstract, Yang and Wen abstract, Editorial

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