Elsevier

The Lancet

Volume 375, Issue 9712, 30 January–5 February 2010, Pages 408-418
The Lancet

Seminar
Diabetes in Asia

https://doi.org/10.1016/S0140-6736(09)60937-5Get rights and content

Summary

Prevalence of type 2 diabetes has rapidly increased in native and migrant Asian populations. Diabetes develops at a younger age in Asian populations than in white populations, hence the morbidity and mortality associated with the disease and its complications are also common in young Asian people. The young age of these populations and the high rates of cardiovascular risk factors seen in Asian people substantially increase lifetime risk of cardiovascular disease. Several distinctive features are apparent in pathogenetic factors for diabetes and their thresholds in Asian populations. The economic burden due to diabetes at personal, societal, and national levels is huge. National strategies to raise public awareness about the disease and to improve standard of care and implementation of programmes for primary prevention are urgently needed.

Introduction

Diabetes and associated complications pose a major health-care burden worldwide and present major challenges to patients, health-care systems, and national economies (panel 1). WHO estimates that between 2000 and 2030, the world population will increase by 37% and the number of people with diabetes will increase by 114%.1 Asia is the major site of a rapidly emerging diabetes epidemic.1, 2 Conservative estimates based on population growth and ageing and rate of urbanisation in Asia show that India and China will remain the two countries with the highest numbers of people with diabetes (79·4 million and 42·3 million, respectively) by 2030.1 Additionally, among the top ten countries, four more are in Asia—Indonesia, Pakistan, Bangladesh, and the Philippines. Prevalences are probably underestimated because changes due to other diabetes-related risk factors have not been considered.

The world population is expected to reach 7·9 billion by 2025. Six countries account for almost 50% of the population increase every year; among them, three Asian countries, India, China, and Pakistan, contribute 21%, 12%, and 5%, respectively.3 Asian populations are racially heterogeneous and have differing demographic, cultural, and socioeconomic characteristics. Differences in genetic and environmental attributes affecting diabetogenesis could also be heterogeneous. We discuss type 2 diabetes in Asian countries other than Japan.

Section snippets

Epidemiology

In 2003, an estimated 194 million adults worldwide had diabetes (5·1%) and 314 million people had impaired glucose tolerance (8·2%).4 These prevalences increased to 6·0% and 7·5% in 2007 and are predicted to increase to 7·3% and 8·0% by 2025.2 380 million people are expected to have diabetes in 2025.2 85–95% of all diabetes cases are of type 2 in developed countries and this percentage is even higher in developing countries.2 Roughly 80% of people with diabetes are in developing countries, of

Pathophysiology

Asian populations are multiracial and have multifactorial causes of type 2 diabetes. The mechanisms underlying development of the disease are complex and varied, even within these populations. The major aetiological components of type 2 diabetes are impaired insulin secretion and impaired insulin action, which are aggravated by the presence and degree of glucotoxicity. Both components might also be genetically predetermined. Lipotoxicity plays an important part in causing insulin resistance and

Genetic factors

Type 2 diabetes has a strong genetic component and most Asian patients have a first-degree relative with diabetes.48, 49 Much progress has been made in our understanding of the genetics of this disease. Importantly, most of the loci originally associated with diabetes in European populations have been replicated in Asian populations. Whereas monogenic forms of diabetes result from rare genetic mutations with large effects, such as those seen in maturity-onset diabetes of young people,50 most

Urbanisation and migration

Rates of urbanisation are variable, but substantial increases in urbanisation will occur in most Asian countries5 (table 1). By 2010, the proportion of urbanisation will be more than 50% in Singapore, Korea, Malaysia, the Philippines, and Indonesia, and more than 30% in China, Pakistan, India, and Thailand. The remaining countries (Bangladesh and Sri Lanka) have slow rates of urbanisation. Increasing urbanisation is due to natural population growth and expansion of urban areas. It is also

Age

The results of the Diabetes Epidemiology Collaborative Analysis of Diagnosis Criteria in Asia (DECODA) study have shown several variations in age-specific prevalence within Asian populations.83 In Indian populations, the prevalence of diabetes peaks at 60–69 years of age, whereas in Chinese populations it peaks at age 70–89 years. Indian people have higher age-specific prevalence and higher prevalence of impaired glucose regulation at a younger age than do Chinese people.83 Findings from India,6

Adipose tissue and insulin resistance

The prevalence of insulin resistance and metabolic syndrome is high in Asian people.95 Features of insulin resistance are manifested in children and adolescents of south Asian origin even in the absence of obesity.46, 47 Obesity is a major determinant of type 2 diabetes, and is associated with many metabolic aberrations that impair insulin sensitivity.96, 97 These abnormalities include excess lipolysis causing increased concentrations of non-esterified fatty acids and triglycerides in blood and

Intrauterine environment and imprinting

Intrauterine and postnatal environment can affect future risk of diabetes and cardiovascular disease via fetal programming.117 The thrifty genotype and thrifty phenotype hypotheses seem to apply to Asian populations. Maternal undernutrition, infant's low birthweight, and rapid postnatal child growth are all associated with increased risk of diabetes in offspring, and these factors might be especially relevant to developing countries such as India88 and China.118 Additionally, offspring of women

Diagnosis and complications

The latest WHO report on the definition and diagnosis of diabetes recommended that the oral glucose tolerance test be retained as a diagnostic test.120 The need to identify postprandial hyperglycaemia seems especially relevant in Asian populations. In the DECODA study,83 more than half the patients with diabetes had isolated postprandial hyperglycaemia, which is also a powerful predictor of cardiovascular disease and premature death.121 In Asian populations, fasting plasma glucose83, 122 and

Health-care outcome

The diabetes health-care situation is similar across most developing countries. Economic disparities, scarcity of adequate health-care facilities, and low educational status prevalent in these countries pose major hurdles for achievement of optimum glycaemic control. The cost of diabetes care is high and is increasing worldwide. The economic burden is very high, especially in developing countries, and more so in the lower economic groups, who spend 25–34% of their income on diabetes care.131,

Prevention and future action

Prevention of obesity and diabetes is more cost effective than is the treatment of complications resulting from diabetes. A 2–3% reduction in energy intake or an extra 10–15 min of walking each day could offset weight gain in roughly 90% of the population in China.85 Lifestyle intervention can have a sustained benefit, with a 43% reduction in incidence of diabetes over a 20-year period.135 The results of a primary prevention study in India have also shown that lifestyle modification is

Search strategy and selection criteria

We searched PubMed using the keywords “diabetes in developing countries”, “diabetes in Asia”, “type 2 diabetes in Asia”, “risk of diabetes in Asian populations”, “obesity and diabetes in Asians”, “genetics of type 2 diabetes in Asian populations”, “Chinese”, “polymorphisms”, and “adipokines and diabetes in Asian populations”. Peer-reviewed reports published between 1980, and 2009, in English and Chinese were included. Several International Diabetes Federation and WHO publications were

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