Asia's drive for better diabetes control
More than 4,000 experts in diabetes research and medicine from all over Asia met last month at a conference in Kyoto, Japan, where a new mandate called the Kyoto Declaration on Diabetes was drawn up. The mission: to eliminate the disease in Asia.
The fourth Asian Association for the Study of Diabetes (AASD) scientific meeting, jointly held with the ninth International Diabetes Federation Western Pacific Region(IDF-WPR) Congress, saw speakers emphasise the importance of research specific to the region and how gains in diabetes care must be made for the sake of Asia's health.
The AASD executive board made a strong appeal for prioritising science-navigated care and research in the region. "Diabetes in Asia today is as big and uncontrollable as a tsunami, and being from Japan - I know exactly what a tsunami wave feels like," said Professor Nigishi Hotta, president of this year's meeting and editor-in-chief of the Journal of Diabetes Investigation, in his opening address.
It's important to distinguish between diabetes care in Asia and the rest of the world. The highest prevalence of diabetes is in Asia, and because of diverse ethnicities and cultures, diabetes is manifested in different forms.
According to last year's Diabetes Atlas published by the IDF, 366 million people globally are living with diabetes, and the number is projected to rise to more than 565 million by 2030. East and Southeast Asia are the regions with the highest number of people with diabetes, where about 100 million people now have the disease. Type-2 diabetes, also called non-insulin-dependent diabetes, accounts for at least 90 per cent of all cases in Asia.
This statistic is coupled with the perplexing fact that the number of diabetes patients in Asia is rising even more rapidly than in other parts of the world, and the prevalence of diabetes at younger ages is becoming more prominent. Undiagnosed or poorly cared for diabetes can lead to cardiovascular disease, blindness, kidney failure and lower limb amputation.
But current clinical practice guidelines for diabetes are generated in the West - primarily from the American Diabetes Association and the European Association for the Study of Diabetes. Dr Yutaka Seino, chair of the IDF-WPR, has put in place a plan of action to tailor current guidelines to Asian patients.
In the West, it is generally accepted that environmental factors such as food intake and lower levels of exercise play an important role in type-2 diabetes. Most white people with type-2 diabetes are either overweight or obese. In comparison, most Indian diabetics are of normal weight but are metabolically obese. They have higher body fat, visceral fat, a larger waist circumference and are profoundly insulin resistant.
"In East Asia, 3 per cent of the population is obese, but this doesn't mean diabetes doesn't exist; it means that even if you're not obese, you are still at risk," says Seino.
Many researchers believe most East Asians are challenged by low insulin secretion where obesity may not even play a role. Many patients are diagnosed with diabetes in their 20s and 30s, with a type called maturity onset of diabetes in the young (MODY). They are generally not overweight and don't have other risk factors for type-2 diabetes like high blood pressure or abnormal blood fat levels. MODY is difficult to diagnose and can be confused with type-1 diabetes, which is an autoimmune disease that destroys the body's ability to make insulin.
Professor Juliana Chan Chung-ngor, director of the Institute of Diabetes and Obesity at Chinese University, describes this form of diabetes as "the result of swift economic development in a region where low birth weight due to poverty for centuries made an imprint on future generations".
Called the thrifty phenotype hypothesis, this genetic anomaly may be seen in Hong Kong patients when blood sugar rises sharply after a meal, but is normal at non-meal hours or when fasting. This form of diabetes is difficult to detect, especially when the diagnostic test called HbA1c - the gold standard in the West - fails to diagnose Asian patients.
"There are not so many studies in this area, so we need to do more research related to the Asian phenotype," says Seino, who has led diabetes research and care in Asia for more than 40 years.
What makes the modification of Western guidelines more complex is that within Asia there are population differences and cultural nuances that require even more specific guidelines tailored for each nation.
Japan has driven diabetes research in the region, but Chan, who is also an AASD executive board member, believes all of Asia needs to work harder and invest in research "because successful outcomes for patients are not being achieved". Chan doesn't deny that diabetes is expensive for governments to tackle, but says diabetes patients are even more expensive to ignore. "There is no system set up to manage chronic illness, and new evidence is needed to provide better models for care," says Chan, adding that Hong Kong is the perfect place to develop best-care prototypes for Asia.
But the progress of care extends beyond science, says IDF president Dr Jean Claude Mbanya. "The world is conscious of diabetes, yes," he says. "Governments are listening, but children are dying in the Pacific islands and Africa because they have no access to care, and in India if you are a woman and you have diabetes, you won't find a husband."
Kyoto was also the city for the 1997 Third Conference of the Parties to the United Nations Framework Convention on Climate Change, at which the Kyoto Protocol - a template for global agreements committed to stabilising greenhouse gas emissions and climate change - was drawn up.
Leaders backing the Kyoto Declaration on Diabetes want Asia to come to terms with the epidemic because, as one conference speaker said: "The risk of ignoring diabetes is as severe as ignoring the impact of climate change."