Mohamad Afif, a 21-year-old new father from Yogyakarta, was diagnosed with diabetes earlier this year. Mayang Kamayang, 23, a cake seller from West Java, found out she had the disease when she was 17. They are among the increasing numbers of people in Southeast Asia diagnosed with diabetes at younger ages. In Indonesia, many young people have diabetes due to unhealthy lifestyles, Afif said. “Not infrequently this disease is due to poor diet and lifestyle,” Kamayang said, although she also estimated nearly half the people she knows with diabetes developed the disease young, due to genetic predisposition. Death by sugar: can Southeast Asia win the war on diabetes? Indonesia is home to nearly 270 million people, making it the world’s fourth-largest nation by population. It is also a young nation: in 2017, about 42 per cent of the population were under the age of 25, and 84 per cent under 55. The percentage of its population with type 2 diabetes – which can largely be prevented or delayed with diet and exercise – has doubled in the past 30 years. An estimated 16 million adults live with type 2 diabetes – more than 3 million of whom are thought to have had early-onset diabetes. “We have recently shown that across Asia, about one in every five people with type 2 diabetes is now diagnosed before the age of 40,” said Ronald Ma, head of diabetes and endocrinology at the Chinese University of Hong Kong. A 2014 study by Indonesia’s National Institute of Health Research and Development found that people of working age were likely to be living with undiagnosed diabetes at a rate nearly twice that of those who had identified the condition. Across Asia, around one in every five people with type 2 diabetes is now diagnosed before the age of 40 Ronald Ma, Chinese University of Hong Kong One of the greatest obstacles to medical care in Indonesia is geography. Accessing well-trained primary care doctors and basic supplies such as insulin and blood-glucose meters can be a challenge on Indonesia’s many rural islands, said Gadjah Mada University medical professor Hari Kusnanto. “We face very difficult problems with distributing doctors in remote areas,” he said, adding that the government should provide incentives for doctors to relocate there. While the government has been working to increase the accessibility of well-trained doctors and basic medication in rural parts of the country, Kusnanto said more can be done – including an emphasis on routine exercise and healthy diets in school health programmes. The current lack of access to health care makes early detection – essential for preventing or delaying the onset of type 2 diabetes – nearly impossible. When patients turn up at a clinic, they are often already experiencing advanced symptoms, he said. Insulin is not generally available at most medical clinics in Indonesia, though metformin, an oral tablet used in diabetes treatment, is more widely available, according to the World Health Organisation. Both drugs are imported, raising costs and reinforcing the logistical challenges of distribution. How to turn your life around and get healthier. The good thing is, it’s never too late, say experts Just half of public primary care facilities, known locally as puskesmas , have the capacity to conduct blood glucose tests, according to a 2014 World Bank survey – and doctors are unlikely to perform them unless a patient is overweight. “Otherwise, there is no suspicion that a young person could have diabetes, and the doctors might not think to test for it,” Kusnanto said. Data from Euromonitor International indicates the volume of confectionery products sold in Indonesia – such as processed snacks and biscuits – has increased 13 per cent in the past five years. “Now in the diet we have more sugar, and sugar is less expensive than in years past,” said Kusnanto, who noted the prevalence of sugary snacks and lack of dietary diversity as compounding the problem. “We’re facing more overnutrition than we have in previous decades.” Now in the diet we have more sugar, and sugar is less expensive than in years past Hari Kusnanto, Gadjah Mada University Non-communicable diseases – such as diabetes, heart disease, and respiratory diseases – accounted for 73 per cent of deaths in Indonesia in 2016, according to the World Health Organisation. The World Economic Forum estimates that these diseases will cost the country an estimated US$2.8 trillion from 2012 to 2030 – nearly three times Indonesia’s 2017 GDP. In 2014, McKinsey reported that diabetes cost the Indonesian health care system US$1.6 billion annually – consuming more than 40 per cent of government spending on non-communicable diseases. The rise in patients under 40 with diabetes can have a lasting generational impact, according to research released last year by Ma at the Chinese University of Hong Kong. “Studies from multiple populations have highlighted that children born at times of maternal undernutrition, when exposed to later life overnutrition and excess calories, are at significantly higher risk of diabetes, obesity, and other non-communicable diseases,” he said. “This has been postulated to play an important role in the emerging epidemic of diabetes in Asia.” The Indonesian government is working to strengthen the quality of primary care across the archipelago. Kusnanto at Gadjah Mada said a programme is being developed to send ships with necessary medications directly to remote islands. Are you at risk of diabetes? Chinese AI system could predict disease 15 years in advance “The most important thing is we have to strengthen primary care and teach the primary care providers to prevent diabetes,” Kusnanto said. In a country where half the population uses social media every day, so young people with diabetes have also turned to online communities to help deal with their condition. In Facebook groups like Berdamai Dengan Diabetes (Make Peace with Diabetes), users share recipes and post blood glucose meter readings. “My diabetes community helped me manage,” said Kamayang, the cake seller from West Java. Last year, Indonesia’s largest pharmaceutical company, Kalbe Farma, opened its first biological drug factory east of Jakarta, to produce biosimilar insulin – similar to imported, patented versions of the drug – and reduce the country’s dependence on imported insulin. Insulin costs between US$13 and US$26 for 10 millilitres, depending on whether it is natural or synthetic, according to Health Action International, and Kalbe claims its biosimilar version will be nearly 40 per cent cheaper than imported insulin. A recent study published by The Lancet found that insulin consumption will rise globally by more than 20 per cent in the next decade.