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Diabetes in Asia: Epidemiology, Risk Factors, and Pathophysiology

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Diabetes in Asia: Epidemiology, Risk Factors, and Pathophysiology REVIEW Diabetes in Asia Epidemiology, Risk Factors, and Pathophysiology Juliana C. N. Chan, MBChB, MD Context With increasing globalization and East-West exchanges, the increasing epidemic Vasanti Malik, MSc of type 2 diabetes in Asia has far-reaching public health and socioeconomic implications. Weiping Jia, MD, PhD Objective To review recent data in epidemiologic trends, risk factors, and compli- cations of type 2 diabetes in Asia. Takashi Kadowaki, MD, PhD Evidence Acquisition Search of MEDLINE using the term diabetes and other rel- Chittaranjan S. Yajnik, MD, PhD evant keywords to identify meta-analyses, systematic reviews, large surveys, and co- Kun-Ho Yoon, MD hort studies. Separate searches were performed for specific Asian countries. The re- Frank B. Hu, MD, PhD view was limited to English-language articles published between January 1980 and March 2009; publications on type 1 diabetes were excluded. NCE CONSIDERED A DIS- Evidence Synthesis The prevalence of diabetes in Asian populations has increased ease of the West, type 2 rapidly in recent decades. In 2007, more than 110 million individuals in Asia were liv- diabetes is now a global ing with diabetes, with a disproportionate burden among the young and middle aged. health priority.1 The Inter- Similarly, rates of overweight and obesity are increasing sharply, driven by economic Onational Diabetes Federation has pre- development, nutrition transition, and increasingly sedentary lifestyles. The “meta- dicted that the number of individuals bolically obese” phenotype (ie, normal body weight with increased abdominal adi- with diabetes will increase from 240 posity) is common in Asian populations. The increased risk of gestational diabetes, com- million in 2007 to 380 million in 2025, bined with exposure to poor nutrition in utero and overnutrition in later life in some with 80% of the disease burden in low- populations, may contribute to the increasing diabetes epidemic through “diabetes 2 begetting diabetes” in Asia. While young age of onset and long disease duration place and middle-income countries. More Asian patients with diabetes at high risk for cardiorenal complications, cancer is emerg- than 60% of the world’s population with ing as an important cause of morbidity and mortality. diabetes will come from Asia, because Conclusions Type 2 diabetes is an increasing epidemic in Asia, characterized by rapid it remains the world’s most populous rates of increase over short periods and onset at a relatively young age and low body region. The number of individuals with mass index. Prevention and control of diabetes should be a top public health priority diabetes and impaired glucose toler- in Asian populations. ance (IGT) in each Asian country will JAMA. 2009;301(20):2129-2140 www.jama.com increase substantially in coming de- cades (TABLE 1).1 Unlike in the West, creased health care expenditure and lost plications of type 2 diabetes in Asian where older populations are most af- productivity.3 However, there is consid- populations and discuss risk factors im- fected, the burden of diabetes in Asian erable heterogeneity in ethnicity, cul- plicated in this epidemic. countries is disproportionately high in tures, and stages of socioeconomic de- young to middle-aged adults (FIGURE).2 velopment within Asia, all of which affect EVIDENCE ACQUISITION Asia has undergone marked eco- clinical presentation, management, and We searched MEDLINE using the term nomic and epidemiologic transition in re- prevention of diabetes. In this article, we diabetes and other relevant keywords cent decades. Increasing globalization review epidemiologic trends and com- (diabetes mellitus, metabolic syndrome, and East-West exchanges have been ac- Author Affiliations: Hong Kong Institute of Diabetes Tokyo, Japan (Dr Kadowaki); Diabetes Unit, KEM Hos- companied by increasing population and Obesity, Department of Medicine, and Li Ka Shing pital Research Center, Pune, India (Dr Yajnik); and De- movements, changes in food supply and Institute of Health Sciences, The Chinese University partment of Endocrinology and Metabolism, Seoul St. dietary patterns, technology transfer, and of Hong Kong, Hong Kong SAR, China (Dr Chan); De- Mary’s Hospital, The Catholic University of Korea, partments of Nutrition and Epidemiology, Harvard Seoul, Republic of Korea (Dr Yoon). cultural admixtures. In the recent World School of Public Health, and Channing Laboratory, De- Corresponding Authors: Juliana C. N. Chan, MBChB, Economics Forum Report, the increas- partment of Medicine, Brigham and Women’s Hos- MD, Department of Medicine and Therapeutics, The pital, and Harvard Medical School, Boston, Massa- Chinese University of Hong Kong, The Prince of Wales ing burden of chronic diseases includ- chusetts (Drs Malik and Hu); Department of Hospital, Shatin, Hong Kong SAR, China (jchan@cuhk ing diabetes was highlighted as a major Endocrinology and Metabolism, Shanghai Jiaotong Uni- .edu.hk) and Frank B. Hu, MD, PhD, Departments of versity Affiliated Sixth People’s Hospital, Shanghai, Nutrition and Epidemiology, Harvard School of Pub- global risk predicted to cause substan- China (Dr Jia); Department of Metabolic Diseases, lic Health, 665 Huntington Ave, Boston, MA 02115 tial financial loss resulting from in- Graduate School of Medicine, University of Tokyo, ([email protected]). ©2009 American Medical Association. All rights reserved. (Reprinted) JAMA, May 27, 2009—Vol 301, No. 20 2129 Downloaded From: http://jamanetwork.com/pdfaccess.ashx?url=/data/journals/jama/4465/ by a Harvard University User on 02/10/2017 DIABETES EPIDEMIC IN ASIA diabetic complications, clinical studies, persistent organic pollutants, environ- Separate searches were performed for registry, prospective cohorts, cross- mental toxins, pollutants, urbanization, specific Asian countries. We limited the sectional cohorts, case-control, cohorts, acculturation, iron, iron overload, birth- searches to English-language articles epidemiology, prevalence, incidence, weight, body mass index, waist circum- published between January 1980 and causes, causation, diagnosis, prognosis, ference, central obesity, waist hip ratio, March 2009; non–English-language socioeconomic status, ethnicity, depres- exercise, physical activity, risk score, risk studies were excluded, because the sion, psychosocial stress, smoking, hae- equation, risk prediction, adolescent obe- quality of these studies is difficult to moglobinopathy, thalassaemia, visceral sity, gestational diabetes, inflammation, evaluate. Publications on type 1 diabe- fat, hepatitis, C reactive proteins, infec- nutritional transition, sleep, television tes were excluded. High-priority ar- tions, tobacco, alcohol, dietary factors, watching). ticles included meta-analyses, system- atic reviews, large surveys, and cohort studies. Table 1. Top 10 Countries in Asia With the Highest Number of Persons With Type 2 Diabetes and Impaired Glucose Tolerance in the Age Group 20 to 79 Years in 2007 and Projected Data in 2025a EVIDENCE SYNTHESIS Impaired Glucose Epidemiologic Trends Diabetes Tolerance of Diabetes in Asia Country 2007 2025 2007 2025 In this global epidemic of diabetes, India 40 850 69 882 35 906 56 228 Asian countries undergoing eco- China 39 809 59 270 64 323 79 058 nomic and nutritional transitions Japan 6978 7171 12 891 12 704 have experienced a particularly Bangladesh 3848 7416 6819 10 647 notable increase (TABLE 2).4-46 In Korea 3074 4163 3224 4240 China, the prevalence of diabetes Thailand 3162 4660 1896 2399 increased from 1% in 1980 to 5.5% Philippines 3055 5572 4410 7582 in 2001,7 with much higher rates in Indonesia 2887 5129 14 144 20 597 urban areas such as Shanghai.51 Malaysia 1530 2743 2915 4442 Nearly 10% of Chinese adults resid- Vietnam 1294 2500 1175 1902 ing in affluent regions such as Hong Subtotalb Kong and Taiwan have diabetes.52 Western Pacific 66 993 99 401 111 898 142 693 Among individuals with diabetes, Southeast Asia 46 543 80 341 45 169 70 525 Grand total Asiab 113 536 179 742 157 067 213 218 two-thirds in Mainland China and a Source: International Diabetes Federation.2 All values are in thousands. one-half in Hong Kong and Taiwan b Includes numbers from Asian countries not shown here. remain undiagnosed.52 Figure. Number of Persons With Diabetes in Different Age Groups and Number of Deaths Attributable to Diabetes in Different Regions of the World in 2007 Diabetes Deaths Attributable to Diabetes, Ages 20-79 Years 40 600 000 Age group, y Men 35 20-39 Women 500 000 40-59 30 60-79 400 000 25 20 300 000 15 No. of Deaths 200 000 10 No. With Diabetes (Millions) 100 000 5 0 0 Africa EMME Europe North SACA SEA Western Africa EMME Europe North SACA SEA Western America Pacific America Pacific Source: International Diabetes Federation.2 EMME indicates Eastern Mediterranean/Middle East; SACA, South America/Central America; SEA, Southeast Asia (com- prises Bangladesh, Bhutan, India, Maldives, Mauritius, Nepal, and Sri Lanka [total population, 770 350 000; estimated prevalence of diabetes in the region, 6%]). Western Pacific comprises Australia, Brunei Darussalam, Cambodia, China, Hong Kong, Macau, Cook Islands, Fiji, French Polynesia, Guam, Indonesia, Japan, Kiribati, Korea (Democratic People’s Republic of ), Korea (Republic of ), Lao People’s Democratic Republic, Malaysia, Marshall Islands, Micronesia (Federal States of ), Mongolia, Myanmar, Nauru, New Caledonia, New Zealand, Niue, Palau, Papua New Guinea, Philippines, Samoa, Singapore, Solomon Islands, Taiwan, Thailand, Timor-Leste, Tokelau,
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