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diabetes_care 9/30/05 12:40 Page 29 CLINICAL CARE: DIABETES Diabetes care in China: meeting the challenge CHANGYU PAN PHYSICIAN, DEPARTMENT OF ENDOCRINOLOGY, PLA GENERAL HOSPITAL, BEIJING,CHINA Abstract In both human and economic terms, diabetes is becoming one of the most serious and costly health conditions worldwide. Economic development, bringing changes from a traditional to a modernized lifestyle, is driving a huge increase in the number of people with obesity-related type 2 diabetes in China. The extraordinary size of the problem is worrying; if current trends continue, diabetes will become a massive health burden in China. In this article, Changyu Pan looks at the status of diabetes care in China and highlights the need for regional and national initiatives to increase awareness amongst the general population of the risk factors for diabetes, and thus prevent a further rapid increase in the prevalence of the condition Since the early 1990s, China’s soaring economy has apparently raised the population’s quality of life. However, as China modernizes, Chinese people eat more and exercise less. Huge numbers of people in China, who previously walked or cycled, now drive cars or ride motorcycles; nowadays there are more high-calorie, high-fat, processed foods on dining tables in China. Such factors have triggered a rapid increase in the prevalence of obesity-driven diabetes in the country. How many millions have diabetes? Over the past two decades, the number of people in China with diabetes or the pre-diabetes condition impaired glucose tolerance has increased dramatically. The data presented 10 years ago from a national diabetes survey of 19 provinces – including cities and rural areas – demonstrated that the overall prevalence of diabetes and impaired glucose tolerance in people in China aged 25-64 years was 2.5% and 3.2% respectively. This prevalence is about three times higher than it was 20 years ago. It was estimated that the diabetes prevalence in rural areas was around half that of urban areas. Compared with those of developed countries, these prevalence figures for China appear to be low. The estimates may in fact be artificially reduced due to the differences in diagnostic methods and criteria, and an overall lack of data in the country. China has a huge population, estimated at 1.3 billion, with the number of adults with diabetes estimated at about 30 million. This total number of people with diabetes in China may be the largest diabetes population in the world. Indeed, two years ago, with a diabetes population of 23.8 million, China was second in the world to India (35.5 million). 1 Twenty years from now, this figure is expected to rise above 46 million. 1 These numbers are alarming; they will inevitably impact on society and individuals in China unless drastic country-wide measures are taken. The health-care and financial costsof the rise in the number of people with diabetes complications are compounded by the psycho-social burden to people with the condition. Theirs is a life-long chronic condition that requires around-the-clock self-care to optimize daily and long-term health outcomes and quality of life. Moreover, not only is there an increase in diabetes prevalence in China, the number of diabetes-related deaths is also on the rise. Data from the Annual Statistical Reports of Death, Injuries and Causes of Death 2002 revealed a three-fold increase in the mortality rate per 100 000 people – from 5.1 per 100 000, 20 years ago, to 15.4, five years ago. 2 Limited resources With a limited infrastructure for diabetes care, China is illequipped to deal with this pandemic, particularly in the context of continued rapid urbanization. Lifestyle-driven conditions such as diabetes are likely to have a greater negative impact on societies in which the unhealthy lifestyle changes that are forced by economic development continue to occur at a much faster rate than in other countries. According to health-economic studies, the delivery of health care varies considerably from one setting to another, depending on the resources available, training and interest in diabetes amongst healthcare professionals, and the ability of people to pay for treatment where necessary. The disparity between rural and urban health in China has been exacerbated by increased privatization. In most rural areas, healthcare has shifted to a fee-for-service system. While the number of urban healthcare centres is increasing, people in the rural areas have experienced reduced access to medical Vol. 41 No. 3 | World Hospitals and Health Services | 29
diabetes_care 9/30/05 12:40 Page 30 CLINICAL CARE: DIABETES care. In fact, the number of village health officials has been reduced by up to a third; the number of healthcare centres has decreased significantly in the townships and villages. The status of care Given the limited data available on diabetes epidemiology (the last nationwide study was performed over a decade ago), it is essential that a reliable overview be obtained of the status of diabetes care in China. This will form the basis for any initiatives to reduce the medical and socio-economic burden of diabetes complications. A contribution to this knowledge was made recently by the Diabcare-China 2003 study. As part of the Diabcare-Asia 2003 study, this Chinese research collected data from a cohort of around 2,700 people with diabetes at 30 specialist centres across China. Status of people with diabetes Of the people who participated in the study, around 97% had type 2 diabetes. More than half of the people with diabetes had poor blood glucose control (glycaemic control). Only half of the people had an HbAlc measurement (an indicator of long-term blood glucose levels) during the previous 12 months. Furthermore, about three-in-five people with diabetes had poor metabolic control, showing above-average levels of triglycerides and LDL cholesterol (so-called “bad” cholesterol). The American Association of Clinical Endocrinologists has declared that, as well as intensive glycaemic control, optimal diabetes care must also include proper nutrition, weight control, physical activity programmes and smoking cessation. 3 It was therefore encouraging to find that a good proportion of the people with diabetes in this study were following a controlled diet (77%) and exercising regularly (62%). In this study, 65% of people with diabetes had had an eye examination in the previous 12 months; 31% underwent foot examinations. Psycho-social well-being and quality of life Interestingly, responses to questions on psycho-social wellbeing indicated that many people with diabetes either all or most of the time felt “cheerful and in good spirits” (67%), “calm and relaxed” (66%) and “active and vigorous” (53%). There was a statistically significant relationship between glycaemic control and psycho-social well-being. The study outcomes also revealed that more than half of the people with diabetes rated their quality of life to be good or at least acceptable, with 65% agreeing that they felt that their diabetes is “well regulated”. Again, a statistically significant correlation was seen between glycaemic control and quality of life. These findings underline the importance of identifying and developing models and systems of care that better support people with diabetes to achieve a desirable quality of life. Education and awareness in the community There is a lack of diabetes awareness in countries around the world; but this lack of education has a tremendous significance in China, with its huge population. The low diabetes awareness among the general public is compounded by misunderstandings around various aspects of diabetes care, such as the use of insulin. Indeed, only a decade ago, it was unthinkable that people with diabetes could inject themselves with insulin. The lack of diabetes awareness in China results in relatively low rates of diagnosis – about 10%-15% for people with type 2 diabetes, compared with 50% in Europe. In order to address this gap, many diabetes education programmes have been initiated for healthcare professionals. It is estimated that during the past five years, 3000-5000 doctors in 300 provinces in China have received diabetes education. Nurse education programmes are increasing also. Encouragingly, there is growing recognition in China of the need for healthcare providers to work together in a teambased approach to care. Given the size of the population, the growing body of evidence that the cost of diabetes to societies can be reduced through the provision of diabetes education is particularly relevant in China. In an effort to resolve widely held misunderstandings, between 1997 and 2004, 490 lectures were held at the People’s Liberation Army (PLA) General Hospital in Beijing, offering diabetes education to over 15,000 people with the condition. The objective of these events is to encourage a greater degree of self-care for people with diabetes and nthus reduce disabling complications. A person has impaired glucose tolerance (IGT) when their Triglycerides in the blood come from fats eaten in foods but are also made in the body from other energy sources such as carbohydrates. Any calories consumed in a meal which are excess to requirements are converted into triglycerides and transported to fat cells to be stored. Excess triglycerides in the blood are linked to cardiovascular disease and other diseases of the arteries. Elevated triglycerides may be a consequence of inadequately controlled diabetes. blood glucose levels are higher than normal, but below the level of a person with diabetes. Most people with IGT are at increased risk for developing type 2 diabetes. In addition, the Chinese Ministry of Health, in accordance with the guidelines of the International Diabetes Federation- Western Pacific Region and the American Diabetes Association, launched in 2003 their Guidelines for Diabetes Prevention and Treatment, which were designed to reduce the rates of death and disability due to diabetes. In the guidelines, emphasis has been placed on regular screening, lifestyle modifications supported by dietary and behavioural advice, and drug therapy options. Country-wide interventions The Chinese media has been used to enhance the public awareness of diabetes. In 2002, television programmes 30 | World Hospitals and Health Services | Vol. 41 No. 3
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