Series

Diabetes in China 1 Diabetes in China: a societal solution for a personal challenge Juliana C N Chan, Yuying Zhang, Guang Ning

China has a large burden of diabetes: in 2013, one in four people with diabetes worldwide were in China, where 11·6% of adults had diabetes and 50·1% had prediabetes. Many were undiagnosed, untreated, or uncontrolled. This epidemic is the result of rapid societal transition that has led to an obesogenic environment against a backdrop of traditional lifestyle and periods of famine, which together puts Chinese people at high risk of diabetes and multiple morbidities. Societal determinants including social disparity and psychosocial stress interact with factors such as lowgrade infection, environmental pollution, care fragmentation, health illiteracy, suboptimal self-care, and insufficient community support to give rise to diverse subphenotypes and consequences, notably renal dysfunction and cancer. In the China National Plan for Non-Communicable Disease Prevention and Treatment (2012–15), the Chinese Government proposed use of public measures, multisectoral collaborations, and social mobilisation to create a healthenabling environment and to reform the health-care system. While awaiting results from these long-term strategies, we advocate the use of a targeted and proactive approach to identify people at high risk of diabetes for prevention, and of private–public–community partnerships that make integrated care more accessible and sustainable, focusing on registry, empowerment, and community support. The multifaceted nature of the societal and personal challenge of diabetes requires a multidimensional solution for prevention in order to reduce the growing disease burden.

Introduction An epidemic is deemed to occur when the number of new cases of a disease in a given human population and during a given period substantially exceeds that expected from past experience. It is typically caused by rapid changes in the ecology of the host population resulting in biological maladaptation with clinical manifestation. Although this concept is widely recognised of communicable diseases—for example, overcrowding and tuberculosis, water contamination and cholera outbreaks—the effects of environments and settings on the cognitive–psychological–behavioural responses of an individual resulting in biological changes and disease manifestation must be taken into account in pursuit of a holistic solution to tackle the current epidemic of type 2 diabetes and non-communicable diseases (NCDs).1 China is home to 20% of the world’s population. Extreme hardship was experienced in the first 30 years of establishment of the present government.2 With globalisation and political changes, the increasing east– west exchanges have led to rapid socioeconomic, technological, and cultural transitions in China. Although these transitions have alleviated poverty, they have had substantial health consequences. Compared with a rate of 0·9% in 1980,3 the prevalence of diabetes had increased to 11·6% in the 2010 national survey (table).4 That survey used the 2010 American Diabetes Association diagnostic criteria (75 g oral glucose tolerance test and HbA1c) and included nearly 100 000 people representative of the Chinese adult population. All ages were affected, with 80·8% of people older than 60 years and 48·6% of those aged 18–39 years having diabetes or prediabetes. Only 30·1% of those with diabetes had been previously diagnosed; of them, only 25·8% had been treated, and diabetes was controlled in only 39·7% of those treated.4

In a prospective community-based survey in Shanghai,5 prediabetes was associated with ten times higher risk of incident diabetes than was normal glucose tolerance. In that 3-year follow-up study, the annual incidence of diabetes by 1997 American Diabetes Association diagnostic criteria was less than 1% in individuals with normal glucose tolerance, 8% in those with prediabetes, 10% in those with isolated impaired fasting glucose (IFG), 6% in those with isolated impaired glucose tolerance (IGT), and 18% in those with IFG plus IGT.5 Given the high prevalence of diabetes and prediabetes in China, and the close associations between glycaemic indexes (HbA1c and plasma glucose) and multiple morbidities, these figures herald an epidemic of NCDs including but not limited to heart disease, renal failure, and cancer.6 In this Series paper, we provide a historical overview of Chinese people’s traditional lifestyle and the rapid societal transition that has culminated in an obesogenic environment, putting many people, especially the young, old, and socially deprived, at high risk of type 2 diabetes. In the China National Plan for NCD Prevention and Treatment,7 the government advocated the use of policies and mandates to create a health-enabling environment (eg, tobacco control), reform the health-care system (eg, family medicine), and adopt a life-course strategy to prevent NCDs (eg, maternal and child health programmes). While we wait for the results of these long-term strategies, we can learn from the success of introducing midwives to reduce maternal and perinatal mortality and using public notification to control tuberculosis during the period after World War 2. Given the personal and public health implications of diabetes, the use of registries and collaborative care have long been proposed by the International Diabetes Federation

www.thelancet.com/diabetes-endocrinology Published online September, 2014 http://dx.doi.org/10.1016/S2213-8587(14)70144-5

Lancet Diabetes Endocrinol 2014 Published Online September 11, 2014 http://dx.doi.org/10.1016/ S2213-8587(14)70144-5 See Online/Comment http://dx.doi.org/10.1016/ S2213-8587(14)70154-8 This is the first in a Series of three papers about diabetes in China Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China (Prof J C N Chan FRCP, Y Zhang MBBS); Li Ka Shing Institute of Health Sciences, Hong Kong Institute of Diabetes and Obesity, and International Diabetes Federation Centre of Education, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China (Prof J C N Chan); and Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, Shanghai Clinical Center for Endocrine and Metabolic Disease, National Clinical Research Center for Metabolic Diseases, E-Institute of Shanghai Universities, RuiJin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (G Ning MD) Correspondence to: Prof Juliana C N Chan, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China [email protected]

1

Series

Area

N

Age (years)

19803

14 provinces/areas

107 954

≥30

199419*

19 provinces/areas

213 515

2000–0120†

10 provinces/areas

15 540

2007–0821‡

14 provinces/areas

46 239

≥20

9·7%

20104§

National

98 658

≥18

11·6%

25–64 35–74

Diabetes (%)

IGT (%)

IFG (%)

HbA1c 5·7–6·5% Prediabetes (%)

0·9%

0·8%

..

..

..

2·5%

3·2%

..

..

..

5·5%

.. 12·9% (men), 12·6% (women) 8·3%

7·3% 5·1% (men), 3·9% (women) 27·2%

.. .. 35·4%

.. 15·5% 50·1%

Data are percentages unless otherwise stated. IGT=impaired glucose tolerance. IFG=impaired fasting glucose. *Diabetes was diagnosed according to 1985 WHO criteria: self-reported history of diabetes or fasting plasma glucose (FPG) ≥7·8 mmol/L or 2 h plasma glucose ≥11·1 mmol/L on 75 g oral glucose tolerance test; IGT was defined as FPG

Diabetes in China: a societal solution for a personal challenge.

China has a large burden of diabetes: in 2013, one in four people with diabetes worldwide were in China, where 11·6% of adults had diabetes and 50·1% ...
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