DI­A­BETES TSUNAMI HITS ASIA

BioSpectrum (Asia) - - Content - Aish­warya Venkatesh aish­warya.venkatesh@mmac­tiv.com (With in­puts from Dr Man­beena Chawla)

Be­tween 1980 and 2014, the global preva­lence of di­a­betes nearly dou­bled from 4.7% to 8.5%. Nearly 60% of world’s di­a­bet­ics live in Asia. Ahead of world di­a­betes day cel­e­brated on Novem­ber 14, BioSpec­trum Asia analy­ses cur­rent sce­nario of di­a­betes in the Asian sub­con­ti­nent and the need to have a na­tional pol­icy for bet­ter di­a­betes man­age­ment.

Be­tween 1980 and 2014, the global preva­lence of di­a­betes nearly dou­bled from 4.7% to 8.5%. Nearly 60% of world’s di­a­bet­ics live in Asia. Ahead of world di­a­betes day ob­served on Novem­ber 14, BioSpec­trum Asia analy­ses cur­rent sce­nario of di­a­betes in the Asian sub­con­ti­nent and the need to have a na­tional pol­icy for bet­ter di­a­betes man­age­ment.

“These two tablets in the morn­ing and these two at night,” said, the doc­tor to a vis­i­bly de­jected Ria Paul (my friend). She was just 32 and has been di­ag­nosed with type 2 di­a­betes. Within sec­onds her en­tire world turned up­side down. Doc­tors handed her a huge sheet with list of do’s and dont’s. No sweets, less white rice, re­duce weight, no junk food, and the list went on and on! She looked at me with deep pain and her eyes mir­rored im­mense fear, sor­row, and worry of her 2 year old.

We came out of the doc­tor room and saw a huge queue, many in their 30s wait­ing in an­tic­i­pa­tion to meet the doc­tor, each with a re­port de­tail­ing their blood work in their hands. That one re­port, which is go­ing to change their lives to­tally from to­day!

Di­a­betes is a chronic dis­ease that oc­curs when either the pan­creas doesn’t pro­duce enough in­sulin (type 1) or when the body can’t ef­fec­tively use the in­sulin it pro­duces (type 2). The dis­ease is so com­mon nowa­days, that ex­perts say the ques­tion now is not ‘will I get di­a­betes,’ it is –‘when will I get di­a­betes.’ Un­less prop­erly man­aged, over time, high blood sugar can se­ri­ously com­pro­mise ev­ery ma­jor or­gan sys­tem in the body, caus­ing heart at­tacks, strokes, nerve dam­age, kid­ney fail­ure, blind­ness, im­po­tence and in­fec­tions that can lead to am­pu­ta­tions.

Asia’s di­a­betes ‘epi­demic’ is grow­ing at ter­ri­fy­ing speed

While statis­tics from in­fec­tious swine flu, Ebola seem stag­ger­ing, there are many non- com­mu­ni­ca­ble dis­eases like di­a­betes which kill thou­sands ev­ery year with­out grab­bing head­lines. Sadly, in­fec­tious dis­eases garner more at­ten­tion from health of­fi­cials, de­spite the piles of death cer­tifi­cates atop their desks at­test­ing to a grow­ing toll from non-com­mu­ni­ca­ble dis­eases such as di­a­betes, can­cer and heart dis­ease. The last three decades have wit­nessed an epi­demic rise in the num­ber of peo­ple with di­a­betes, es­pe­cially type 2 di­a­betes, and par­tic­u­larly in devel­op­ing coun­tries of the Asian re­gion. Out of the 422 mil­lion peo­ple world­wide who have been di­ag­nosed with di­a­betes as of 2014, more than 60% of the cases were from Asia, re­ports the In­ter­na­tional Di­a­betes Fed­er­a­tion (IDF). China alone has recorded 100 mil­lion di­a­bet­ics and 1.5 mil­lion deaths from the con­di­tion, the high­est num­ber of di­a­betes cases and mor­tal­i­ties of any coun­try. By 2030, China is pre­dicted to have 150 mil­lion di­a­bet­ics. In­dia is close be­hind, with roughly 78 mil­lion cases last year, and will have an es­ti­mated 140 mil­lion di­a­bet­ics by 2030, says the IDF. Across Asia, the num­ber of di­a­betes cases is pro­jected to in­crease to more than 320 mil­lion over the next 10 years. Ja­pan’s num­ber of sus­pected di­a­bet­ics hit 10 mil­lion for the first time last year, ac­cord­ing to health min­istry es­ti­mates.

“Although ge­net­i­cally south Asians are sus­cep­ti­ble to di­a­betes and heart dis­ease more than any other eth­nic group, the ma­jor cause ap­pears to be due to chang­ing life style and wrong food im­bibed from child­hood and lack of phys­i­cal ex­er­cise,” points out, Dr Anil Bho­raskar, chair, IDF, South­east Asia. It is es­ti­mated that by 2030, the num­bers will al­most dou­ble up to 140 mil­lion. “Be­hind ev­ery known di­a­betic there will be one un­known di­a­betic, this is like an epi­demic, we call it tsunami of di­a­betes,” he said.

“We are rec­om­mend­ing changes that will make healthy food more af­ford­able. The find­ings of the ICMR-In­dia di­a­betes study, pub­lished in the in­ter­na­tional med­i­cal jour­nal Lancet re­cently, sug­gests that the ur­ban ar­eas of more af­flu­ent states have tran­si­tioned fur­ther along the di­a­betes epi­demic. Less af­flu­ent in­di­vid­u­als have a higher preva­lence of di­a­betes than their more af­flu­ent coun­ter­parts in rich states. We are try­ing to un­der­stand the preva­lence pat­tern of di­a­betes across states since the dis­ease is dis­pro­por­tion­ately catch­ing up with the ur­ban poor in the coun­try’s de­vel­oped states.” - Dr Soumya Swami­nathan, di­rec­tor gen­eral, In­dian Coun­cil of Med­i­cal Re­search (ICMR) and deputy di­rec­tor gen­eral for pro­grammes (DDP) of World Health Or­gan­i­sa­tion (WHO)

Di­abtetes is not new to Asia, books and ref­er­ences in­di­cate that this dis­ease was known for past 3000 years, how­ever, it was rel­a­tively rare and lesser cases were known un­til mid-half of the 20th cen­tury. Change in life­style, diet, ur­ban­iza­tion boom in the lat­ter half of 20th cen­tury has re­sulted in sig­nif­i­cant rise in num­ber of di­a­betic pa­tients. Dr Gampo Dorji, tech­ni­cal of­fi­cer for non­com­mu­ni­ca­ble dis­eases (NCDs) with WHO’s Re­gional Of­fice for South-East Asia, men­tioned in the WHO bul­letin that the life-style changes as­so­ci­ated with rapid ur­ban­iza­tion, mech­a­nized trans­porta­tion, in­creased con­sump­tion of pro­cessed foods and phys­i­cal in­ac­tiv­ity are fu­elling the epi­demic. Ur­ban­iza­tion and in­ter­nal ru­ral to ur­ban mi­gra­tion has re­sulted in sev­eral ad­verse im­pacts; there is de­creased phys­i­cal ac­tiv­ity, diet habits shift towards high-en­ergy foods and body mass in­dex (BMI) and up­per body adi­pos­ity in­creases con­sid­er­ably.

Ex­perts in the busi­ness cau­tion that the dis­ease has now as­sumed epi­demic pro­por­tions killing one per­son ev­ery seven sec­onds. Un­less ma­jor steps are taken to curb this pan­demic, by 2040, di­a­betes will af­fect ap­prox­i­mately 642 mil­lion peo­ple. Dr Sowmya Swami­nathan, di­rec­tor gen­eral, In­dian Coun­cil of Med­i­cal Re­search (ICMR), the apex body in In­dia for the for­mu­la­tion, co­or­di­na­tion and pro­mo­tion of biomed­i­cal re­search, ex­plained, “There are a num­ber of rea­sons lead­ing to di­a­betes. The most im­por­tant be­ing the life­style. ICMR has con­ducted sur­veys in al­most 17 states in In­dia and the data re­veals that the ru­ral ar­eas have a high num­ber of pre- di­a­betic pop­u­la­tion. An­other thing that has been high­lighted is that there is a high calo­rie food in­take in the diet.”

Are Asians at higher risk?

The Asia-Pa­cific re­gion is gen­er­ally con­sid­ered as the epi­cen­tre of the di­a­betes cri­sis. In these coun­tries, peo­ple de­velop the dis­ease ear­lier, get sicker, and die sooner than their coun­ter­parts in de­vel­oped coun­tries. Ex­perts opine that Asia is cur­rently un­der an eco­nomic

“Di­a­betes is the king of dis­ease pro­duc­ing com­pli­ca­tions. It vir­tu­ally af­fects ev­ery or­gan, par­tic­u­larly the blood ves­sels of eyes, kid­ney, heart and the limbs. It also re­duces your im­mu­nity to fight in­fec­tions, in­creases chances of stroke, heart at­tacks and gan­grene of the legs, lead­ing cause of kid­ney fail­ure and blind­ness.” - Dr Anil Bho­raskar, Chair, South­East Asian re­gion, In­ter­na­tional Di­a­betes Fed­er­a­tion (IDF)

boon which is in­creas­ing chronic dis­eases too, in the sub­con­ti­nent. Ear­lier, in Asia’s most pop­u­lous coun­tries, in­clud­ing China and In­dia, a gen­er­a­tion grew up in ru­ral poverty, with too lit­tle to eat and jobs in­volv­ing hard man­ual labour. They now live in ur­ban high-rise apart­ments, with seden­tary jobs, cars, and food en­vi­ron­ments loaded with cheap and con­ve­nient calo­ries. As a re­sult of these changes, mil­lions of peo­ple lifted out of poverty join the boom­ing mid­dle class and find them­selves trapped in the mis­ery of chronic dis­eases.

Apart from these, stud­ies also high­light that Asians have a strong eth­nic and ge­netic pre­dis­po­si­tion for di­a­betes when com­pared with peo­ple of Euro­pean an­ces­try. Asians are more likely to de­velop the dis­ease even at a lower BMI. This means that even though some Asian pop­u­la­tions cur­rently have a lower preva­lence of over­weight and obese in­di­vid­u­als than pop­u­la­tions in the West, they have a dis­pro­por­tion­ately high per­cent­age of peo­ple with di­a­betes. The ad­verse ef­fect of phys­i­cal in­ac­tiv­ity and fatty food are man­i­fested as the in­creas­ing rate of over­weight­ness and obe­sity, even among chil­dren. Dr Anil un­der­scores, “Asians are at very high risk to get di­a­betes even though they may not be over­weight like Cau­casians. An In­dian with a low body weight gen­er­ally has more fat in the ab­domen we call him “THIN FAT IN­DIAN ‘’. It is this ab­dom­i­nal fat- white fat is bad fat, has fewer mi­to­chon­dria as com­pared to the brown fat which is

healthy fat seen in ba­bies. White fat is the dead weight and big­gest risk fac­tor for di­a­betes. Indians have this fat ac­cu­mu­lated around their waist, hence waist line is an im­por­tant marker of di­a­betes and heart dis­ease. It very aptly said ‘Life­line is in­versely pro­por­tional to waist line’”

Is it time to have a na­tional pol­icy to curb di­a­betes?

Cur­rently, only about seven out of 11 coun­tries in the South-East Asia Re­gion have op­er­a­tional poli­cies for di­a­betes, either stand-alone or in­te­grated with other NCD poli­cies, ac­cord­ing to WHO. Dr Swami­nathan, said, “In­dia does not have a pol­icy as such. But there are guide­lines be­ing pro­cesse d. Cur­rently, we have started a pro­gramme on hy­per­ten­sion. So, on the sim­i­lar lines we are plan­ning some­thing for com­bat­ing di­a­betes as well in the fu­ture.”

In its new global re­port re­leased last year, the WHO urged South Asian gov­ern­ments to take “vig­or­ous and con­certed” ac­tion to pre­vent and treat di­a­betes. The health agency em­pha­sized that gov­ern­ments “must” reg­u­late the mar­ket­ing of food to chil­dren as well as en­sure ac­cu­rate food la­belling to help the con­sumers make in­formed health de­ci­sions that can help them avoid di­a­betes.

“Di­a­betes rarely makes head­lines, and yet it will be the world’s seventh largest killer by 2030 un­less in­tense and fo­cused ef­forts are made by gov­ern­ments, com­mu­ni­ties and in­di­vid­u­als,” said Dr Poonam Khetra­pal Singh, Re­gional Di­rec­tor, WHO South-East Asia.

Di­a­betes is a huge dis­ease bur­den and Asian gov­ern­ments like China, Malaysia, Sin­ga­pore, Ja­pan and In­dia have iden­ti­fied di­a­betes as a sig­nif­i­cant dis­ease threat and strain on their pub­lic health sys­tems. For in­stance, a re­cent joint study by the IDF and the Chi­nese Di­a­betes So­ci­ety (CDS) in­di­cated that ex­penses re­lated to di­a­betes ac­count for ap­prox­i­mately 13% of to­tal med­i­cal ex­pen­di­ture in China. Even in those Asian coun­tries that have pro­grams for di­a­betes man­age­ment, im­ple­men­ta­tion of these pro­grams and fund­ing is a big chal­lenge. Ba­sic tech­nolo­gies for early de­tec­tion, di­ag­no­sis and mon­i­tor­ing of di­a­betes in pri­mary care set­tings are gen­er­ally not avail­able in low-in­come and lower mid­dle in­come coun­tries, and as a re­sult many cases go un­di­ag­nosed till the last stage. As per a WHO sur­vey only few coun­tries have con­ducted a na­tional, pop­u­la­tion-based sur­vey with mea­sure­ment of blood glu­cose sta­tus within the past 5 years.

Dr Bho­raskar, added, “In In­dia present prime min­is­ter has taken the cog­nizance of the prob­lem of non-com­mu­ni­ca­ble dis­ease and the states run by his gov­ern­ment have come down heav­ily on the fast food at least around the schools which is the first im­por­tant step to con­tain this epi­demic. Out­door sports are be­ing en­cour­aged and our prime min­is­ter with his own life­style has in­flu­enced our youth to prac­tice yoga and healthy eat­ing, which I feel is a good be­gin­ning.”

Dr Singh em­pha­sized that tax­ing sug­ary bev­er­ages and re-in­vest­ing the rev­enue in health pro­mo­tion ac­tiv­i­ties is an ev­i­dence-based in­ter­ven­tion that makes real change. “Gov­ern­ments must also in­crease ac­cess to health care and pro­mote ed­u­ca­tional

cam­paigns re­gard­ing self-man­age­ment and con­trol and aim at mak­ing treat­ment less costlier. Di­a­betes can be man­aged suc­cess­fully. It does not have to lead to com­pli­ca­tions or be fa­tal,” Dr Singh said.

Di­a­betic Asia- A huge op­por­tu­nity for in­dus­try play­ers

As per re­ports, five out of top ten sell­ing drugs in In­dia are anti-di­a­betes, a sad re­minder of the grow­ing cases in the coun­try. An­tidi­a­beteic mar­ket is poised to reach $ 110 bil­lion by 2024; ac­cord­ing to a new re­search re­port by Global Mar­ket In­sights, Inc.

With surg­ing cases, large MNCs are al­ready cap­i­tal­iz­ing on the ris­ing de­mand for di­a­betic prod­ucts in the re­gion. Re­cently, Novo Nordisk made an an­nounce­ment that its drug Tre­siba for the treat­ment for di­a­betes re­ceived the Chi­nese reg­u­la­tory nod. Global phar­ma­ceu­ti­cal giants have re­al­ized the huge po­ten­tial of­fered by Asian mar­kets in di­a­betes man­age­ment and are part­ner­ing with Asian com­pa­nies to make in­roads into the re­gion. For in­stance, Ther­ma­lin Inc. of Cleve­land said it has raised $17.5 mil­lion in Se­ries A fi­nanc­ing and has formed a part­ner­ship with phar­ma­ceu­ti­cal com­pany Sanofi, to de­velop in­sulin ther­a­pies for peo­ple with di­a­betes.

Many com­pa­nies are also us­ing tech­nol­ogy to ad­dress the un­met needs in Asia. Novo Nordisk, in col­lab­o­ra­tion with health tech startup Glooko has de­vel­oped an app called Corner­stones4Care Pow­ered by Glooko, or the C4C app for short, and it al­lows peo­ple with di­a­betes to mea­sure and track blood glu­cose, ac­tiv­i­ties and meals. Like­wise, Abott re­cently bagged an FDA ap­proval for nee­dle-less blood sugar mon­i­tor­ing, which is a great re­lief for peo­ple with nee­dle pho­bia or dis­taste of nee­dles or blood.

Ex­perts opine that with in­creas­ing aware­ness and af­ford­abil­ity the de­mand for novel means of di­a­betes man­age­ment is in­creas­ing in Asia. Ja­pan, for in­stance, has a high per capita health­care ex­pen­di­ture, Ja­panese con­sumers en­joy rel­a­tively high in­comes and have an ap­petite for ad­vanced health­care tech­nolo­gies. Ja­panese man­u­fac­tur­ers of di­ag­nos­tic tests for di­a­betes are ramp­ing up op­er­a­tions in the rest of Asia, as they hope to catch up with global play­ers by tap­ping into emerg­ing mar­kets.

“At an in­di­vid­ual level, one must prac­tice reg­u­lar ex­er­cise, yoga, healthy eat­ing habits, stay away from en­ergy dense, bad fatty acids such as omega-6 fats and reg­u­lar check­ups, avoid un­due fast life and am­bi­tions which are out of pro­por­tion and peace of mind. Keep a mea­sur­ing tape in your din­ing room and keep it less than 88 cm, try to in­crease your phys­i­cal ac­tiv­i­ties, like walk while talk­ing on phone, take stair­cases in­stead of the el­e­va­tor.’’ - Dr Anil Bho­raskar, Chair, South­East Asian re­gion, In­ter­na­tional Di­a­betes Fed­er­a­tion (IDF)

Need for holis­tic ap­proach

The huge bur­den of di­a­betes in Asia poses sig­nif­i­cant so­cial and eco­nomic prob­lems to most na­tions in the re­gion and could im­pede na­tional and global devel­op­ment. More ac­tion is re­quired to un­der­stand the driv­ers of the epi­demic to pro­vide a ra­tio­nale for pre­ven­tion strate­gies and ad­dress the ris­ing global pub­lic health “tsunami.” Un­less dras­tic steps are taken through na­tional pre­ven­tion pro­grams to curb the es­ca­lat­ing trends in all of the coun­tries, the so­cial, eco­nomic, and health care chal­lenges are likely to be in­sur­mount­able. Many ex­perts are now rec­om­mend­ing holis­tic ap­proaches to treat­ment of di­a­betes, which largely in­volves mind and body in­stead of just treat­ing the symp­toms of dis­ease. This in­volves, un­box­ing and ex­plor­ing the wealth of tra­di­tional medicine of China and AYUSH prac­tices of In­dia, in cul­mi­na­tion with al­lo­pathic in­ter­ven­tions. Con­certed ef­forts, gov­ern­ment sup­port for re­search and in­te­gra­tion of holis­tic prac­tices, can help In­dia and China soon be­come the cap­i­tal for di­a­betes man­age­ment in the world.

Source: World Health Or­gan­i­sa­tion (WHO)

Di­a­betes is a huge dis­ease bur­den and Asian gov­ern­ments like China, Malaysia, Sin­ga­pore, Ja­pan and In­dia have iden­ti­fied di­a­betes as a sig­nif­i­cant dis­ease threat and strain on their pub­lic health sys­tems. For in­stance, a re­cent joint study by the IDF and the Chi­nese Di­a­betes So­ci­ety (CDS) in­di­cated that ex­penses re­lated to di­a­betes ac­count for ap­prox­i­mately 13% of to­tal med­i­cal ex­pen­di­ture in China.

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