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the diabetes
epidemic and its
impact on Thailand
Researched and written by:
1
DIABETES, A GLOBAL EPIDEMIC Diabetes is a chronic disease that requires life-long treatment and greatly increases the risk of serious, costly complications including heart attack, stroke, kidney failure, blindness and limb amputa- tion1,2. Today, 382 million people in the world have diabetes3. The number of people with diabetes is increasing in every country in the world3. 2
“No country is immune to the threat and no country is fully equipped to re-
pel this common enemy alone. The coming fight will require a united stand
with the full support of the international community, for this is a battle the
world cannot afford to lose.”
Prof Jean Claude Mbanya, President of the International Diabetes Federation, 2009-2012
IDF press release, 18 October 2009
“If we fail to give people with diabetes the long and healthy lives we are
capable of giving them, we will not be forgiven.”
Bill Clinton, US President, 1993-2001
Keynote lecture at the ‘Global Changing Diabetes Leadership Forum’, New York, 2007
“Without tackling the diabetes epidemic which is now gripping our world,
we will, I fear, find many of our ambitions for the future simply impossible to
achieve.”
Kofi Annan, Secretary-General of the United Nations, 1997-2006
Keynote lecture at the ‘Unite to Change Diabetes Forum’, Moscow, 2008
“We believe addressing the prevention and control of chronic noncommu-
nicable diseases offers a window of opportunity to create healthy develop-
ment. Unless this opportunity is seized by donors, governments and other
partners, the current progress on the internationally agreed development
goals will be undermined and countries will face unbearable costs to their
economies and health systems. The world is thus at a unique tipping point
in the history of public health; an opportunity that will rapidly fade if no
timely action is taken.”.
Prof Pierre Lefebvre, Chairman of the World Diabetes Foundation, 2003-present
Annual Review of the World Diabetes Foundation, 2010
“Cancer, diabetes, and heart diseases are no longer the diseases of the
wealthy. Today, they hamper the people and the economies of the poorest
populations even more than infectious diseases. This represents a public
health emergency in slow motion.”
Ban Ki-Moon, Secretary-General of the United Nations, 2007-present
United Nations global summit on non-communicable disease, New York, 2011
“In the absence of urgent action, the rising financial and economic costs of
these diseases will reach levels that are beyond the coping capacity of even
the wealthiest countries in our world.”
Margaret Chan, Director-General of the World Health Organisation, 2007-present
The First Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Disease Control, Moscow, 2011
3
DIABETES IN THAILAND Today, 3.2 million people have diabetes in Thailand3. By 2035 an additional 1.1 million Thai adults will live with diabetes3. An estimated 183 people die of the consequences of diabetes in Thailand... every day3. 4
PREFACE
Changing lifestyles lead to overweight and obesity, which has now become one of the leading caus-
es of chronic non-communicable diseases (NCDs), also known as lifestyle diseases. These diseases
are currently spreading globally and becoming increasingly more severe. If they are not adequately
addressed, the NCDs will likely cause more morbidity, disability, mortality, and substantial healthcare
burden and economic loss.
Thailand is also facing the problem and is attempting to address the threats of five major preventable
lifestyle diseases including diabetes mellitus, hypertension, heart diseases, cerebrovascular disease and
cancers. The attempt to tackle these diseases is included as one of the major development goals in the
10th and 11th National Economic and Social Development Plan. We realise the need for multisectoral
engagement in order to adequately address the problems, the Ministry of Public Health (MoPH), the
National Economic and Social Development Board (NESDB) and Mahidol University have collaborated
to develop the ‘Thailand Healthy Lifestyle Strategic Plan 2011-2020’ in response. The cabinet has, in
principle, approved this national strategic plan and its implementation mechanism, which will be used
as a framework to advance coordinated and united efforts of program implementation at all levels,
with the aim to campaign for a new, healthy way of life which reduces risk factors, morbidity, compli-
cations, disability, mortality and financial burden at individual, family, community, society and national
levels.
H.E. Mr. Pradit Sintavanarong
Minister of Public Health, Thailand, 2013
5
FOREWORD Diabetes mellitus was the first chronic noncommunicable disease that was brought up to the attention of the National Epidemiology Board of Thailand. In 1987, a Task Force for Control of Diabetes Mellitus was estab- lished. One year after gathering all existing data, a technical report was released with the title ‘Diabetes Mel- litus in Thailand 1987: Review and Prospective’. The report called for the need of standardised data collection in all aspects of diabetes including epidemiology, care process, management outcome, risk factors and com- plications. Updating diabetes knowledge for practising physicians, care teams and education for patients and caregivers was required among many priorities of care delivery. For almost two decades of accumulated works, an improvement in many areas was recorded in the ‘Diabetes Situation in Thailand 2007’. The progress was recently summarised by Prof. Chaicharn Deerochanawang and published in Globalisation and Health in 2013. The National Health Security Office (NHSO) also paid attention to the importance of holistic management of diabetes mellitus and foresaw the necessity of improving the quality of care and outcomes. A working group of NHSO and diabetes experts launched a ‘Clinical Practice Guideline for Diabetes Mellitus’ in 2008. The NHSO and the Ministry of Public Health guided and supported the implementation of the clinical practice guidelines countrywide. A chronic care model has been initiated to facilitate efficient and effective care of diabetes in Thailand. This booklet represents another version illustrating the burden and impact of diabetes mellitus in Thailand. Bringing diabetes care and outcomes to a higher quality level is a big challenge to all care providers with high expectations of success. Wannee Nitiyanant, M.D. President, Diabetes Association of Thailand Under the Patronage of Her Royal Highness Princess Maha Chakri Sirindhorn Diabetes is a threat to Thai society, to avert the worst, clear priorities should be set for the future management of diabetes. First, screening should be increased; screening for diabetes in high risk populations as well as sys- tematic annual screening for diabetes complications in patients already diagnosed. Second, the factors affect- ing poor treatment outcomes in the majority of patients not well controlled today have to be identified and addressed. These priorities address the need for early diagnosis and successful intervention to help prevent and delay the onset and progression of the serious and costly complications of diabetes. Third, policy should specify clear targets. Fourth, a monitoring framework should be provided and used to track progress towards these targets, requiring further improvement in data availability. Up-to-date data on the med- ical and economic burden of diabetes at the national level and at least a regional level is essential to identify needs and monitor progress. Priority areas for data collection include the incidence of diabetes in children and adults, the prevalence of GDM, the cost of diabetes and its complications and finally treatment compliance and outcomes at an individual level. Some data is available from individual studies, however systematic and longi- tudinal data collection is essential. The NHES survey is conducted regularly and includes good data on diabetes prevalence, however these surveys are only conducted every 5 to 7 years. Fifth, promotion of a healthy lifestyle for the prevention of diabetes has to be stepped up through education and quality health information delivered to the public. Efforts to address these issues have already started in some areas of the country but not nationwide. In order to achieve this, a multisectoral effort including concert- ed policy actions from a variety of policy makers (beyond the Ministry of Public Health) and of public opinion leaders as well as interventions involving public and private delivery channels is required. Professor Chaicharn Deerochanawong Diabetes and Endocrinology Unit, Department of Medicine Rajavithi Hospital, Rangsit Medical School, Bangkok, Thailand 6
7
8
1. Executive summary
Much progress has been made in recent years, but there is still room for
improvement in tackling the growing diabetes challenge in Thailand.
Successfully controlling type 2 diabetes will help millions with the disease
lead a longer, healthier life but will also significantly contribute in the
prevention of other chronic diseases, due to their shared risk factors,
underlying determinants and opportunities for intervention.
The burden of chronic diseases quately controlled. Following this, the burden of diabetes in
Until recently, communicable diseases have been the Thailand is discussed, reviewing available data on the prev-
primary cause of mortality and morbidity across the globe. alence of diabetes and discussing the human and financial
The balance is however tipping towards non-communi- burden of the disease in Thailand.
cable diseases (NCDs). Chronic diseases are one of the
greatest challenges for Thailand. The most common of ‘The Rule of Halves’ is then introduced as a simple concept
these diseases are cardiovascular disease (heart disease and to reveal the real challenges of managing diabetes success-
stroke), cancer, respiratory disease and diabetes4, together fully. The book continues with a review of the quality of
they account for a substantial proportion of total mortality diabetes care and the current diabetes health in Thailand,
and disability5. Within the scope of a decade, the share of stressing the importance of women’s and children’s health
all deaths in Thailand by NCDs has increased from 59% in in the following section.
2002 to 71% in 20086.
The book then asks the important question “What needs
to change?”, outlining the benefits of early detection and
the need for education and data collection. Finally, this
book shares experiences from across the globe, showcas-
ing successful national health strategies and local diabetes
projects.
The objectives we have in mind
As effective interventions exist for the prevention and
An integrated approach control of chronic diseases such as diabetes, the evidence
Most healthcare systems today are organised to treat the investigated and summarised in this book aims to pro-
acute symptoms of disease and manage conditions sepa- vide payers, policymakers, patient associations, the expert
rately. We are less advanced when it comes to integrated community and other stakeholders in Thailand at a local,
prevention efforts, early detection and care and treatment regional and national level with a clear demonstration of
for chronic non-communicable diseases. An integrated pa- the challenges presented by diabetes and offers possible
tient-centred approach will capitalise on common treatment solutions.
needs and thus have a greater impact.
It is hoped this book will contribute to the development
In the case of type 2 diabetes treatment, research has of sustainable improvements in diabetes prevention and
shown the benefits of an integrated approach. Intensifying detection, and the provision of affordable, effective care
treatment to include tight control of multiple diabetes risk throughout Thailand.
factors such as high blood glucose, blood pressure and
cholesterol have been found to significantly reduce the risk Acknowledgement
of death from cardiovascular causes and the development We thank Prof. Chaicharn Deerochanawong; this booklet
of end-stage renal disease7. draws inspiration and important insight and knowledge
from his recently published review article ‘Diabetes man-
What you can find in this book agement in Thailand: a literature review of the burden,
‘The diabetes epidemic and its impact on Thailand’ begins costs, and outcomes’. His paper can be downloaded from:
with an introduction to diabetes and describes the serious http://www.globalizationandhealth.com/content/9/1/11.
complications that may occur when the disease is not ade-
9
10
Table of contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1. Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2. About diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3. Diabetes in Thailand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
4. The human burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
5. The financial burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
6. The rule of halves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
7. Current diabetes health in Thailand . . . . . . . . . . . . . . . . . . . . . . . . 26
8. Women, diabetes and the next generation . . . . . . . . . . . . . . . . . . . 30
9. What needs to change? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
10. Prevention provides the greatest potential for gain . . . . . . . . . . . . . 33
11. Improving outcomes by early detection . . . . . . . . . . . . . . . . . . . . . . 35
12. Patient self-management, education and support . . . . . . . . . . . . . . 37
13. Treatment towards target . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
14. Measure, share, improve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
15. Conclusion: diabetes affects Thailand, at every level . . . . . . . . . . . . 41
16. Sharing experiences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
17. About Novo Nordisk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
18. Diabetes glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
19. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
1112
2. ABOUT DIABETES
Diabetes is defined by a failure of the pancreas to produce insulin or to
produce and utilise sufficient insulin to keep blood glucose under control8.
Diabetes and Insulin Other types of diabetes exist, including latent autoimmune
Diabetes is a chronic disease that occurs when the pancreas diabetes in adults (LADA). This is sometimes referred to as
is no longer able to make insulin, or when the body cannot type 1.5 diabetes, as people present signs of both type 1
make good use of the insulin that it does produce8. and type 2 diabetes. At least 10% of all cases of type 2
diabetes have some symptoms of type 1 diabetes13.
Insulin is a hormone made by the pancreas whose main ac-
tion is to enable glucose to be transported from the blood Pre-diabetes occurs when blood glucose levels are higher
into the cells of the body so it can be used for energy. It than normal but not high enough for a diagnosis of ‘full-
acts like a key that opens the door for the food (glucose) to blown’ diabetes. People with pre-diabetes are at high risk
leave the bloodstream and get into the body’s cells9. of developing type 2 diabetes and have an increased risk of
cardiovascular disease9.
When not enough insulin is produced, or when it is not
used effectively, glucose builds up in the blood (known as Symptoms and diagnosis
hyperglycaemia). Over the long-term high glucose levels are The onset of type 1 diabetes is usually sudden and dramatic
associated with damage to the body and failure of various while the symptoms of type 2 diabetes can often be mild
organs and tissues8. or absent, making it hard to detect8. All too often type 2
diabetes is only diagnosed when presenting to the doctor
Types of diabetes with the first signs of complications or during a random
Type 1 diabetes is usually caused by an autoimmune reac- test. As early detection and treatment can decrease the risk
tion where the body’s defence system attacks and destroys of developing the complications of diabetes, it is important
the insulin-producing cells. The disease may affect people to recognise its symptoms, which include14:
of any age, but usually develops in children or young adults.
People with type 1 diabetes are dependent on insulin injec- • Tiredness • Blurry vision
• Feeling of thirst • Slow healing cuts
tions for survival8.
• Frequent urination • Tingling or numbness in
hands or feet
Type 2 diabetes accounts for at least 90% of all cases of di- • Feeling hungry
abetes. It is characterised by insulin resistance and a relative
insulin deficiency, either or both of which may be present Living with diabetes
at the time of diagnosis. It most commonly occurs after the It is not easy to hear a diagnosis of diabetes. There is no
age of 40 and is strongly associated with overweight and cure and people will often have seen headlines of what can
obesity which contributes to insulin resistance10. Increasing- go wrong or frequently will have witnessed first-hand the
ly, type 2 diabetes also affects overweight children, adoles- negative effects of uncontrolled diabetes9.
cents and young adults11.
It entails a number of physical problems which affect both
Both type 1 and type 2 diabetes are serious. There is no private and working life and may require additional sup-
such thing as mild diabetes8. port from friends or family. These may include discomfort
caused by high blood sugar, such as tiredness and frequent
GDM (Gestational Diabetes Mellitus) is a form of diabetes infections, or discomfort caused by low blood sugar such as
occuring during pregnancy. Estimates of its prevalence palpitations and mood swings.
differ across the world depending on diagnostic criteria,
however it may develop in as many as one in 6 pregnancies The stress involved can often lead to depression, especially
worldwide12. GDM is associated with complications to both for young people with diabetes, so support form healthcare
mother and baby such as larger than normal babies and professionals and family members is vital. If people with
higher rates of foetal abnormalities. Although the diabetes diabetes have access to adequate support, they are more
typically disappears after delivery, both women with GDM confident and more able to manage their own treatment
and their offspring are at increased risk of developing type effectively.
2 diabetes later in life8.
13Diabetes complications
Diabetes can lead to many serious health problems, usually after a number of years and particularly if diabetes is not detect-
ed early or well treated. Consistently high blood glucose levels can damage the small blood vessels in the eyes (retinopathy),
kidneys (nephropathy) and the nerves (neuropathy); these are called micro-vascular complications. High blood glucose also
affects larger blood vessels by accelerating the build-up and inflammation of plaque (atherosclerosis) which contributes to
stroke, coronary heart disease and peripheral artery disease; these are called macro-vascular complications. People with
diabetes have a 2-fold excess risk of a wide range of vascular diseases18 and are also more likely to die from these142. Other,
non-vascular, complications of diabetes include teeth and gum problems and infections and people with diabetes also have
a higher risk of cancer and are more likely to develop depression18.
3-4 higher risk of vision threatening 10%
times stroke eye complications people
Diabetic retinopathy is the leading cause of
Strokes occur when the flow of oxygen to
blindness among working-aged adults around
the brain is interrupted, most often caused by
the world17. As many as 1 in 2 people with
a blood clot that blocks blood vessels in the
long-standing diabetes in Thailand will devel-
brain. Diabetes accelerates atherosclerosis, the
op mild to moderate eye complications such
hardening of arteries, which leads to accu-
as blurred vision37 whereas 1 in 10 will experi-
mulation of plaque and when this ruptures a
ence vision threatening eye complications15.
stroke may occur. Stroke occurs 3 to 4 times
as often in people with diabetes compared to
those without diabetes20,47,48. For people below higher risk of fatal 3
65 years of age the risk is 15 times higher20. heart disease times
Coronary heart disease is caused by
# 1 of kidney failure plaque building up along the inner walls
cause in Thailand of the arteries (atherosclerosis) of the
heart which narrows the arteries and
Kidney disease is caused by dam-
restricts the blood flow. This may cause a
age to small blood vessels in the
heart attack. For both men and women
kidneys leading to the kidneys
with diabetes the risk of fatal coronary
becoming less efficient or to fail al-
heart disease is elevated, the risk for
together. People with kidney failure
women with diabetes is higher (3.5 times)
require dialysis or kidney transplan-
than in men (2.1 times)85
tation for survival. Diabetes is the
leading cause of kidney failure in
Thailand, 6 to 7 people start renal
replacement therapy every day42. have nerve 70%
damage people
Diabetes can cause damage to the nerves
10% experience foot throughout the body when blood glucose and
people ulcers
blood pressure are too high17. The majority
Loss of feeling in the feet from nerve damage
of people with diabetes will develop some
can allow injuries to go unnoticed, leading
form of nervous system damage16 leading to
to infections. As diabetes slows healing of
impaired sensation or pain in extremities of
wounds, serious ulcers may develop affecting
the body, including the feet or hands, slowed
ten percent of people with diabetes. In Thai-
digestion of food and erectile dysfunction.
land, 3 to 4% of people with long-standing
diabetes undergo a lower limb amputation as
a consequence of progressing ulcers37.
+
Diabetes is associated with a 2-fold higher risk of death48,142 and, diagnosed at age 50,
6-8 early death
years diabetes reduces a person’s life expectancy by 6 to 8 years 18,136.
14Diabetes is a chronic, progressive disease that requires life-long treatment
and greatly increases the risk of serious, costly complications including heart
attack, stroke, kidney failure, blindness and limb amputations.
How is diabetes managed? Challenges in diabetes management
People with type 1 diabetes have lost the ability to pro- The challenges of treating diabetes are many. People with
duce insulin themselves and insulin therapy is required diabetes require extensive education and motivation to
to stay alive9. Most people with type 2 diabetes begin comply with pharmacotherapy, monitor glucose levels and
treatment with dietary changes and increased exercise but participate in self-care to control their disease. Medication
unfortunately most patients are unsuccessful in controlling requires titration and monitoring and a careful balance
blood sugar without pharmacotherapy. Tablets that has to be maintained between strict glycaemic control
stimulate insulin release or enhance insulin sensitivity are required to avoid complications and side-effects such as
typically the first medications used in treatment19. weight gain and hypoglycaemia (low blood glucose).
Progression of type 2 diabetes and
Hypoglycaemia is often considered the limiting factor
treatment intensification19
in the successful treatment of diabetes22. Whereas mild
Diet and exercise hypoglycaemia is definitely unpleasant, if left untreated it
can lead to severe hypoglycaemia (very low blood glucose)
possibly resulting in unconsciousness and in some cases
Beta cell function
Tablets can even be fatal. Evidence further shows that severe but
also moderate hypoglycaemia is associated with an overall
increased rate of long-term mortality in type 2 diabetes23.
GLP-1
Delaying the onset of complications
It is well established that the risk of micro- and macrovas-
Insulin cular complications is related to glycaemia as measured by
HbA1c. Reducing glucose therefore remains a major focus
of therapy. Prospective randomised clinical trials have doc-
umented reduced rates of complications in people with
diabetes treated to lower glycaemic targets21. Findings
Time from a long-term, landmark study in the UK show that
intensive blood-glucose control substantially decreases
As the number of insulin producing cells (Beta-cells) inevi- the risk of microvascular complications24. After 10 years of
tably decline over time, blood sugar rises and further phar- follow-up these benefits are maintained and demonstrate
macotherapy is required to maintain control10. Treatment lower mortality in the intensively controlled group25.
guidelines from the American Diabetes Association (ADA)
and the European Association for the Study of Diabetes Data from the same study was used to demonstrate that
(EASD) propose a step-wise intensification. Ultimately, each 1%-point reduction in HbA1c reduces the risk of
insulin therapy will be required in many people with type 2 complications, without an apparent lower threshold26.
diabetes to maintain good glycaemic control21.
1516
3. DIABETES IN THAILAND
An estimated 3.2 million Thai adults have diabetes today; 6.4% of the adult
population. This number will increase by more than 1.1 million by 20353.
Diabetes is a serious problem
The growth of diabetes is serious. Increasing obesity
in children and adults is to diabetes (and other chronic
diseases) what melting glaciers are to climate change: a
warning signal of times to come.
The prevalence of diabetes in Thailand - diagnosed and
undiagnosed - has grown dramatically in the last decade
and if nothing changes its growth will continue. A good
indication of the challenge to come is the 4.1 million Thai
adults with pre-diabetes today3. This group has impaired
glucose metabolism but has not - yet - developed overt
diabetes. They are at high risk of developing diabetes in
the future unless a significant change in lifestyle is made,
often aimed at reducing weight.
of Thai women were estimated to be overweight, a rate
that has doubled over the last 2 decades28,29. Data from
the National Health Examination Survey (NHES) shows the
prevalence of diabetes to be as high as 1 in 7 in adults
with a BMI over 30 kg/m2, more than 3 times as high as in
those with a normal BMI30.
Although the typical time of onset of type 2 diabetes is
after the age of 50, childhood and adolescent obesity is
causing the emergence of type 2 diabetes in the young as
a serious health problem. Whereas virtually all (19 out of
20) diagnosed cases of diabetes in the young were iden-
tified as type 1 diabetes until 1995, a near-tripling of the
obesity prevalence in the same period31 has caused a rapid
increase of type 2 diabetes in the young to 1 in 5 cases of
diabetes diagnosed.
Obesity
Obesity is an important risk factor for chronic diseases,
including diabetes. Obesity, defined as a body mass index
(BMI) in excess of 30 kg/m2 but also overweight (BMI >25
kg/m2), greatly increases the risk of developing type 2
diabetes.
Being obese leads to more than a seven-fold increase in
the risk of developing type 2 diabetes, while being over-
weight increases the risk nearly three-fold. Furthermore,
people who are severely obese (BMI >35 kg/m2) have a
risk of developing type 2 diabetes up to 60 times greater
than those with a normal bodyweight27.
In 2009 more than 30% of Thai men and more than 40%
17The growth in the number of people with diabetes in Thailand is being
fuelled by an ageing population and by increasingly unhealthy lifestyles with
poor diets and falling levels of exercise causing a rapid increase in the rate of
obesity.
Ageing
With the typical onset of type 2 diabetes in Thailand
after the age of 50 and with prevalence peaking at 1 in
6 between the ages of 55 and 74, the ageing of the Thai
population points towards a rise in the disease burden32.
Urbanisation
Sedentary lifestyles and unhealthy diets are more common
in urban areas. Not suprisingly, the prevalence of diabetes
is higher in urban areas than in rural areas of Thailand. In
Population data suggests the number of Thai people over particular people moving from rural areas to urban areas
the age of 60 to be close to 20% of the total population are at a higher risk of developing diabetes34.
by 2030, a doubling since 200033.
18RAPID GROWTH OF DIABETES IN THAILAND
The number of people with diabetes will grow by 1.1 million over
the coming 2 decades, affecting 1 in 12 adults by 20353.
This growth is being fuelled by an ageing population and a rapid
rise in the prevalence of obesity.
Overweight doubles the risk of diabetes, obesity triples the risk of
diabetes30.
194. the human burden
Diabetes often affects people in their productive years when they carry a
substantial responsibility for their families. The complications of diabetes are
not only a personal tragedy, families and close ones are impacted and the
burden of poorly treated diabetes can push families into poverty.
Diabetes is a leading cause of death
As the number of people with diabetes continues to
grow, diabetes is establishing itself as a leading cause of
death. Diabetes already is the third leading cause of death
in women of all ages and the leading cause of death in
women over the age of 50. In men, diabetes ranks lower
due to the higher mortality levels related to road traffic
accidents and HIV/AIDS35.
Leading causes of death in women35
15-49 years 50-74 years >74 years
1 HIV/AIDS Diabetes Stroke
2 Traffic acc. Stroke Isch. heart disease
3 Cancer cervix Isch. heart disease Diabetes
4 Stroke Nephritits Respiratory
5 Diabetes Cancer cervix Nephritis Similarly, whereas less than 1% of the people with dia-
betes with a disease duration less than 15 years will have
According to estimates of the International Diabetes had a lower-limb amputation, this is 3.5% in the group
Federation, 180 Thai people die of the consequences of with long-standing diabetes37.
diabetes every day, nearly 8 every hour3.
Kidney disease (nephropathy)
Complications The job of the kidneys is to remove waste products from
The long-term complications of diabetes are a serious and the blood. Sustained high levels of blood glucose can
major burden of the disease. In a 2003 cross-sectional damage the blood-filtering capillaries in the kidneys and
study with participation of 11 hospitals and more than cause them to leak useful proteins into the urine. Small
9.400 patients it was identified that diabetic nephropathy amounts of protein in the urine is called micro-albuminu-
was the most common complication affecting 43.9% of ria38 which occurs in up to 40% of Thai people with type
the people with diabetes. This was followed by diabetic 2 diabetes39,40 and increasies to more than 60% with
retinopathy (30.7%) and ischaemic heart disease (8.1%)36. long-standing diabetes37.
A 4-year study conducted from 2006 to 2010 in 1,120 Unless diagnosed and treated early, kidney disease will
patients reported very similar numbers and also found get worse. When larger amounts of protein appear in the
24% of patients to have lost protective sensation in the urine this is called macro-albuminuria which may result in
feet due to neuropathy143. end-stage renal disease when the kidneys fail and waste
products start to build up in the blood. This is very serious
It is important to realise the impact of disease duration on and a person with end-stage renal disease requires a kid-
the prevalence of complications. Prolonged uncontrolled ney transplant or machinal blood filtering (dialysis)38.
blood glucose is a major predictor of diabetes compli-
cations24,25,26 and it is expected to see the prevalence of Macro-albuminuria occurs in approximately 8% of Thai
complications increase with diabetes duration. After 15 people with diabetes with 0.5% to 1% requiring dialy-
years of diabetes the prevalence of diabetic retinopathy sis or kidney transplantation39,40,41. Diabetes is the most
was found to be 4 times as high as in Thai people with common cause of end-stage renal disease accounting for
less than 5 years of diabetes37. nearly half of all new cases in Thailand. In 2009, dialysis
was initiated in 2,425 Thai people with diabetes or 6 to 7
20people every day42. In the same year, the total number of blocking a blood vessel in the brain or neck38.
people with diabetes on dialysis was 9,487, an increase of
90% compared to 200742. Peripheral arterial disease (PAD) occurs when the blood
vessels in the legs are narrowed or blocked by fatty de-
Eye disease (retinopathy) posits and blood flow to feet and legs decrease, it increas-
Tiny blood vessels (capillaries) in and behind the eyes’ es the risk of heart attack and stroke. PAD is not easily
retina - responsible for recording images - provide the diagnosed as it is often symptomless or symptoms are
required energy for the eye to function. When due to not recognised. In the Thailand Diabetes Registry Project
sustained high blood glucose the capillaries in the back of prevalence of PAD was found to be 7.4% in long-standing
the eye balloon and pouches are formed, blurred vision diabetes37, however a study with specialised diagnostic
may appear. This most common form of diabetic retinop- equipment in a high risk diabetic population in Thailand
athy is called non-proliferative retinopathy, developing in has demonstrated a prevalence of 60%51.
stages as more and more blood vessels become blocked38.
One-in-five Thai people with diabetes has non-proliferative Foot complications
retinopathy41,43,44,45 and with duration of diabetes a major People with diabetes can develop many different foot
risk factor the prevalence in people with 20 years of diabe- problems, most often caused by nerve damage (peripheral
tes was found to be 43%46. neuropathy) when loss of feeling results in injuries going
unnoticed. Poor circulation (PAD) in the lower limbs may
Blood vessels can become so damaged they close off and also contribute to foot problems as feet may be less able
cause new blood vessels to grow in the retina. This can to fight infection and heal38.
lead to blood leaking onto the retina or scar tissue form-
ing leading to blocked vision. This is called proliferative Nerve damage and PAD make it easier to get ulcers and
retinopathy and may ultimately lead to blindness38. Dura- infections leading to amputations. Twenty-four percent of
tion of diabetes is again a major risk factor and prevalence Thai people with diabetes have loss of protective sensation
of proliferative retinopathy increases from 2% in those in the feet143 and 5 to 6% have a history of foot ulcers36,41.
with diabetes duration less than 5 years to 10% in those Amputations occur in 2% of all people with diabetes41
with diabetes for more than 15 years46. Blindness may and in long-standing diabetes 1 in 10 people will have had
occur in 1.5% of people with diabetes43 making diabetes a foot ulcer and 3.5% will have undergone amputation37.
a leading cause of blindness. Diabetes is the leading cause of non-traumatic lower limb
amputation.
Regular screening for diabetic retinopathy and aggressive
management of associated risk factors (glucose, blood Depression
pressure) can help to prevent and delay the prevalence Having diabetes is associated with a significantly higher
of diabetic retinopathy. Laser therapy can help delay its risk of developing depression and other psychological
progression and prevent severe visual impairment and problems compared with the general population38. This
blindness. may be because of the stress of daily diabetes manage-
ment or when facing diabetic complications. According
Cardiovascular disease (CVD) to a 2008 study amongst people with diabetes visiting a
People with diabetes have a higher than average risk of Bangkok tertiary university hospital out-patient clinic 28%
having a heart attack or stroke, striking three to four times suffered from depression, with a higher prevalence identi-
as often than in people without diabetes20,47,48. More than fied in those with poor glycaemic control52.
half of all people with diabetes globally18 and in Thailand49
will die of cardiovascular disease. People with diabetes of Depression not only causes suffering to the individual but
50 years and older with CVD live on average 7.5 (men) can also adversely affect treatment adherence and is as-
and 8.2 (women) years less than people without diabe- sociated with poor medical outcomes and high healthcare
tes50. costs53.
Macrovascular complications are reported by 1 in 3 Thai Families
people with long-standing diabetes37. Coronary arterial A diagnosis of diabetes imposes a lifelong burden, not
disease, sometimes called hardening of the arteries, is only on the individual but also on their family, due to the
reported by 1 in 6 and may lead to a heart attack or myo- constant need for practical and emotional management of
cardial infarction. Stroke, the no.1 leading cause of death the disease. The social and emotional impact on a family
in Thailand35, strikes 4.4% of all people with diabetes36,41. dealing with diabetes may be greater than the direct costs
Strokes are caused by a sudden interruption of the blood of treatment and lost income.
supply to the brain most often as a result of a blood clot
215. the FINANCIAL burden
Dying young or living with long-term illness or disability has economic
implications. The rapid growth in the number of people with diabetes has
a dramatic impact on the direct and indirect cost for the individual with
diabetes, the family, the national economy and the government.
The size of the problem Economic costs of diabetes
As the number of people with diabetes grows, the disease Direct non-medical cost contribute 40% to the total cost
takes an ever-increasing proportion of national health care of illness with cost of informal care alone contributing
budgets. Because of its chronic nature, the severity of its 28%. The biggest contributor to indirect cost was found
complications and the means required to control them, to be the cost of permanent disability, contributing 19%
diabetes is a costly disease, not only for the affected indi- to the total cost of illness. The study is likely to have un-
vidual and his/her family, but also for health authorities54. derestimated the real cost of illness by as much as 60% as
it used minimum wages only to calculate cost of informal
It is estimated that diabetes accounts for 12% of the care and disability and not GDP per capita57.
total healthcare expenditure globally, although individual
country estimates differ widely55. Whereas the estimated The morbitiy and premature mortality rates attributable to
average spend on diabetes per person is USD 53 in South chronic diseases highlight the need for effective interven-
East Asia, this is USD 7,900 in the United States56. tions. Dying young or living with long-term illness or dis-
ability has economic implications for families and society
The costs of diabetes in Thailand and the cost to employers and economies is increasing.
Little information is available on the actual cost of dia-
betes in Thailand. A 2009 micro-costing study of people Complications drive cost
receiving treatment in a 30-bed public district hospital in Data from the Ministry of Public Health on diabetes-re-
North-East Thailand estimated a mean cost of illness of lated hospitalisations shows a dramatic increase over the
THB 28,200 (1 USD = 31 THB)57 and the Minister of Public past decades, a strong indication of the increasing finan-
Health recently estimated the total cost of diabetes to cial burden of diabetes33. This is supported by actual cost
approach 50 billion THB144. data showing hospitalisation to contribute nearly 50% to
the total cost of diabetes illness57.
Although the cost of diabetes is most visible in direct med-
ical costs such as dispensing and drug bills; these however A patient requiring hospitalisation sees a nearly 10-fold
make up less than a quarter of the yearly total cost. It is cost increase compared to a patient managed in the
the in-hospital care of complications that contributes most out-patient-department. Similarly, a patient with diabetic
with nearly half of the total cost57. nephropathy or diabetic foot has a greatly increased cost
of illness compared to one without58.
22With the prevalance of complications of diabetes increas- Data from Thailand on hypoglycaemia is scarce, one study
ing with diabetes duration, it is unsurprising to see that however investigated the clinical risk factors associated
the cost of illness increases with diabetes duration. During with severe hypoglycaemia and recorded the length of
the first 5 years of the disease, the median yearly cost is stay after being admitted to hospital62. The study showed
THB 3,400 and is multiplied by more than 6-fold for those that at least 2 people with diabetes and severe hypogly-
with a disease duration over 20-years57. It is the future caemia were admitted to the hospital monthly, half of
burden of diabetes that is thus of greatest concern and an them unconsciousness. The average hospital stay was
investment in prevention, early diagnosis and treatment 6 days resulting in a direct cost per event of nearly THB
may save cost later. 22,00058.
The cost of hypoglycaemia
It is well understood that reducing blood glucose levels
helps prevent or delay complications24 and may thus save
costs. A key barrier to reducing blood glucose however is
hypoglycaemia23. It has been demonstrated that patients
are just as worried about hypoglycaemia as they are about
complications such as blindness59. Many patients decrease
their insulin dose after a hypoglycaemic event resulting in
sub-optimal glucose control60. Beyond the indirect impact
of hypoglycaemia on treatment compliance there is also
a direct medical cost of hypoglycaemia. Severe hypogly-
caemic events frequently require medical intervention and
hospital admission61.
236. THE RULE OF HALVES
According to the concept of the Rule of Halves63, only around 6% of people
with diabetes live a life free from diabetes-related complications.
The silent pandemic high blood sugar because they fear the consequences of
While diabetes care has improved greatly in recent dec- low blood sugar (hypoglycaemia), a common side effect of
ades, the International Diabetes Federation estimates (insulin) treatment.
4.8 million people died of diabetes in 20123. This makes
diabetes a bigger killer than HIV/AIDS, malaria and tuber- Ultimately, the Rule of Halves suggests that only around
culosis combined64. 6% of people with diabetes live a life free from diabe-
tes-related complications.
The Rule of Halves shows the gravity of diabetes and ex-
plores which factors play a role - displaying the inequality UN resolution
of access to the right treatment and support63. In 2006, the IDF and the global diabetes community
brought the “UNite for Diabetes” campaign to the highest
The Rule of Halves political forum – the United Nations - to raise awareness.
Of all the people with diabetes in the world, only about The UN passed Resolution 61/225 in December 2006,
50% are thought to have been diagnosed3, meaning a affirming diabetes as a major global health threat.
huge part of the population is at risk of developing com-
plications that will significantly impair their quality of life. The UN High-Level Summit on Non-Communicable
Diseases (NCDs) held in 2011 in New York was a major
Due to late diagnosis up to half of all people with diabetes milestone. The Summit was only the second time the
have some evidence of complications at the time of detec- UN General Assembly devoted exclusive attention to a
tion65,66. For others the treatment they receive is inade- health-related issue and world leaders made unprecedent-
quate or they do not have access to medicine or doctors ed commitments to accelerate global progress on diabetes
who can tell them how to use it. Yet others maintain too and NCDs66.
DIABETES
DIAGNOSED
RECEIVE
CARE ACHIEVE
TREATMENT ACHIEVE
TARGETS DESIRED
OUTCOMES
2425
7. CURRENT DIABETES HEALTH in
thailand
Poor glycaemic control increases the risk of long-term complications24.
With around half of patients diagnosed and only a third of them reaching
treatment targets, many people with diabetes in Thailand are at risk and will
develop complications.
Data sources Diabetes diagnosis in Thailand
An extensive literature search was conducted for a 2013 The IDF estimates that half of all people with diabetes in
review of diabetes management in Thailand, finding 46 Thailand are not aware they have diabetes69. Findings from
peer-reviewed papers68. These provide an accurate and up- the NHES suggest that diagnosis rates have improved in
to-date insight in the current diabetes health in Thailand recent years to reach 65%, however the NHES uses single
and this booklet builds on this. The key sources of diabe- Fasting Plasma Glucose measures for diagnostic purposes
tes data used include: which may underestimate the prevalence of diabetes, as
also acknowledged in the paper70. Late diagnosis allows
• National Health Examination Survey (NHES); dis- unchecked high blood glucose levels and thus contributes
ease data from a national representative sample of to the risk of the long-term complications of diabetes.
>20,000, conducted in 1991, 1997, 2004 and 2009
• Diabetes Registry Project; including 9,419 people with Access to care is not the same for all
type 1 and type 2 diabetes, conducted in 2003 with Access to doctors and medicines to treat diabetes in
follow-up until 2006 on mortality Thailand should be adequate since the introduction of
• DiabCare Asia; data collection from over 2,300 pa- the Universal Coverage Scheme (UCS) in 2002. Today the
tients, conducted in 1998, 2001, 2003 and 2008 in scheme provides access to 75% of the population with
Thailand and throughout South East Asia the remaining 25% of the population covered by the Civil
• InterASIA; survey of nationally representative sample Servant Medical Benefit Scheme (CSMBS) and the Social
of more than 5,100 people conducted in 2000 Security Scheme (SSS) for formal employees.
• DM/HT study (NHSO research project); large national
cross-sectional survey of quality of care in 28,649 Although coverage is universal, access to healthcare staff
people with diabetes from >600 hospitals throughout and medication does differ between the schemes. A
Thailand, data collected from 2010 to 2012 comparative study showed a higher proportion of patients
• A substantial number of other - mostly local - studies from the CSMBS than the UCS accessing secondary and
contribute to insights in specific sub-groups of people tertiary care71, this is important as more patients were
with diabetes or specific diabetes related topics found to successfully reach their HbA1c target when treat-
ed in specialised secondary and tertiary care hospitals139.
26The national DM/HT study conducted by the NHSO Quality of care (responsible for administering the Universal Coverage To control diabetes with the aim to reduce complications, Scheme) found its members least successful in achieving it is essential to optimise physiological values such as an HbA1c level
Regional variation Know your ABC
The NHSO’s DM/HT study was conducted from 2010 to Strong evidence exists that controlling blood glucose helps
2012 in 602 hospitals in 76 provinces. The data available delay and prevent complications25 and with more than half
makes it possible to compare treatment outcomes on a of people with diabetes also suffering from high cholester-
regional level and this reveals considerable variation in ol and high blood pressure it is important to aim for good
average glucose control as measured by HbA1c; the risk control of all these three risk-factors7.
of complications in some areas will thus be considerably
higher than in others. A = A1c = Blood Glucose
A1c (or HbA1c) is a measure of average blood glucose
Whereas in Bangkok 45% of patients reached target levels over the last 2 to 3 months. It shows whether blood
HbA1c of less than 7.0%, in the North-East of Thailand glucose stayed close to the target range most of the time
only 23% of patients reached target, approximately or was too high or too low. The American (ADA) and
half the patients compared to Bangkok139. Some of the European (EASD) diabetes associations recommend an
individual provinces in the North-East of Thailand show HbA1cspecific level of glycemic control and to prevent hypo- C = Cholesterol
glycemia141. In Thailand, the glucose strips required for The third risk factor for many of the long-term complica-
SMBG are not reimbursed and the proportion of patients tions is elevated levels of bad cholesterol (dyslipidaemia).
using SMBG as part of their treatment plan is low at 36% Dyslipidaemia is present in as many as 80% of people with
despite most physicians advocating its use80. diabetes. Before the introduction of the Universal Care
Scheme 55% of all patients were prescribed lipid-lowering
All studies reviewed show that unfortunately only a minor- agents with a further 30% requiring but not receiving this
ity of people with diabetes in Thailand manages to achieve type of medication84. Cheap generic statins have made
their glucose target of HbA1c8. WOMEN, DIABETES AND THE
NEXT GENERATION
Gender influences the development of risk factors and diseases and affects
health risks, access to and utilisation of healthcare.
Women are at greater risk than men than men have diabetes; 8.3% vs. 6.6%70. This may be
In women with diabetes, the risk of death from coronary explained by a 50% higher prevalence of overweight and
heart disease is about 50% greater than in men85. It also obesity in women compared to men29.
appears that the effects of hyperglycaemia in combination
with other risk factors such as smoking, hypertension, hy- The foundations of life are laid in
percholesterolaemia and overweight are more harmful to early life
women than men86. In type 1 diabetes, women are twice In addition to the genes they pass on to their offspring
as likely as men to suffer neural and retinal problems87. and the direct biological influene imparted during preg-
nancy (through the uterine environment), women can also
These gender differences in mortality and risk of complica- influence the next generation by feeding and caring for
tions may be explained by more frequently occurring high their children and encouraging them to adopt a healthy
levels of bad cholesterol and high blood pressure in wom- lifestyle88. Healthy habits, such as eating a balanced diet,
en85. Another potential reason is that pre-menopausal exercising and not smoking, are learnt early in life, and are
women with diabetes lose the natural protection against associated with parental examples89.
heart disease that non-diabetic women have86.
Interventions that account for a life-course approach
Diabetes kills more Thai women to chronic diseases highlight that chronic disease risks
than men increase with age and that interventions made early in life
In Thailand, more than twice as many women die of produce a substantial risk reduction later in life.
diabetes than men. At ages 50-74, diabetes is ranked as
7th cause of death in men whereas it is ranked as the 1st Gestational diabetes
leading cause of death in women, responsible for 1 in 8 The value of a healthy pregnancy cannot be underestimat-
deaths36. Although independent factors such as road-traf- ed, directly, Gestational Diabetes Mellitus (GDM) is asso-
fic and HIV / Aids mortality play a role in explaning these ciated with an elevated risk of birth complications. From
differences, it is also true that in Thailand more women a diabetes perspective, women diagnosed with GDM are
seven times more likely to develop type 2 diabetes later in
Impact of intervention to chronic diseases
30life compared with women without GDM90. Furthermore, per 100,000 are diagnosed with type 1 diabetes annually
children of mothers with GDM or pre-existing diabetes are in Northern Europe97, this number is as low as 1.6 per
more likely to develop diabetes themselves in later life91,92. 100,000 children in Bangkok98 and possibly even lower at
0.6 per 100,000 children in Northern99 and Southern100
According to WHO criteria, GDM affects 1 in 7 preg- Thailand. Genetic susceptibility may play a role101 and it
nancies in Thailand93 and with the stricter criteria of the has been suggested that a lower exposure to sunlight and
International Association of the Diabetes and Pregnancy vitamin D contributes to the higher incidence in Europe102.
Study Groups as many as 23% of pregnancies in Thailand
was found impacted by GDM12. Reason for the preva- It is also worthwhile to note that in Thailand, the inci-
lence estimates to vary significantly are the differences in dence rate of type 1 diabetes appears to be much higher
screening methodology, testing procedures and diagnos- in girls than in boys, for reasons not explained.
tic criteria applied in various studies and the controversy
around these. It is evident though that if and when close Tomorrow’s challenge: children with
follow-up and testing is applied, prevalence of GDM is type 2 diabetes
high. This was recently confirmed by a prospective study Although the incidence of type 1 diabetes in Thai children
in Chulalongkorn hospital which identified up to 1 in 5 is suspected to increase98-100, there is more concern for the
women with GDM142. increase in the number of children with type 2 diabetes
coinciding with the rapidly increasing prevalence of obesi-
Fact is, as young Thai women approach the age of first ty in children31.
birth their level of physical activity is going down and at
age 18 is less than a third it was at age 1394. Prevalence of The paediatric department of Ramathibodi hospital has
overweight and obesity in women increases rapidly after seen the proportion of children with type 2 diabetes in-
age 18 and nearly a third of women is overweight26 at the crease from virtually none in the 1990s to 40% of all cases
time when their first child is born95. With a rising average by 2005103. Similar data is reported from Siriraj hospital
age of marriage in Thailand96, together with weight a where 30% of all children with newly diagnosed diabetes
key risk factor for GDM, the prevalence of GDM is set to in 2004 were diagnosed with type 2104. The incidence
increase. rate of type 2 diabetes in children can be expected to have
increased further in the last years but no recent data was
Children with type 1 diabetes discovered to provide further insight. Better data availabil-
The incidence of type 1 diabetes in Asia and Thailand is ity should help contribute to an appropriate health policy
low in comparison to Europe. Whereas 30 to 40 children response.
319. WHAT nEEDS TO CHANGE? The social and financial burden of diabetes is large and growing fast. Most of the cases of type 2 diabetes are preventable and most of the long-term complications can be delayed or prevented. If we fail to act now, the future costs will be even higher. Long-term rather than short-term thinking is essential. Investment in measures to prevent diabetes, to diagnose the disease early and treat it well is critical and urgent. Strong systems are also needed to track progress and drive improvement. • Measure: collect information on as local a level as possible • Share: publish this information and identify the best practices • Improve: learn from the differences, exchange best practices and implement them to improve outcomes for people with diabetes 32
10. PREVENTION PROVIDES THE
GREATEST POTENTIAL FOR GAIN
Diabetes and other chronic diseases, especially for people at high risk, can
be delayed or even avoided by prevention programmes.
Common risk factors A community-based prevention programme – for example,
The chronic disease burden is largely caused by shared one that encourages a healthy diet – could have the ben-
modifiable risk factors, including diet, physical activity, efit of reducing the rise in diabetes, but also of reducing
alcohol and tobacco105. Based on these common risk fac- the risk of other chronic diseases. Furthermore, multiple
tors, a common approach could reap significant rewards. risk factors are often present within the same individual.
Primary prevention of chronic This has clear benefits for the individual and society, as
preventing or delaying the onset of diabetes will reduce
diseases the occurrence of costly and irreversible diabetes-related
Prevention programmes must be recognised as a corner-
complications.
stone in a global response to the chronic disease bur-
den105. By encouraging and facilitating a healthier lifestyle
The complex nature of chronic diseases, including diabe-
with a balanced diet, moderate exercise, and an avoidance
tes, requires a sustainable and comprehensive approach
of tobacco and alcohol, primary prevention aims to pre-
to prevention. Ideally, prevention programmes should
vent people from developing chronic diseases.
combine broad population-based primary prevention while
simultaneously targeting disadvantaged groups and peo-
Large clinical trials as well as ‘real-world’ prevention
ple at high risk of developing a chronic disease105.
programmes have provided evidence that lifestyle inter-
ventions can prevent or delay the onset of type 2 diabetes
in people at high risk107. Specifically, the risk of developing
type 2 diabetes can be reduced by 58% over a 3 to 5
year period for people with impaired glucose tolerance by
intensive lifestyle modification programmes108,109. A risk
reduction of 31% can be achieved through pharmacologi-
cal intervention109.
The key to successful prevention is lifestyle changes, such
as weight reduction, increased physical activity, and dietary
modifications to increase dietary fibre and reduce total
and saturated fat intake. The more of these lifestyle goals
or healthy behaviours that are achieved, the lower the
incidence of type 2 diabetes107,110.
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