Prevalence and risk factors of diabetes and prediabetes in Vietnam: findings from

community diabetes screenings

Ngoc Minh Pham Asia Health Policy Postdoctoral Fellow Supervisor: Karen Eggleston February 10, 2015

Overview

§ Global status of non-communicable diseases (diabetes mellitus)

§ Study procedures § Results § Comments

Disease and economic burdens Disease burdens in 2008

Global deaths by cause and sex, 2008 (WHO)

Deaths from NCDs among persons <60 y by income, 2008 (WHO)

N Engl J Med 2013;369:1336-43.

63% of 57 mil total deaths

70% by 2030

Projected cost of global NCDs: $47 trillion between 2011-2030

Global Action Plan

Prevalence of diabetes by region and income

Age-standardized prevalence of diabetes in persons >25 y by region and income group in 2008 (WHO - Global NCD report 2010)

Prevalence of diabetes and estimated diabetes numbers by regions among adults aged 20-79 y in 2011 & 2030

Diabetes Res Clin Pract 2011;94:311-21.

Cost of diabetes A review of 30 studies shows that: l  Overall, total annual costs of diabetes $141.6 million

to $174 billion Ø  Direct cost: $150-$14,060/patient/year Ø  Indirect cost: $39.6-$7,164/patient/year

l  Asian countries: Country Total cost ($) Direct cost ($)/y Indirect cost ($)/y

India 628.3/pt/y 525.5 (83.6%) 102.8 (16.4%)

Iran 1707.4/pt/y 842.6 (49.3%) 864.8 (50.7%)

China 1707.8/pt/y 1501.7 (87.9%) 206.1 (12.1%)

Japan 4584/pt/y NA NA

Vietnam ? ? ?

Diabetes Res Clin Pract 2014;105:151-63

NA: not available

Actual & projected prevalence of impaired glucose tolerance in adults aged 2010 & 2030 (Lancet 2012;379:2279-90)

Journal of Diabetes and Its Complications 27 (2013) 429–35

n = 46,091

Epidemiological studies of diabetes and prediabetes in Vietnam ①

Year Data source Age (yrs) Area of residence

Size Prediabtes Diabetes

1994 Population-based ≥15 , 39.9 Urban & rural

4,912 1.6% 1.2%a

2004 Population-based ≥15 Urban & rural

2,932 3.8% 2.5%b

2006 Hospital admission

30-64 NA 9,057 NA 2.9%

2010 Population-based 30-70 Urban 2,142 NA M: 10.8%c

W: 11.7% 2012 Population-based

≥15

Urban & rural

2,130 NA M: 8.0%b W: 6.2%b

2012 Population-based

40-64 Urban & rural

2,710 4.3-8.7%

3.7%b

NA, not available aAge-adjusted; bAge-sex-adjusted; cCrude

Risk factors of diabetes and prediabtes

Genetic factors, family aggregation, gene-environmental interaction, ethnicity, low threshold for risk factors (age, BMI, central obesity ), adverse intra-urine, maternal and perinatal condition

Urbanization, modernization, rural-urban migration, globalization and industrialization, sedentary lifestyle, consumption of energy and dense food, smoking, tobacco chewing, excess alcohol

Low awareness about diabetes, cultural & religious taboos, psycho-social factors affecting health, insufficient health facilities, lack of built-in environment for physical activity

Diabetes Res Clin Pract 2014 ;103:231-7

Epidemiological studies of diabetes and prediabetes in Vietnam ②

l  Age

l  Overweight

l  High waist-hip ratio

l  Systolic/diastolic blood pressure

l  Urban area

l  High alcohol drinking

l  Family history of diabetes

Aims

a)  To determine prevalence rates of diabetes and prediabetes

b)  To identify demographic, anthropometric and lifestyle factors in relation to diabetes and prediabtes

among Vietnamese adults in northern Vietnam

Methods l  Data were drawn from community-based diabetes

screening programs (2011-2013) in Thai Nguyen province of Vietnam

l  Diabetes screening is a component of the national strategic plan for tackling diabetes and hypertension, starting from 2010 nationwide

l  Leading organizations: Ministry of Health, National Hospital of Endocrinology

l  Implementing institution: Provincial Center for Preventive Medicine

Study setting Thai Nguyen province •  Gateway to Vietnam’s

mountainous northeastern

region

•  Population (2009): 1,123,116

•  Women: 51%

•  Rural population: 74.4%

•  Ethnicity: 8 groups (90%:

Kinh )

•  Home to 17 universities/

colleges

Community-dwelling people (Aged: 30-69 y)

>55 40- 54+ 1 risk factor 30- 39+ 2 risk factors

Previously diagnosed diabtes

IFG NGT

IGT

Interview-administered questionnaire Blood sugar measurement

Excluded for management

Prediabetes

Self-rating checklist to identify risk factors for

diabetes

Without diabetes risk factors

Newly diagnosed diabetes

Total diabetes (previous and new

cases)

Diabetes screening

Study subjects

16,730 aged 24-87 (2011-2013)

16,730

-  Fasting <8 h (n =106) -  30 y <Age <69 y (n = 194)

16,282 (men: 5,602, women: 10,680)

Extreme values: PFG & 2-h OGTT (n = 97), anthropometric variables & hypertension (n = 35), missing data (n = 16)

Definition of diabetes & prediabetes

According to the 2006 WHO recommendation:

Diabetes

Fasting plasma glucose ≥7.0 mmol/l (126mg/dl) OR

2-h plasma glucose ≥11.1mmol/l (200mg/dl)

Impaired Glucose Tolerance (IGT) Fasting plasma glucose <7.0mmol/l (126mg/dl) AND

2–h plasma glucose ≥7.8 and <11.1mmol/l (140mg/dl and 200mg/dl)

Impaired Fasting Glucose (IFG)

Fasting plasma glucose 6.1 to 6.9mmol/l (110mg/dl to 125mg/dl)

2–h plasma glucose AND <7.8mmol/l (140mg/dl)

Definition & classification of other variables

Age 30-39, 40-49, 50-59, 60-69 y

Job physical activity Light, moderate or heavy

Area of residence Urban vs. rural

History of diseases Yes/no

Overweight or obesity BMI (kg/m2) ≥23 or ≥25

Central obesity Waist circumference ≥90 cm (men), ≥80 cm (women)

Hypertension systolic BP ≥140 mmHg or diastolic BP ≥90 or current use of antihypertensive drugs

Prehypertension Systolic BP 120-139 mmHg or diastolic BP 80-89 mmHg

Educational level Low, medium or high

Statistical analysis ①

-  By men and women -  Means (SD) or percent -  T-tests and χ² tests -  Standardization of prevalence of diabetes & prediabtes

by 10-year age group, sex, area of residence using the national population in 2009

-  Projections for 2035 using a static model (multiplication of age & sex-specific prevalence by the 2035 population estimates)

Statistical analysis ② Vietnam pop in 2009: 85,846,997 (women: 50.6%)

Men Women

Aged 30-69 y: 41.6%

Statistical analysis ③

-  Bivariate analysis -  Multinomial regression models, using normal glucose

tolerance as the referent category -  Adjustment for potential confounding -  Analyses performed with Stata

RESULTS

Men Women P Age (yr, mean) 54.6 (7.8) 53.1 (8.3) <0.001

Body mass index (kg/m2) 22.7 (3.0) 22.2 (3.1) <0.001

Waist circumference (cm) 80.4(8.6) 76.5 (8.3) <0.001

Waist-hip ratio 0.89 (0.06) 0.86 (0.06) <0.001

Hypertension (%) 56.9 38.8 <0.001

Ethnic minority group 27.3 23.1 <0.001

Rural area 71.2 69.6 0.03

Family diabetes 13.0 14.7 0.001 Educational level

Primary or lower 13.9 21.6

Junior secondary 48.3 49.2

Senior secondary 24.0 17.0

Vocational or university 13.8 12.1 <0.001

Table 1. Characteristics of subjects by sex

Figure 1. Age-standardized prevalence of diabetes by sex & projection for 2035

All: 5.6 (5.1-6.2)

Year 2035: 7.0 (6.5-7.5)

Figure 2. Age-standardized prevalence of prediabetes by sex & projection for 2035

All: 13.3 (12.4-14.2) Year 2035: 15.7 (15.0-16.4)

Figure 3. Age- & sex-standardized prevalence of diabetes by area

All: 6.0 (5.2-6.7)

Figure 4. Age- & sex-standardized prevalence of prediabetes by area

All: 13.5 (12.4-14.5)

RESULTS

Normal Prediabetes Diabetes Age (y, mean) 52.8 55.5 56.4

Female (%) 66.4 65.9 57.7

BMI (mean) 22.2 22.8 23.3 Systolic blood pressure (mean) 132 135 142

Diastolic blood pressure (mean) 79 80 84

Hypertension (%) 41.8 49.5 63.5

Family diabetes 14.7 11.6 14.8

Low job physical activity (%) 23.5 25.9 29.3

Ethnic minority group 26.7 19.2 18.2 CVD history (%) 21.3 23.3 23.1 Dyslipidemic history 8%) 5.5 8.9 12.7

Table 2. Average risk factors among diabetic, prediabetic individuals compared to normal subjects

Figure 5. Diabetes in relation to selected risk factors in men

Increased risk Decreased risk No

Figure 6. Diabetes in relation to selected risk factors in women

Increased risk Decreased risk No

Figure 7. Prediabetes in relation to selected risk factors in men

Increased risk Decreased risk No

Figure 8. Prediabetes in relation to selected risk factors in women

Increased risk Decreased risk No

Prevalence rates of diabetes & diabetes in previous studies in Vietnam

Figure 9. Prevalence of diabetes/prediabetes (95% CI) among Vietnamese adults

Prevalence rates of diabetes in previous studies in Vietnam & present data

Figure 10. Pooled prevalence of diabetes (95% CI)

Percent

Diabetes prevalence in Asia - 2013 estimates Country Prevalence (%) Country Prevalence (%)

Cambodia 2.5 Japan 7.6

Nepal 4.5 Srilanka 8.0

Bangladesh 5.5 India 8.6

Indonesia 5.6 South Korea 8.9

Myanmar 5.7 China 9.6

Philippines 6.0 Taiwan 9.8

Thailand 6.4 Australia 10.0

North Korea 7.3 Malaysia 10.1

The present finding: 6.0% Diabetes Res Clin Pract 2014;103:137-49.

Diabetes prevalence in representative countries of other regions- 2013 estimates

Country Prevalence (%) Country Prevalence (%)

Canada 10.2 Argentina 6.0

US 10.9 Venezuela 6.6

Mexico 11.8 Brazil 9.0

UK 6.6 Uganda 4.1

Spain 10.8 Nigeria 5.0

Germany 11.9 South Africa 8.3

The present finding: 6.0% Diabetes Res Clin Pract 2014;103:137-49.

Prediabetes prevalence in some Asian countries

Country Prevalence (%) Year Source

Singapore 9.1% 2011 Diabetologia 2011;54:767-75

Thailand 13.0 2012 Int J Gen Med 2012;5:219-25.

Cambodia 13.0 2005 Lancet 2005;366:1633-9

Bangladesh 22.4 2014 Bull World Health Organ 2014:92:204-213A

Japan 31.9 (men) 2014 Diabetes Res Clin Pract 2014;106:118-27.

China 50.1% 2013 JAMA 2013;310:948-59

The present finding: 13.5%

Sex-difference and diabetes risk We found that prevalence of diabetes was 26% higher in men compared to women (6.5% vs. 4.8%)

Country Men Women Indonesia 6.6% 7.1% Malaysia 11.6% 11.2% Philippines 6.5% 6.6% Thailand 7.3% 7.1% Sri Lanka 9.3% 8.6% Bangladesh 9.2% 9.9% China 9.6% 9.4% Japan 7.2% 4.7% India 11.1% 10.8% Worldwide 9.8% 9.2%

Lancet 2011;378:31-40; Annu Rev Nutr 2012;32:417-39

Data in 2008

Journal of Diabetes and Its Complications 2013;27:429–35

*Age, smoking, high BP, BMI, health insurance, poverty line, heart failure, CHD, physical activity, times eating vegetables

Fully-adjusted odds ratio*

Association between gender (male vs. female) and diabetes Among Californians

But not the case in sub-Saharan Africa

Bull World Health Organ 2013;91:671-682D

Advancing age and diabetes

Aging and metabolic disorders International Journal of Endocrinology. Volume 2012,. doi:10.1155/2012/320482

Overweigh/obesity and diabetes risk

Abdominal obesity and incident diabetes

Present results: OR for diabetes among centrally obese subjects vs. normal-weight ones : 1.78 (men), 1.82 (women)

Int J Clin Pract 2008, 62, 9, 1391–6

Physical inactivity and diabetes

Association between sedentary time and diabetes Diabetologia 2012;55:2895-2905

Our data: OR:1.69, 95% CI: 1.02-2.78, comparing men with light physical activity (PA) to those with heavy PA

Urban exposure and likelihood of diabetes

Public Health 2014;128:886-95

Our finding: urban men was 1.2 times likely to have diabetes relative to rural men

Conclusion -  Analysis of 16,282 individuals aged 30-69 y during 2011-2013 -  About one in 17 adults had diabetes, projected to rise to one in 14 by 2035 -  Prevalence of diabetes was higher in men (8.0%) than in women (5.4%) -  Prevalence of diabetes was higher in urban residents (6.7%) than in rural ones (5.2%) -  Older age, overweight/obesity, hypertension physical inactivity are major determinants

Summary of this work was accepted for publication as a letter in Diabetes Care.

Policy implications

Level Prevention Detection

Government - Built-in environment for physical activity - Reduction of sedentary lifestyle - Investment for diabetes research

Raising awareness of diabetes: campaigns, mass media, education

Healthcare system Personnel training, strengthening inter-sectoral collaboration

Surveillance of diabetes and risk factors, provision of low-cost facilities for detection

Clinicians Counselling Evaluation of risk factors, lifestyle intervention

- Participants who attended community diabetes

screening programs (2011-2013)

- Thai Nguyen Center for Preventive Medicine, Vietnam

- National Endocrinology Hospital, Vietnam

- Shorenstein APARC at Stanford and APO

Acknowledgments

My upcoming activities

- Review of epidemiological studies of diabetes in Vietnam over

the past 20 years using international & domestic publications

-  Collecting data on costs of diabetes in Vietnam

-  Interviewing some key persons at the Vietnam Ministry of

Health for the national NCD strategic plan & policy

-  Compiling a policy paper addressing NCDs in Vietnam

-  Talking about this issue in late Spring 2015