Advertisement

Diabetes in the Western Pacific Region—Past, Present and Future

  • Juliana C.N. Chan
    Correspondence
    Corresponding author at: Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China.
    Affiliations
    Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China

    Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China

    Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China
    Search for articles by this author
  • Nam H. Cho
    Affiliations
    Department of Preventive Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
    Search for articles by this author
  • Naoko Tajima
    Affiliations
    Jikei University School of Medicine, Tokyo, Japan
    Search for articles by this author
  • Jonathan Shaw
    Affiliations
    Baker IDI Heart and Diabetes Institute, Melbourne, Australia
    Search for articles by this author
Published:January 13, 2014DOI:https://doi.org/10.1016/j.diabres.2013.11.012

      Abstract

      In the 2013 issue of the International Diabetes Federation (IDF) Diabetes Atlas, the prevalence of diabetes in the Western Pacific (WP) Region was reported to be 8.6% in 2013, or 138 million adults, and estimated to rise to 11.1%, or 201 million adults, in 2035. The prevalence estimates of impaired glucose tolerance in 2013 and 2035 were 6.8% and 9.0%, respectively. Over 50% of people with diabetes were undiagnosed. In 2013, 187 million deaths were attributable to diabetes, 44% of which occurred in the under the age of 60. The WP Region is home to one quarter of the world's population, and includes China with the largest number of people with diabetes as well as Pacific Islands countries with the highest prevalence rates. There is a rapid increase in diabetes prevalence in the young-to-middle aged adults, possibly driven by high rates of childhood obesity and gestational diabetes as well as rapid demographic and sociocultural transitions. Differences in genetics, ethnicity, cultures and socioeconomic development have led to complex host-environment-lifestyle interactions with marked disease heterogeneity, further influenced by access to care and treatment. Despite these challenges, the WP Region has provided notable examples to prevent and control diabetes.

      Keywords

      1. Introduction

      The Western Pacific (WP) Region is home to more than 1.6 billion people accounting for 31% of the world population and contributing to over 34% of the global adult diabetic population. In the early 1980s, studies in the WP Region reported a prevalence of 1–2% of diabetes [
      • Chan J.C.
      • Malik V.
      • Jia W.
      • Kadowaki T.
      • Yajnik C.S.
      • Yoon K.H.
      • Hu F.B.
      Diabetes in Asia Epidemiology, risk factors, and pathophysiology.
      ] with type 1 diabetes being very rare even in young people [
      • Tajiman N.
      • La Porte R.E.
      • Hibi I.
      • Kitagawa T.
      • Fujita H.
      • Drash A.L.
      A comparison of the epidemiology of youth-onset insulin-dependent diabetes mellitus between Japan and the United Sates (Allegheny County, Pennsylvania).
      ]. In the WP Region, stroke and renal disease were the leading causes of death in people with diabetes [
      • Morrish N.J.
      • Wang S.
      • Stevens L.K.
      • Fuller J.H.
      • Keen H.
      Mortality and causes of death in the WHO Multinational Survey of Vascular Diseases in Diabetes.
      ].
      Since early 1990s, studies were conducted reporting the prevalence of diabetes using standard methodologies and found both differences and similarities in terms of risk factors, epidemiology and pathophysiology of diabetes in the WP Region compared to Europe and North America [
      • Chan J.C.
      • Malik V.
      • Jia W.
      • Kadowaki T.
      • Yajnik C.S.
      • Yoon K.H.
      • Hu F.B.
      Diabetes in Asia Epidemiology, risk factors, and pathophysiology.
      ,
      • Yoon K.H.
      • Lee J.H.
      • Kim J.W.
      • Cho J.H.
      • Choi Y.H.
      • Ko S.H.
      • et al.
      Epidemic of obesity and type 2 diabetes in Asia.
      ,
      • Ramachandran A.
      • Ma R.C.W.
      • Snehalatha C.
      Diabetes in Asia.
      ].
      In this article, we summarized the latest landscape of diabetes based on estimates from the International Diabetes Federation (IDF) Diabetes Atlas [
      ] and discussed our current understanding of this complex disease in the WP Region and possible strategies to combat this potential public health challenge and personal disaster.

      2. Methodology

      The search strategy for the generation of the IDF Diabetes Atlas data has been described in detail elsewhere [
      • Guariguata L.
      • Beagley J.
      • Linnenkamp U.
      • Hambleton I.
      • Shaw J.
      • Cho N.H.
      • et al.
      Global estimates of prevalence of diabetes in adults for 2013 and projections to 2035 from the IDF diabetes Atlas.
      ]. Briefly, a literature search was conducted for studies reporting the age-specific prevalence for diabetes, and the Analytic Hierarchy Process was used to systematically select studies to generate estimates. Estimates for countries without available source data were modeled from pooled estimates of countries that were similar in regard to geography, ethnicity, and economic development. Logistic regression was applied to generate smoothed age-specific prevalence estimates for adults 20–79 years which were then applied to population estimates for 2013 and 2035.

      3. Diabetes in adults

      The prevalence of diabetes in the WP Region was estimated at 8.6% in 2013, or 138 million adults, and projected to rise to 11.1% by 2035, or 201 million adults [
      ]. While China harbors the largest number of affected subjects, some small Pacific Islands countries, led by Tokelau, have some of the world's highest prevalences of diabetes (Table 1, Table 2, Table 3).
      Table 1Key facts and figures about diabetes in the Western Pacific Region
      .
      20132035
      Adult population (20–79 years, 1000s)1,613,207.011,818,169.03
      Diabetes in adults (20–79 years)
      Regional Prevalence (%)8.5711.10
      Comparative Prevalence (%)8.078.42
      Diabetes cases (1000s)138,194.80201,789.37
      Cases undiagnosed (1000s)74,655.96
      IGT in adults (20–79 years)
      Regional Prevalence (%)6.829.05
      Comparative Prevalence (%)6.597.77
      Number of people with IGT (1000s)110,091.17164,546.89
      Type 1 diabetes in youth (0–14 years)
      Number of children with type 1 diabetes (1000s)32.50
      Number of newly-diagnosed (per 100,000 per year)5.30
      Deaths due to diabetes in adults (20–79 years)
      Total deaths due to diabetes1,868,810.93
      % of deaths under 6044.3
      Health expenditure
      Health expenditure due to diabetes (billion USD)88.37
      Table 2Top 10 countries in the Western Pacific Region in terms of number of subjects affected by diabetes
      .
      Country/TerritoryNumber of subjects (in 1000s), 2013
      China98,407.379
      Indonesia8554.165
      Japan7203.776
      Republic of Korea3323.903
      Viet Nam3299.113
      Philippines3256.215
      Thailand3150.670
      Myanmar1988.846
      Malaysia1913.236
      Taiwan1721.062
      Table 3Top 10 countries in the Western Pacific Region in terms of prevalence of diabetes
      .
      Country/TerritoryPrevalence (%), 2013
      Tokelau37.49
      Federated States of Micronesia35.03
      Marshall Islands34.89
      Kiribati28.77
      Cook Islands25.66
      Vanuatu23.97
      Nauru23.29
      French Polynesia22.41
      New Caledonia19.49
      Guam19.48
      Rapid development and associated increases in obesity and unhealthy lifestyle are the main drivers of increases in the diabetes epidemic in the WP Region. In 2008, 60–70% of people in Tonga, Nauru and Cook Islands were considered obese [
      • Stevens G.A.
      • Singh G.M.
      • Lu Y.
      • Danaei G.
      • Lin J.K.
      • Finucane M.M.
      • et al.
      Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group. National, regional, and global trends in adult overweight and obesity prevalences.
      ]. Using the Diabetes Epidemiology Collaborative analysis of Diagnostic criteria in Asia (DECODA) data, 30–50% of subjects in the WP Region had metabolic syndrome, a strong predictor for future development of diabetes [
      • DeCODA Study Group
      Prevalence of the metabolic syndrome in populations of Asian origin. Comparison of the IDF definition with the NCEP definition.
      ].
      In 2004, the sex-standardized diabetes prevalence was reported to be 13.0% in men and 14.4% in women in Nauru. The age-specific prevalence rose from 4.5% in the 15–24 age group to 42.7% in the 55–64 age group [
      • Khambalia A.
      • Phongsavan P.
      • Smith B.J.
      • Keke K.
      • Dan L.
      • Fitzhardinge A.
      • Bauman A.E.
      Prevalence and risk factors of diabetes and impaired fasting glucose in nauru.
      ]. In the islands of Vanuatu, researchers reported close associations of economic development with increased consumption of animal proteins and simple carbohydrates, as well as increased tobacco and alcohol consumption in men in areas with high tourism [
      • Dancause K.N.
      • Dehuff C.
      • Soloway L.E.
      • Vilar M.
      • Chan C.
      • Wilson M.
      • et al.
      Behavioral changes associated with economic development in the South Pacific: Health transition in Vanuatu.
      ]. In a national survey conducted in China in 2010, the authors reported a diabetes prevalence of 11.6% with number of affected people already exceeding the IDF estimates for 2013. One third of the subjects had either central or general obesity, with diabetes closely associated with other risk factors such as hypertension and dyslipidemia [
      • Xu Y.
      • Wang L.
      • He J.
      • Bi Y.
      • Li M.
      • Wang T.
      • et al.
      On behalf of the 2010 China Non-communicable Disease Surveillance Group
      Prevalence and control of diabetes in Chinese adults.
      ].

      4. Undiagnosed diabetes

      In the WP Region, the proportions of subjects with undiagnosed diabetes were estimated to be 63% in the low income countries, 54.1% in the middle income countries and 49.4% in the high income countries [
      ]. In two national surveys conducted in China in 2007 [
      • Yang W.
      • Lu J.
      • Weng J.
      • Jia W.
      • Ji L.
      • Xiao J.
      • et al.
      Prevalence of diabetes among men and women in China.
      ] and 2010 [
      • Xu Y.
      • Wang L.
      • He J.
      • Bi Y.
      • Li M.
      • Wang T.
      • et al.
      On behalf of the 2010 China Non-communicable Disease Surveillance Group
      Prevalence and control of diabetes in Chinese adults.
      ], only 50% and 30% of subjects respectively, were previously diagnosed, suggesting low levels of awareness and diagnosis.

      5. Impaired glucose tolerance (IGT) and prediabetes

      In the WP Region, the prevalence of people with IGT was estimated to increase from 6.8% in 2013 to 9.0% by 2035 [
      ]. In the 2010 China national survey, 50.1% of subjects had either impaired fasting glycemia and/or IGT [
      • Xu Y.
      • Wang L.
      • He J.
      • Bi Y.
      • Li M.
      • Wang T.
      • et al.
      On behalf of the 2010 China Non-communicable Disease Surveillance Group
      Prevalence and control of diabetes in Chinese adults.
      ]. In the 2003 Shanghai survey, the 3-year cumulative incidence of diabetes and prediabetes were 4.9% and 11.1% respectively with a 10% annual progression rate from IGT to diabetes [
      • Jia W.
      • Xiang K.
      • Chen L.
      • Lu J.
      • Wu Y.
      Epidemiological study on obesity and its comorbidities in urban Chinese older than 20 years of age in Shanghai, China.
      ]. Without prevention strategies, a large proportion of people with IGT in the WP Region will progress to type 2 diabetes.

      6. Type 1 diabetes in children

      Compared to Europid populations in whom the majority of people diagnosed before the age of 40 had autoimmune type 1 disease [
      • Laakso M.
      • Pyorala K.
      Age of onset and type of diabetes.
      ], less than 10% of young Asian people with diabetes have classical type 1 presentation [
      • Kong A.P.S.
      • Chan J.C.N.
      Other disorders with type 1 phenotype.
      ]. In the WP Region, the number of children with type 1 diabetes was estimated at 32,500 with an annual incidence estimate of 5300 [
      ].
      There is large variability in the incidence of type 1 diabetes in children across countries in the WP Region. Compared to a mean age standardized incidence of 16.5 per 100,000 person years in Western Australia [
      • Haynes A.
      • Bower C.
      • Bulsara M.K.
      • Jones T.W.
      • Davis E.A.
      Continued increase in the incidence of childhood Type 1 diabetes in a population-based Australian sample (1985–2002).
      ], the annual incidence of type 1 diabetes in Japan was 1.5–2.5 per 100,000. While the majority of children diagnosed with diabetes before the age of 10 years have type 1 diabetes, after the introduction of a urine glucose screening programme in 1974, more cases of childhood type 2 diabetes were detected in Japan with a reported annual incidence of 3.0 per 100,000 [
      • Tajima N.
      • Morimoto A.
      Epidemiology of childhood diabetes mellitus in Japan.
      ].
      Outcomes for children with type 1 diabetes in Japan have improved. Between 1965 and 1979, the mortality rate of type 1 diabetes was 12.9-fold higher than that of the general Japanese population [
      • Tajima N.
      • Morimoto A.
      Epidemiology of childhood diabetes mellitus in Japan.
      ]. With better medical care, the standardized mortality ratio has declined markedly over the past 30 years [
      • Morimoto A.
      • Onda Y.
      • Nishimura R.
      • Sano H.
      • Utsunomiya K.
      • Tajima N.
      Diabetes Epidemiology Research International Mortality Study Group. Cause-specific mortality trends in a nationwide population-based cohort of childhood-onset type 1 diabetes in Japan during 35 years of follow-up: The Deri Mortality Study.
      ]. However, for many of the least developed communities in the WP Region, access to insulin remains limited and early death due to type 1 diabetes is not uncommon.

      7. Young-onset diabetes and latent autoimmune diabetes in adults

      Slowly progressive type 1 diabetes or latent autoimmune diabetes in adults (LADA) with features of both type 1 and type 2 diabetes was first reported in the WP Region [
      • Kobayashi T.
      • Tamemoto K.
      • Nakanishi K.
      • Kato N.
      • Okubo M.
      • Kajio H.
      • et al.
      Immunogenetic and clinical characterization of slowly progressive IDDM.
      ]. In the LADA China study involving 4880 ketosis-free diabetic patients aged over 30 years, 6% were considered to have LADA defined by a glutamic acid decarboxylase antibodies (GADA) ≥18 units/mL. Patients with GADA positivity tended to have lower body mass index and were less likely to have the metabolic syndrome [
      • Zhou Z.
      • Xiang Y.
      • Ji L.
      • Jia W.
      • Ning G.
      • Huang G.
      • et al.
      Frequency, immunogenetics, and clinical characteristics of latent autoimmune diabetes in China (LADA China Study Group): A nationwide, multicenter, clinic-based cross-sectional study.
      ]. There was an inverse relationship between GADA positivity and beta cell function although the association of GADA positivity with haplotypes were less consistent compared to Western populations [
      • Zhou Z.
      • Xiang Y.
      • Ji L.
      • Jia W.
      • Ning G.
      • Huang G.
      • et al.
      Frequency, immunogenetics, and clinical characteristics of latent autoimmune diabetes in China (LADA China Study Group): A nationwide, multicenter, clinic-based cross-sectional study.
      ].
      In contrast to developed countries in which the largest number of people with diabetes are aged 60–79 years, in developing countries, the age-group with the largest number of people with diabetes is 40–59 years [
      • Shaw J.E.
      • Sicree R.A.
      • Zimmet P.Z.
      Global estimates of the prevalence of diabetes for 2010 and 2030.
      ]. In the latest survey in China, 5–8% in the 18–40 age group had diabetes and 40–50% had prediabetes [
      • Xu Y.
      • Wang L.
      • He J.
      • Bi Y.
      • Li M.
      • Wang T.
      • et al.
      On behalf of the 2010 China Non-communicable Disease Surveillance Group
      Prevalence and control of diabetes in Chinese adults.
      ]. Studies from the WP Region have highlighted the phenotypic and genotypic heterogeneity of these young subjects. In the early 1990s, small case series indicated that 10–20% of Asian patients diagnosed before the age of 40 had autoimmune or monogenic diabetes with predominant lean phenotypes, although with rising obesity rate, atypical presentation with features of both insulin insufficiency and resistance, so called ‘double diabetes’ were not uncommon [
      • Kong A.P.S.
      • Chan J.C.N.
      Other disorders with type 1 phenotype.
      ,
      • Ma R.C.
      • Chan J.C.
      • Diabetes:
      incidence of childhood type 1 diabetes: a worrying trend.
      ,
      • Alberti G.
      • Zimmet P.
      • Shaw J.
      • Bloomgarden Z.
      • Kaufman F.
      • Silink M.
      • et al.
      Consensus Workshop Group
      Type 2 diabetes in the young: The evolving epidemic: The International Diabetes Federation Consensus Workshop.
      ].
      On average, diabetes reduces life expectancy by 6 years [
      • Seshasai S.R.
      • Kaptoge S.
      • Thompson A.
      • Di Angelantonio E.
      • Gao P.
      • SarwarF N.
      • et al.
      Diabetes mellitus, fasting glucose, and risk of cause-specific death.
      ], especially in subjects with young onset of disease. In a recent analysis of over 2000 Chinese patients diagnosed before the age of 40 years, 10% had type 1 diabetes, 60% were overweight type 2 diabetic patients, and 30% were normal-weight type 2 diabetic patients. Overweight type 2 diabetic patients had the worst metabolic profile and highest prevalence of microvascular complications with 15-fold greater hazard of progression to cardiovascular disease compared to type 1 diabetic patients who had the lowest event rates [
      • Luk A.O.Y.
      • Lau E.
      • So W.Y.
      • Ma R.C.W.
      • Kong A.P.S.
      • Ozaki R.
      • Chow F.C.C
      • et al.
      Prospective study on the incidences of cardiovascular-renal complications in Chinese patients with young-onset type 1 and type 2 diabetes mellitus.
      ].

      8. Health expenditures and costs

      The World Health Organization (WHO) recognized diabetes, heart disease, respiratory disease and cancer as the leading non-communicable diseases (NCD) which contributed to 60% of global deaths. Diabetes frequently coexists with these NCDs and may be causal to the development of cardiovascular disease. In 2013, approximately USD 88.4 billion was spent in the WP Region on diabetes-related direct healthcare expenditures. This figure is projected to increase to USD 98.4 billion by 2035 [
      ].
      In China, the medical costs attributable to overweight and obesity in 2003 were estimated at USD 2.7 billion. The latter accounted for 25.5% of the total medical costs attributable to diabetes, heart disease, respiratory disease and cancer, or 3.7% of national total medical costs. This figure was expected to increase to USD 4.8 billion if the epidemic of obesity continued to rise [
      • Zhao W.
      • Zhai Y.
      • Hu J.
      • Wang J.
      • Yang Z.
      • Kong L.
      • et al.
      Economic burden of obesity-related chronic diseases in Mainland China.
      ]. In Australia, the annual direct per person costs for people with known diabetes was A$4390 compared to A$1898 for those with normal glucose tolerance. In 2005, the total annual cost of diabetes for Australians aged ≥30 years was A$10.6 billion (A$4.4 billion in direct costs; A$6.2 billion in government subsidies) which represented an excess annual cost of A$4.5 billion (A$2.2 billion in direct costs; A$2.3 billion in government subsidies) associated with diabetes [
      • Lee C.M.
      • Colagiuri R.
      • Magliano D.J.
      • Cameron A.J.
      • Shaw J.
      • Zimmet P.
      • et al.
      The cost of diabetes in adults in Australia.
      ].
      In Taiwan, provision of national coverage has led to more frequent annual assessments for risk factors and complications in the last decade with improved diabetes care [
      • Chang T.J.
      • Jiang Y.D.
      • Chang C.H.
      • Chung C.H.
      • Yu N.C.
      • Chuang L.M.
      Accountability, utilization and providers for diabetes management in Taiwan, 2000–2009: an analysis of the National Health Insurance database.
      ]. However, government subsidies for preventive care remain minimal in many low- and middle-income countries in the WP Region, often leading to either late presentation with high hospitalization costs or out of pocket expenditures for outpatient visits [
      • Wang W.
      • Fu C.
      • Zhuo H.
      • Luo J.
      • Xu B.
      Factors affecting costs and utilization of type 2 diabetes healthcare: a cross-sectional survey among 15 hospitals in urban China.
      ]. In a recent analysis of inpatient spending due to type 2 diabetes in India, China, Thailand and Malaysia, the authors reported an expenditure of 11–75% of per-capita income in patients without complications, which were increased by 6–300% in those with complications treated at the same hospital. Overall, uninsured patients had higher A1c than those insured. These figures highlighted the substantial out-of-pocket financing burdens in some areas such as India and China [
      • Goldhaber-Fiebert J.D.
      • Li H.
      • Ratanawijitrasin S.
      • Vidyasagar S.
      • Wang X.Y.
      • Aljunid S.
      • et al.
      Inpatient treatment of diabetic patients in Asia: Evidence from India, China, Thailand and Malaysia.
      ].
      Despite differences in treatment costs and financing systems, in a recent systematic analysis, health economists identified interventions which were considered cost-saving or very cost-effective. These included use of renin-angiotensin system (RAS) inhibitors for renoprotection, comprehensive foot care to prevent ulcers, multi-component interventions for control of risk factors in both type 1 and type 2 diabetes, intensive lifestyle interventions to prevent progression from IGT to diabetes, intensive glycemic control in newly diagnosed diabetes, use of statins for cardiovascular protection, annual screening for diabetic retinopathy and counseling for smoking cessation [
      • Li R.
      • Zhang P.
      • Barker L.E.
      • Chowdhury F.M.
      • Zhang X.
      Cost-effectiveness of interventions to prevent and control diabetes mellitus: a systematic review.
      ]. To this end, several programs initiated in the WP Region have confirmed the benefits of lifestyle modification and use of metformin and alpha glucosidase inhibitors [
      • Li G.
      • Zhang P.
      • Wang J.
      • Gregg E.W.
      • Yang W.
      • Gong Q.
      • et al.
      The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: A 20-year follow-up study.
      ,
      • Yang W.
      • Lin L.
      • Qi J.
      • Yu Z.
      • Pei H.
      • He G.
      • et al.
      The preventive effect of acarbose and metformin on the progression to diabetes mellitus in the IGT population: A 3-year multicentre prospective study.
      ,
      • Kawamori R.
      • Tajima N.
      • Iwamoto Y.
      • Kashiwagi A.
      • Shimamoto K.
      • Kaku K.
      Voglibose for prevention of type 2 diabetes mellitus: a randomised, double-blind trial in Japanese individuals with impaired glucose tolerance.
      ] in preventing diabetes as well as that of statins [
      • Luk A.O.
      • Yang X.
      • Ma R.C.
      • Ng V.W.
      • Yu L.W.
      • Lau W.W.
      • et al.
      Association of statin use and development of renal dysfunction in type 2 diabetes - the Hong Kong Diabetes Registry.
      ,
      • Ting R.Z.
      • Yang X.
      • Yu L.W.
      • Luk A.O.
      • Kong A.P.
      • Tong P.C.
      • et al.
      Lipid control and use of lipid-regulating drugs for prevention of cardiovascular events in Chinese type 2 diabetic patients: A prospective cohort study.
      ], RAS inhibitors [
      • So W.Y.
      • Chan N.
      • Tong P.C.Y.
      • Chow C.C.
      • Chan W.B.
      • Ng M.C.Y.
      • et al.
      Effect of RAAS inhibition on survival and renal outcomes in 3737 Chinese type 2 diabetic patients.
      ] intensive glycaemic control in type 1 diabetes [
      • Ohkubo Y.
      • Kishikawa H.
      • Araki E.
      • Miyata T.
      • Isami S.
      • Motoyoshi S.
      • et al.
      Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: A randomized prospective 6-year study.
      ] and multifaceted care in type 2 diabetes in reducing major clinical outcomes including death [
      • Leung W.Y.S.
      • So W.Y.
      • Tong P.C.Y.
      • Chan N.N.
      • Chan J.C.N.
      Effects of structured care by a pharmacist-diabetes specialist team in patients with type 2 diabetic nephropathy.
      ,
      • Chan J.C.
      • So W.Y.
      • Yeung C.Y.
      • Ko G.T.
      • Lau I.T.
      • Tsang M.W.
      • et al.
      Effects of structured versus usual care on renal endpoint in type 2 diabetes: The SURE study: A randomized multicenter translational study.
      ].

      9. Mortality

      In 2013, nearly 2 million of deaths in adults in the WP Region were attributable to diabetes, 44% of which occurred under the age of 60. In the Emerging Risk Factors Collaboration which analyzed 97 international prospective studies of 820,900 people with an accrual of 123,205 deaths, diabetes reduced life expectancy by 6 years especially in young-to-middle-aged subjects. Compared to those without diabetes, people with diabetes had a 1.3–3 fold increased risk of death due to cardiovascular disease, renal failure, mental illnesses, all-site cancer, hepato-biliary disease and sepsis [
      • Seshasai S.R.
      • Kaptoge S.
      • Thompson A.
      • Di Angelantonio E.
      • Gao P.
      • SarwarF N.
      • et al.
      Diabetes mellitus, fasting glucose, and risk of cause-specific death.
      ].
      In the Hong Kong Diabetes Registry established in 1995, 7534 Chinese type 2 diabetic patients were censored in 2005. After a mean follow-up period of 5.5 years, 763 died with the main causes of death being neoplasms (24.5%), cardiovascular (23.5%), respiratory (15.3) and renal disease (15.3%) [
      • So W.Y.
      • Yang X.
      • Ma R.C.
      • Kong A.P.
      • Lam C.W.
      • Ho C.S.
      • et al.
      Risk factors in V-shaped risk associations with all-cause mortality in type 2 diabetes - the Hong Kong Diabetes Registry.
      ]. In Taiwan, based on various national databases, the mortality rate of diabetic patients has declined over time (men, women: 3.92%, 3.29% in 2000; 3.64%, 3.11% in 2005, and 3.12%, 2.71% in 2009) although it remained higher in men than women. In 2009, the estimated loss of life due to diabetes was 6.1 years in women and 5.3 years in men in subjects diagnosed at the age of 40. The four major causes of death were diabetes, malignancies, heart diseases, and cerebrovascular diseases [
      • Li H.Y.
      • Jiang Y.D.
      • Chang C.H.
      • Chung C.H.
      • Lin B.J.
      • Chuang L.M.
      Mortality trends in patients with diabetes in Taiwan: a nationwide survey in 2000–2009.
      ].

      10. Morbidity

      10.1 Cardiovascular-renal disease

      The diversity in risk factors and access to care has resulted in marked differences in the geographical distributions of vascular complications in the WP Region. In areas where access to medications, revascularization and renal replacement were limited, end stage renal disease and stroke were often the leading causes of death in type 2 diabetes. In the Pacific Islands, leg amputation continues to be a major cause of morbidity and mortality. In a recent survey of 85 people with diabetes and amputations in the Solomon Islands, Nauru and Vanuatu, the major reasons leading to leg amputation included delayed treatment (42%), use of traditional treatments (18%) and insufficient knowledge about foot care (11%) [
      • Win Tin S.T.
      • Gadabu E.
      • Iro G.
      • Tasserei J.
      • Colagiuri R.
      Diabetes related amputations in Pacific Islands countries: a root cause analysis of precipitating events.
      ].
      Several large scale surveys have indicated that 50–60% of type 2 diabetic patients from different clinic settings in the WP Region have nephropathy [
      • Wu A.Y.
      • Kong N.C.
      • de Leon F.A.
      • Pan C.Y.
      • Tai T.Y.
      • Yeung V.T.
      • et al.
      An alarmingly high prevalence of diabetic nephropathy in Asian type 2 diabetic patients: The microalbuminuria prevalence (MAP) study.
      ]. In prospective studies, the annual incidence of chronic kidney disease was 2–4%, driven primarily by disease duration, smoking, metabolic syndrome and glycemic control [
      • Luk A.O.
      • So W.Y.
      • Ma R.C.
      • Kong A.P.
      • Ozaki R.
      • Ng V.S.
      • et al.
      Metabolic syndrome predicts new onset of chronic kidney disease in 5,829 patients with type 2 diabetes: A 5-year prospective analysis of the Hong Kong Diabetes Registry.
      ]. Other factors such as chronic hepatitis B infection [
      • Cheng A.Y.
      • Kong A.P.
      • Wong V.W.
      • So W.Y.
      • Chan H.L.
      • Ho C.S.
      • et al.
      Chronic Hepatitis B viral infection independently predicts renal outcome in type 2 diabetic patients.
      ] and use of over-the-counter medications including herbal medicine [
      • Wen C.P.
      • Cheng T.Y.
      • Tsai M.K.
      • Chang Y.C.
      • Chan H.T.
      • Tsai S.P.
      • et al.
      All-cause mortality attributable to chronic kidney disease: A prospective cohort study based on 462 293 adults in Taiwan.
      ] might also contribute to this high rate of renal disease in the WP Region.

      10.2 Psycho-social distress

      The bidirectional association between depression and diabetes is increasingly recognized with emerging data from the WP Region. In the population-based Australian Diabetes Obesity and Lifestyle (AusDiab) Study, after 5 years of follow up, perceived stress independently predicted the development of abnormal glucose tolerance in women but not in men [
      • Williams E.D.
      • Magliano D.J.
      • Tapp R.J.
      • Oldenburg B.F.
      • Shaw J.E.
      Psychosocial stress predicts abnormal glucose metabolism: the Australian Diabetes, Obesity and Lifestyle (AusDiab) study.
      ]. In Malaysia, 11.5%, 30.5% and 12.5% of type 2 diabetic patients attending outpatient clinics had depression, anxiety and stress symptoms respectively. Female gender, ethnicity, marital status, family history of psychiatric illness, life events, alcohol use, unemployment, high A1c, short disease duration were some of the associated risk factors [
      • Kaur G.
      • Tee G.H.
      • Ariaratnam S.
      • Krishnapillai A.S.
      • China K.
      Depression, anxiety and stress symptoms among diabetics in Malaysia: a cross sectional study in an urban primary care setting.
      ].
      In Hong Kong Chinese type 2 diabetic patients attending outpatient clinic, 8% had depression upon screening. The presence of depression was independently associated with high A1c, hypoglycemia and somatic complaints. Of note, the majority of patients with depressive symptoms had not been diagnosed [
      • Zhang Y.
      • Ting R.
      • Lam M.
      • Lam J.
      • Nan H.
      • Yeung R.
      • et al.
      Measuring depressive symptoms using the Patient Health Questionnaire-9 in Hong Kong Chinese subjects with type 2 diabetes.
      ]. In prospective analysis, severe depression independently predicted premature cardiovascular diseases notably stroke in Chinese type 2 diabetic patients [
      • Ting R.Z.
      • Lau E.S.
      • Ozaki R.
      • Lau W.W.
      • Kong A.P.
      • Luk A.O.
      • et al.
      High risk for cardiovascular disease in Chinese type 2 diabetic patients with major depression--a 7-year prospective analysis of the Hong Kong Diabetes Registry.
      ]. Apart from depression, 20–50% of Chinese type 2 diabetic patients experienced diabetes-related distress (e.g. treatment demands, concerns about future risks of complications), which were closely correlated with obesity and A1c [
      • Ting R.Z.
      • Nan H.
      • Yu M.W.
      • Kong A.P.
      • Ma R.C.
      • Wong R.Y.
      • et al.
      Diabetes-related distress and physical and psychological health in Chinese type 2 diabetic patients.
      ].
      Other workers have reported poor quality of life in Chinese type 2 diabetic patients with microvascular and macrovascular complications. These negative attributes were associated with depression and unhealthy eating habits, with regular exercise being a protective factor [
      • Cong J.Y.
      • Zhao Y.
      • Xu Q.Y.
      • Zhong C.D.
      • Xing Q.L.
      Health-related quality of life among Tianjin Chinese patients with type 2 diabetes: a cross-sectional survey.
      ]. In a multicenter survey involving type 2 diabetic patients from China, Korea, Malaysia, Thailand, and Taiwan, 36% reported hypoglycemic symptoms, and fear of hypoglycemia which was associated with poor quality of life [
      • Sheu W.H.
      • Ji L.N.
      • Nitiyanant W.
      • Baik S.H.
      • Yin D.
      • Mavros P.
      • Chan S.P.
      • et al.
      Hypoglycemia is associated with increased worry and lower quality of life among patients with type 2 diabetes treated with oral antihyperglycemic agents in the Asia-Pacific region.
      ].

      11. Socioeconomic development

      Given its diversity in terms of ethnicity, culture and socioeconomic development, the many faces of diabetes in the WP Region are not unexpected. Countries and areas with established economies have reported fairly stable rates of diabetes of 4–7% during the last decade [
      • Chan J.C.
      • Malik V.
      • Jia W.
      • Kadowaki T.
      • Yajnik C.S.
      • Yoon K.H.
      • Hu F.B.
      Diabetes in Asia Epidemiology, risk factors, and pathophysiology.
      ]. On the other hand, countries undergoing rapid economic development such as China [
      • Xu Y.
      • Wang L.
      • He J.
      • Bi Y.
      • Li M.
      • Wang T.
      • et al.
      On behalf of the 2010 China Non-communicable Disease Surveillance Group
      Prevalence and control of diabetes in Chinese adults.
      ], Vietnam [
      • Nguyen Q.N.
      • Pham S.T.
      • Do L.D.
      • Nguyen V.L.
      • Wall S.
      • Weinehall L.
      • et al.
      Cardiovascular disease risk factor patterns and their implications for intervention strategies in Vietnam.
      ], Cambodia and Mongolia [
      • Otgontuya D.
      • Oum S.
      • Palam E.
      • Rani M.
      • Buckley B.S.
      Individual-based primary prevention of cardiovascular disease in Cambodia and Mongolia: early identification and management of hypertension and diabetes mellitus.
      ] continued to report rising rates of diabetes and prediabetes with prevalence as high as 50% in the Pacific islands [
      ].
      In general, people of Asian ethnicity are more likely to develop diabetes for the same level of body mass index or waist circumference, compared to their Europid counterparts, in part due to their propensity to store excessive body or visceral fat [
      • Deurenberg-Yap M.
      • Schmidt G.
      • van Staveren W.A.
      • Deurenberg P.
      The paradox of low body mass index and high body fat percentage among Chinese, Malays and Indians in Singapore.
      ]. Additionally, in relatively lean subjects, Asians were more insulin resistant than non-Asians with increased concentration of free fatty acids and inflammatory markers [
      • King G.L.
      • McNeely M.J.
      • Thorpe L.E.
      • Mau M.L.
      • Ko J.
      • Liu L.L.
      • et al.
      Understanding and addressing unique needs of diabetes in Asian Americans, native Hawaiians, and Pacific Islanders.
      ]. Compared to their Europid counterparts, lean Asian subjects with normal glucose tolerance had higher glucose excursion during an OGTT with reduced rate of glucose disposal [
      • Dickinson S.
      • Colagiuri S.
      • Faramus E.
      • Petocz P.
      • Brand-Miller J.C.
      Postprandial hyperglycemia and insulin sensitivity differ among lean young adults of different ethnicities.
      ]. In Japanese subjects with normal glucose tolerance, small incremental increases in body mass index were associated with increased insulin resistance which was not met by proportional increase in insulin response [
      • Nishi Y.
      • Fukushima M.
      • Suzuki H.
      • Mitsui R.
      • Ueda N.
      • Taniguchi A.
      • et al.
      Insulin secretion and insulin sensitivity in Japanese subjects with impaired fasting glucose and isolated fasting hyperglycemia.
      ,
      • Kuroe A.
      • Fukushima M.
      • Usami M.
      • Ikeda M.
      • Nakai Y.
      • Taniguchi A.
      • et al.
      Impaired beta-cell function and insulin sensitivity in Japanese subjects with normal glucose tolerance.
      ]. Using insulin clamp studies, researchers from Thailand reported insulin deficiency as the predominant feature in lean subjects and insulin resistance in the overweight and obese subjects [
      • Suraamornkul S.
      • Kwancharoen R.
      • Ovartlarnporn M.
      • Rawdaree P.
      • Bajaj M.
      Insulin clamp-derived measurements of insulin sensitivity and insulin secretion in lean and obese Asian type 2 diabetic patients.
      ].
      This ‘Asian phenotype’ of low body mass index but high waist circumference could be modified by genetic, environmental and lifestyle factors, resulting in considerable geographical variations in disease prevalence in the WP Region [
      • Kong A.P.S.
      • Xu G.
      • Brown N.
      • So W.Y.
      • Ma R.C.
      • Chan J.C.N.
      Diabetes and its comorbidities – where East meets West.
      ,
      • Ma R.C.
      • Chan J.C.N.
      Type 2 diabetes in East Asians: similarities and differences with populations in Europe and the United States.
      ]. Recent genome wide association studies had found some of the common variants in Caucasians to be rare in Asian populations [
      • Ng M.C.
      • Park K.S.
      • Oh B.
      • Tam C.H.
      • Cho Y.M.
      • Shin H.D.
      • et al.
      Implication of genetic variants near TCF7L2, SLC30A8, HHEX, CDKAL1, CDKN2A/B, IGF2BP2, and FTO in type 2 diabetes and obesity in 6,719 Asians.
      ]. In Asian populations, novel variants implicated in beta cell biology and protein metabolism had also been discovered, highlighting the importance of ethnicity in disease predisposition [
      • Cho Y.S.
      • Chen C.H.
      • Hu C.
      • Long J.
      • Hee Ong R.T.
      • Sim X.
      • et al.
      Meta-analysis of genome-wide association studies identifies eight new loci for type 2 diabetes in East Asians.
      ,
      • Yamauchi T.
      • Hara K.
      • Maeda S.
      • Yasuda K.
      • Takahashi A.
      • Horikoshi M.
      • et al.
      A genome-wide association study in the Japanese population identifies susceptibility loci for type 2 diabetes at UBE2E2 and C2CD4A-C2CD4B.
      ,
      • Ma R.C.
      • Hu C.
      • Tam C.H.
      • Zhang R.
      • Kwan P.
      • Leung T.F.
      • et al.
      Genome-wide association study in a Chinese population identifies a susceptibility locus for type 2 diabetes at 7q32 near PAX4.
      ].

      12. Non-modifiable risk factors

      12.1 Age and gender

      Compared to Europe, where the predominant increase in diabetes prevalence is occurring in the elderly, the most rapid rate of increase occurs in the young to middle-aged group in the WP Region [
      • Shaw J.E.
      • Sicree R.A.
      • Zimmet P.Z.
      Global estimates of the prevalence of diabetes for 2010 and 2030.
      ]. While all countries in the WP Region are facing a dual burden of aging and young-onset chronic disease, men appeared to be at higher risk for diabetes amongst East Asians (e.g. China, Korea, Taiwan, Japan) while women were more at risk in South East Asians (e.g. Malaysia, Philippines) and Indians, in part due to high rates of obesity [
      • Chan J.C.
      • Malik V.
      • Jia W.
      • Kadowaki T.
      • Yajnik C.S.
      • Yoon K.H.
      • Hu F.B.
      Diabetes in Asia Epidemiology, risk factors, and pathophysiology.
      ].

      12.2 Family history

      Using family-based genetic analysis, over 50% of the variance of obesity, diabetes, and dyslipidemia is explained by heritability. Compared to age- and sex-matched controls, siblings of people with diabetes had a 2–4 fold increased risk of diabetes and obesity [
      • Li J.K.Y.
      • Ng M.C.Y.
      • So W.Y.
      • Chiu C.
      • Ozaki R.
      • Tong P.C.Y.
      • et al.
      Phenotypic and genetic clustering of diabetes and metabolic syndrome in Chinese families with type 2 diabetes mellitus.
      ]. Using linkage analysis, several chromosomal regions linked to diabetes and related traits including obesity and dyslipidemia have also been reported in support of the strong genetic determinants of these complex traits [
      • Tam C.H.
      • Lam V.K.
      • So W.Y.
      • Ma R.C.
      • Chan J.C.
      • Ng M.C.
      Genome-wide linkage scan for factors of metabolic syndrome in a Chinese population.
      ,
      • Xiang K.
      • Wang Y.
      • Zheng T.
      • Jia W.
      • Li J.
      • Chen L.
      • et al.
      Genome-wide search for type 2 diabetes/impaired glucose homeostasis susceptibility genes in the Chinese: significant linkage to chromosome 6q21-q23 and chromosome 1q21-q24.
      ,
      • Ng M.C.
      • So W.Y.
      • Cox N.J.
      • Lam V.K.L.
      • Cockram C.S.
      • Bell G.I.
      • et al.
      Genome wide scan for metabolic syndrome and related quantitative traits in Hong Kong Chinese and confirmation of a susceptibility locus on chromosome 1q21-25.
      ].

      13. Modifiable risk factors

      13.1 Intrauterine influences/thrifty phenotype

      Fetal programming associated with in utero exposure to maternal stress and malnutrition might alter gene expression, resulting in phenotypes that promote survival in a nutrient-poor environment but substantially increase risk of diabetes and cardiovascular-renal disease [
      • Diamond J.M.
      Diabetes running wild.
      ,
      • Gluckman P.D.
      • Hanson M.A.
      • Cooper C.
      • Thornburg K.L.
      Effect of in utero and early-life conditions on adult health and disease.
      ]. These ‘thrifty phenotypes’ might be particularly relevant to Asian populations undergoing rapid transition in lifestyle and nutrition.
      In addition, Asian women have a high prevalence of gestational diabetes [
      • Kim C.
      • Newton K.M.
      • Knopp R.H.
      Gestational diabetes and the incidence of type 2 diabetes: a systematic review.
      ] with short stature as a major risk factor [
      • Jang H.C.
      • Min H.K.
      • Lee H.K.
      • Cho N.H.
      • Metzger B.E.
      Short stature in Korean women: a contribution to the multifactorial predisposition to gestational diabetes mellitus.
      ]. This high prevalence of gestational diabetes coupled with childhood obesity could increase the future risk of diabetes in women [
      • Cheung N.W.
      • Byth K.
      Population health significance of gestational diabetes.
      ] and that of obesity in offspring [
      • Tam W.H.
      • Ma R.C.
      • Yang X.
      • Ko G.T.
      • Tong P.C.
      • Cockram C.S.
      • et al.
      Glucose intolerance and cardiometabolic risk in children exposed to maternal gestational diabetes mellitus in utero.
      ] resulting in transgenerational diabetes with increasingly early onset of disease, thus setting up a vicious cycle of ‘diabetes begetting diabetes’ [
      • Ma R.C.
      • Chan J.C.
      • Tam W.H.
      • Hanson M.A.
      • Gluckman P.D.
      Gestational diabetes, maternal obesity, and the NCD Burden.
      ].

      13.2 Healthy lifestyle behaviors

      Studies have shown an incremental benefit to the adoption of healthy behaviors such as smoking cessation, moderate alcohol use and a healthy lifestyle in the reduction of lifetime risk of diabetes [
      • Djousse L.
      • Driver J.A.
      • Gaziano J.M.
      • Buring J.E.
      • Lee I.M.
      Association between modifiable lifestyle factors and residual lifetime risk of diabetes.
      ]. In this context, a dose-response association between smoking and diabetes has been reported in a meta-analysis of prospective studies [
      • Willi C.
      • Bodenmann P.
      • Ghali W.A.
      • Faris P.D.
      • Cornuz J.
      Active smoking and the risk of type 2 diabetes: a systematic review and meta-analysis.
      ]. In the WP Region, the prevalence of smoking was amongst the highest in the world, with over 50% of males smoking cigarettes in China [
      • Xu Y.
      • Wang L.
      • He J.
      • Bi Y.
      • Li M.
      • Wang T.
      • et al.
      On behalf of the 2010 China Non-communicable Disease Surveillance Group
      Prevalence and control of diabetes in Chinese adults.
      ] and Korea [
      • Cho N.H.
      • Chan J.C.
      • Jang H.C.
      • Lim S.
      • Kim H.L.
      • Choi S.H.
      Cigarette smoking is an independent risk factor for type 2 diabetes: a four-year community-based prospective study.
      ].
      Other lifestyle factors implicated in the development of diabetes in the WP Region include television watching [
      • Hansen A.L.
      • Wijndaele K.
      • Owen N.
      • Magliano D.J.
      • Thorp A.A.
      • Shaw J.E.
      • et al.
      Adverse associations of increases in television viewing time with 5-year changes in glucose homeostasis markers: The AusDiab study.
      ], high consumption of rice [
      • Yu R.
      • Woo J.
      • Chan R.
      • Sham A.
      • Ho S.
      • Tso A.
      • et al.
      Relationship between dietary intake and the development of type 2 diabetes in a Chinese population: The Hong Kong Dietary Survey.
      ] and sugar sweetened beverages [
      • Malik V.S.
      • Willett W.C.
      • Hu F.B.
      Sugar-sweetened beverages and BMI in children and adolescents: reanalyses of a meta-analysis.
      ], psychosocial stress [
      • Harding J.L.
      • Backholer K.
      • Williams E.D.
      • Peeters A.
      • Cameron A.J.
      • Hare M.J.
      • et al.
      Psychosocial stress is positively associated with body mass index gain over 5 years: Evidence from the longitudinal AusDiab study.
      ] and sleep hygiene [
      • Cappuccio F.P.
      • D’Elia L.
      • Strazzullo P.
      • Miller M.A.
      Quantity and quality of sleep and incidence of type 2 diabetes: a systematic review and meta-analysis.
      ], all of which might be particularly relevant to populations undergoing health transition.

      13.3 Socioeconomic determinants

      Although diabetes has strong genetic determinants, the 2–5 fold increased risk of diabetes in migrant populations highlights the importance of social determinants in unmasking the genetic predisposition [
      • International Diabetes Federation
      Diabetes Atlas.
      ]. These include poverty and low educational levels which take on particular significance in affluent societies with high levels of physical inactivity and low food deprivation. In these communities, lack of awareness, long working hours and short sleeping hours together with psychosocial stress were often accompanied by high rates of unhealthy lifestyles and obesity [
      • Ko G.T.C.
      • Chan J.C.N.
      • Cockram C.S.
      A low socioeconomic class is associated with diabetes and metabolic syndrome in Hong Kong Chinese.
      ,
      • Ko G.T.
      • Chan J.C.
      • Chan A.W.
      • Wong P.T.
      • Hui S.S.
      • Tong S.D.
      • et al.
      Low levels of awareness of suboptimal health conditions in a high-risk working population: The “Better Health For Better Hong Kong” health promotion campaign.
      ]. In Hong Kong, analysis of trends of self-reported diabetes between 2001 and 2008 consistently revealed low monthly household income as an independent risk factor for diabetes [
      • Wong M.C.
      • Leung M.C.
      • Tsang C.S.
      • Lo S.V.
      • Griffiths S.M.
      The rising tide of diabetes mellitus in a Chinese population: a population-based household survey on 121,895 persons.
      ], suggesting diabetes is often a ‘poor man disease’ in a rich society.
      Other societal determinants and emerging risk factors associated with diabetes reported in the WP Region included endemic infections (e.g. hepatitis B) [
      • Cheng A.Y.
      • Kong A.P.
      • Wong V.W.
      • So W.Y.
      • Chan H.L.
      • Ho C.S.
      • et al.
      Chronic Hepatitis B viral infection independently predicts renal outcome in type 2 diabetic patients.
      ,
      • Lao T.T.
      • Chan B.C.
      • Leung W.C.
      • Ho L.F.
      • Tse K.Y.
      Maternal hepatitis B infection and gestational diabetes mellitus.
      ], gut microflora [
      • Cani P.D.
      • Delzenne N.M.
      • Amar J.
      • Burcelin R.
      Role of gut microflora in the development of obesity and insulin resistance following high-fat diet feeding.
      ] and environmental pollutants [
      • Lim S.
      • Cho Y.M.
      • Park K.S.
      • Lee H.K.
      Persistent organic pollutants, mitochondrial dysfunction, and metabolic syndrome.
      ]. While an efficient innate immune response might confer survival advantage and protect against autoimmunity in primitive communities, these inflammatory responses might be triggered by micronutrients to increase the risk of insulin resistance and diabetes with rapid acculturation [
      • Pickup J.C.
      Inflammation and activated innate immunity in the pathogenesis of type 2 diabetes.
      ]. The effects of these host-environment interactions could be further modified by lifestyle, access to care and treatments resulting in the multi-faceted nature of diabetes and its complications in Asia [
      • Nishi Y.
      • Fukushima M.
      • Suzuki H.
      • Mitsui R.
      • Ueda N.
      • Taniguchi A.
      • et al.
      Insulin secretion and insulin sensitivity in Japanese subjects with impaired fasting glucose and isolated fasting hyperglycemia.
      ].

      14. Prevention, care, and management

      14.1 Current situation

      In many areas, notably low- and middle-income countries, the health care systems are not designed to manage and support the multiple health needs of a person with a lifelong disease such as diabetes. These facilities include cognitive-psychological-behavioral support, laboratory assessments, technologies, medications and hospitalizations [
      • Fisher E.B.
      • Chan J.C.N.
      • Nan H.
      • Sartorius N.
      • Oldenburg B.
      Co-occurrence of diabetes and depression: conceptual considerations for an emerging global health challenge.
      ].
      Control of blood pressure, A1c, and LDL-cholesterol (ABC targets) has been shown to reduce cardiovascular complications and all-cause death [
      • Holman R.R.
      • Paul S.K.
      • Bethel M.A.
      • Matthews D.R.
      • Neil H.A.
      10-year follow-up of intensive glucose control in type 2 diabetes.
      ,
      • Gaede P.
      • Valentine W.J.
      • Palmer A.J.
      • Tucker D.M.
      • Lammert M.
      • Parving H.H.
      • et al.
      Cost-effectiveness of intensified versus conventional multifactorial intervention in type 2 diabetes: Results and projections from the Steno-2 study.
      ,
      • Kong A.P.
      • Yang X.
      • Ko G.T.
      • So W.Y.
      • Chan W.B.
      • Ma R.C.
      • et al.
      Effects of treatment targets on subsequent cardiovascular events in Chinese patients with type 2 diabetes.
      ]. However, in China, amongst the 50% of people detected to have diabetes on A1c or oral glucose tolerance test, only 30% had been diagnosed, of whom, only 26% were treated and amongst those treated, only 40% had A1c < 7% [
      • Xu Y.
      • Wang L.
      • He J.
      • Bi Y.
      • Li M.
      • Wang T.
      • et al.
      On behalf of the 2010 China Non-communicable Disease Surveillance Group
      Prevalence and control of diabetes in Chinese adults.
      ]. In other large scale surveys in the WP Region, only 30% of patients with diabetes ever had clinical or laboratory assessments of risk factors and complications, with only 30–40% of them attaining one of the 3 ABC targets, and only 5–10% attaining all 3 goals [
      • Chan J.C.N.
      • Gagliardino J.J.
      • Baik S.H.
      • Chantelot J.M.
      • Ferreirae S.R.G.
      • Hancuf N.
      • et al.
      on behalf of the IDMPS investigators
      Multi-faceted determinants for achieving glycaemic control: The international Ddiabetes Management Practice Study (IDMPS).
      ]. Similar surveys in the WP Region also revealed particularly poor control of risk factors among patients with young onset of disease [
      • Chuang L.M.
      • Soegondo S.
      • Soewondo P.
      • Young-SeolF K.
      • Mohamed M.
      • Dalisay E.
      • et al.
      Comparisons of the outcomes on control, type of management and complications status in early onset and late onset type 2 diabetes in Asia.
      ].
      Other studies examined patients’ perceptions and expectations for diabetes management. In Guam, based on responses from 125 questionnaires, almost 40% of patients were not aware of the type of diabetes they had, 20% had not received diabetes self-management education and 30–60% of patients had not received nutritional counseling, advice on tobacco cessation, regular eye and foot examinations and immunization services. Over 50% of patients expressed their desire to have better quality diabetes self-management education, preventive services, enhanced access to specialists and specialized care, and more financial support to cover the costs of chronic care and medications [
      • David A.M.
      • Rubio J.M.
      • Luces P.S.
      • Zabala R.V.
      • Roberto J.P.
      Getting the patients’ perspective: a survey of diabetes services on Guam.
      ].

      14.2 General health promotion

      Rapid modernization has led to changes in food technology with increased consumption of processed foods, animal fats, and sugar sweetened beverages. In a few states, there have been efforts to use large-scale programmatic and policy measures to confront these dietary challenges [
      • Popkin B.M.
      Is the obesity epidemic a national security issue around the globe?.
      ].
      While it remains to be seen whether smoking cessation will reduce the rate of diabetes, it is likely that tobacco control would reduce the amplifying effects of tobacco on multiple morbidities associated with diabetes, notably, cancer and cardiovascular-renal disease. To this end, although the levels of development, systems of government and population size differed greatly among countries, there have been successful stories in tobacco control through strong political will and tough measures in the WP Region, such as New Zealand and Hong Kong [
      • Mackay J.
      • Ritthiphakdee B.
      • Reddy K.S.
      Tobacco control in Asia.
      ].

      15. Diabetes management

      15.1 Early prevention

      There is conclusive evidence showing that many cases of diabetes can be prevented or delayed by structured lifestyle modification [
      • Inzucchi S.E.
      • Sherwin R.S.
      The prevention of type 2 diabetes mellitus.
      ]. In this light, most experts recommend targeted screening using known risk factors and simple risk scores [
      • Brown N.
      • Critchley J.
      • Bogowicz P.
      • Mayige M.
      • Unwin N.
      Risk scores based on self-reported or available clinical data to detect undiagnosed Type 2 Diabetes: a systematic review.
      ] to identify high risk subjects for early intervention. Of particular relevance to the WP Region is targeted screening in young subjects, which is highly cost-effective due to their high lifetime risk for complications [
      • CDC Diabetes Cost-effectiveness Study Group
      The cost-effectiveness of screening for Type 2 diabetes.
      ].
      In China, 20 years after the initiation of a 6-year lifestyle modification program, subjects with IGT who received intervention continued to have lower rate of diabetes with reduced incidence of retinopathy [
      • Gong Q.
      • Gregg E.W.
      • Wang J.
      • An Y.
      • Zhang P.
      • Yang W.
      • et al.
      Long-term effects of a randomised trial of a 6-year lifestyle intervention in impaired glucose tolerance on diabetes-related microvascular complications: The China Da Qing diabetes prevention outcome study.
      ]. Similar programs have been successfully translated in a primary care setting in Australia [
      • Laatikainen T.
      • Dunbar J.A.
      • Chapman A.
      • Kilkkinen A.
      • Vartiainen E.
      • Heistaro S.
      • et al.
      Prevention of type 2 diabetes by lifestyle intervention in an Australian primary health care setting: Greater Green triangle (GGT) diabetes prevention project.
      ] while other researchers have adopted similar principles to investigate the effects of exercise prescriptions in indigenous populations in the WP Region taking into consideration their special cultural needs [
      • Sukala W.R.
      • Page R.
      • Cheema B.S.
      Targeting the type 2 diabetes epidemic in Polynesia: historical perspective and rationale for exercise intervention trials.
      ].
      Despite the effectiveness of lifestyle modification, it is important to recognize that many of these subjects went on to develop diabetes despite having lifestyle modification. Early use of medications might be needed in high risk subjects to prevent deterioration of glycemic control [
      • Ting R.Z.
      • Yang X.
      • Yu L.W.
      • Luk A.O.
      • Kong A.P.
      • Tong P.C.
      • et al.
      Lipid control and use of lipid-regulating drugs for prevention of cardiovascular events in Chinese type 2 diabetic patients: A prospective cohort study.
      ,
      • So W.Y.
      • Chan N.
      • Tong P.C.Y.
      • Chow C.C.
      • Chan W.B.
      • Ng M.C.Y.
      • et al.
      Effect of RAAS inhibition on survival and renal outcomes in 3737 Chinese type 2 diabetic patients.
      ]. Indeed, researchers in the WP Region have demonstrated the benefits of intensive glycemic control at diagnosis to produce remission of diabetes, especially in subjects with high body mass index and no complications at presentation [
      • Weng J.
      • Li Y.
      • Xu W.
      • Shi L.
      • Zhang Q.
      • Zhu D.
      • et al.
      Effect of intensive insulin therapy on beta-cell function and glycaemic control in patients with newly diagnosed type 2 diabetes: A multicentre randomised parallel-group trial.
      ].

      15.2 Prevention of childhood obesity and treatment of childhood diabetes

      In its latest action plan, the WHO has called for early prevention of diabetes using a life-course strategy that starts with maternal health. Prospective studies have indicated the high risk of metabolic syndrome and obesity in offspring of women with gestational diabetes [
      • Ma R.C.
      • Chan J.C.
      • Tam W.H.
      • Hanson M.A.
      • Gluckman P.D.
      Gestational diabetes, maternal obesity, and the NCD Burden.
      ], suggesting that optimal glycemic control during pregnancy may reduce long term risks of childhood obesity. Several countries such as Japan [
      • Urakami T.
      • Suzuki J.
      • Mugishima H.
      • Amemiya S.
      • Sugihara S.
      • Kawamura T.
      • et al.
      Screening and treatment of childhood type 1 and type 2 diabetes mellitus in Japan.
      ] and Taiwan [
      • Wei J.
      • Sung F.
      • Lin C.
      • Lin R.
      • Chiang C.
      • Chuang L.
      National surveillance for type 2 diabetes mellitus in Taiwanese children.
      ] have embarked upon national urine glucose screening program which has led to detection of type 2 diabetes and other atypical forms of type 1 diabetes in children. While there is consensus on the use of intensive insulin therapy including insulin pumps to optimize glycemic control in children with type 1 diabetes, the lack of randomized clinical trial data on the efficacy of various drugs and strategies make clinical management of type 2 diabetes in children highly challenging [
      • Urakami T.
      • Suzuki J.
      • Mugishima H.
      • Amemiya S.
      • Sugihara S.
      • Kawamura T.
      • et al.
      Screening and treatment of childhood type 1 and type 2 diabetes mellitus in Japan.
      ].

      15.3 Treatment in adults

      People with diabetes need to be educated, empowered and engaged regarding the nature of the disease and its management. Research has shown that increased contact time between healthcare providers and people with diabetes including regular support, reinforcement, and reminders was the main determinant for initiating and maintaining behavioral changes [
      • Norris S.L.
      • Lau J.
      • Smith S.J.
      • Schmid C.H.
      • Engelgau M.M.
      Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control.
      ]. Furthermore, 20–50% of patients with diabetes have negative emotions which might adversely affect treatment compliance and worsen clinical outcomes [
      • Zhang X.
      • Norris S.L.
      • Gregg E.W.
      • Cheng Y.J.
      • Beckles G.
      • Kahn H.S.
      Depressive symptoms and mortality among persons with and without diabetes.
      ]. In these subjects, a holistic approach including motivational interview, empathetic listening and peer support might be needed to improve their metabolic control and psychological well-being [
      • Fisher E.B.
      • Chan J.C.N.
      • Nan H.
      • Sartorius N.
      • Oldenburg B.
      Co-occurrence of diabetes and depression: conceptual considerations for an emerging global health challenge.
      ].
      Adding to these challenges are the increasing demands from payors on care providers to contain costs and add values to their services with documentation of care processes and attainment of treatment targets [
      • Campbell S.M.
      • Reeves D.
      • Kontopantelis E.
      • Sibbald B.
      • Roland M.
      Effects of pay for performance on the quality of primary care in England.
      ,
      • Farmer S.A.
      • Black B.
      • Bonow R.O.
      Tension between quality measurement, public quality reporting, and pay for performance.
      ]. Until recently, most hospital and primary care systems, even in developed areas, are not designed to manage these patients with accumulating health information for decision making and quality assurance purposes.
      More than a decade ago, several authorities and expert groups recommended improving diabetes and chronic care by (1) redesigning workflow based on best practices; (2) using information technology to manage clinical information with decision support; (3) transferring knowledge and skills to team members to coordinate care; (4) using performance and outcome measures for quality control [

      Institute of Medicine Crossing the quality chasm: a new health system for the 21st century. 2001: http://www.nap.edu/books/0309072808/html/.

      ,
      • Ellrodt G.
      • Cook D.J.
      • Lee J.
      • Cho M.
      • Hunt D.
      • Weingarten S.
      Evidence-based disease management.
      ]. In the same vein, the IDF defined the minimum, standard and comprehensive diabetes care models where empowerment, protocols, team-based care, information technology, peer support, recall and registry were key features [
      • IDF Clinical Guidelines Task Force
      Global guideline for type 2 diabetes: recommendations for standard, comprehensive, and minimal care.
      ]. In a recent meta-analysis, interventions targeting health care systems with team-based care and patient empowerment had the greatest effect size on reducing A1c, blood pressure and LDL-cholesterol, although other initiatives including incentives, registries and electronic medical records also had positive benefits [
      • Tricco A.C.
      • Ivers N.M.
      • Grimshaw J.M.
      • Moher D.
      • Turner L.
      • Galipeau J.
      • et al.
      Effectiveness of quality improvement strategies on the management of diabetes: A systematic review and meta-analysis.
      ].
      Motivated by the marked improvement in control of risk factors and clinical outcomes in clinical trial settings characterized by the use of protocols and care coordinators with regular monitoring [
      • Chan J.C.
      What have we learnt from recent blood glucose lowering megatrials.
      ], researchers in the WP Region adopted these recommendations and demonstrated the marked benefits of these collaborative care models on clinical outcomes including death and cardiovascular-renal complications [
      • Chan J.C.
      • So W.Y.
      • Yeung C.Y.
      • Ko G.T.
      • Lau I.T.
      • Tsang M.W.
      • et al.
      Effects of structured versus usual care on renal endpoint in type 2 diabetes: The SURE study: A randomized multicenter translational study.
      ,
      • Wu J.Y.
      • Leung W.Y.
      • Chang S.
      • Lee B.
      • Zee B.
      • Tong P.C.
      • et al.
      Effectiveness of telephone counselling by a pharmacist in reducing mortality in patients receiving polypharmacy: Randomised controlled trial.
      ]. The efficiency of these care models can be further enhanced using information technology to incorporate inter-linking components of care protocols, risk engines, personalized reports and decision support with ongoing evaluation [
      • Ko G.T.
      • So W.Y.
      • Tong P.C.
      • Le Coguiec F.
      • Kerr D.
      • Lyubomirsky G.
      • et al.
      From design to implementation--the Joint Asia Diabetes Evaluation (JADE) program: A descriptive report of an electronic web-based diabetes management program.
      ,
      • So W.Y.
      • Raboca J.
      • Sobrepena L.
      • Yoon K.H.
      • Deerochanawong C.
      • Ho L.T.
      • et al.
      Comprehensive risk assessments of diabetic patients from seven Asian countries: The Joint Asia Diabetes Evaluation (JADE) program.
      ]. Despite the cost-effectiveness of these care models, these recommendations still remain to be implemented in many low- and middle-income countries in the WP Region.

      16. The way forward

      Diabetes is a major health burden with grave impacts on the society, family and person concerned, if not diagnosed, managed or controlled. There are now proven strategies to prevent the onset of diabetes and its complications, which will save lives and money in the long term. However, due to the non-acute nature of these silent conditions, these preventive strategies which have proven to be efficacious in controlled settings, are often not implemented in the real world due a lack of motivation, mandate and care coordination, as well as insufficient resources, support and incentives.
      In the updated draft of the Global Plan of Action for the Prevention and Control of NCDs (2013–2020), the WHO articulated its vision of a world free of avoidable burden of NCD based on the overarching principles of using a life-course approach to empower people and communities and adopting an evidence-based and multisectoral strategy through partnerships [
      • World Health Organization
      Updated revised draft global action plan for the prevention and control of noncommunicable diseases 2013–2020.
      ]. Despite the challenges due to diabetes in the WP Region, researchers and care professionals had provided notable examples in early detection of diabetes [
      • Tajima N.
      • Morimoto A.
      Epidemiology of childhood diabetes mellitus in Japan.
      ,
      • Wei J.
      • Sung F.
      • Lin C.
      • Lin R.
      • Chiang C.
      • Chuang L.
      National surveillance for type 2 diabetes mellitus in Taiwanese children.
      ] and its complications [
      • Chuang L.M.
      • Soegondo S.
      • Soewondo P.
      • Young-SeolF K.
      • Mohamed M.
      • Dalisay E.
      • et al.
      Comparisons of the outcomes on control, type of management and complications status in early onset and late onset type 2 diabetes in Asia.
      ] through government policies as well as prevention of onset [
      • Ting R.Z.
      • Yang X.
      • Yu L.W.
      • Luk A.O.
      • Kong A.P.
      • Tong P.C.
      • et al.
      Lipid control and use of lipid-regulating drugs for prevention of cardiovascular events in Chinese type 2 diabetic patients: A prospective cohort study.
      ,
      • So W.Y.
      • Chan N.
      • Tong P.C.Y.
      • Chow C.C.
      • Chan W.B.
      • Ng M.C.Y.
      • et al.
      Effect of RAAS inhibition on survival and renal outcomes in 3737 Chinese type 2 diabetic patients.
      ,
      • Pan X.R.
      • Li G.W.
      • Hu Y.H.
      • et al.
      Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance.
      ] and progression of diabetes [
      • Weng J.
      • Li Y.
      • Xu W.
      • Shi L.
      • Zhang Q.
      • Zhu D.
      • et al.
      Effect of intensive insulin therapy on beta-cell function and glycaemic control in patients with newly diagnosed type 2 diabetes: A multicentre randomised parallel-group trial.
      ] and its complications [
      • Ohkubo Y.
      • Kishikawa H.
      • Araki E.
      • Miyata T.
      • Isami S.
      • Motoyoshi S.
      • et al.
      Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: A randomized prospective 6-year study.
      ,
      • Chan J.C.
      • So W.Y.
      • Yeung C.Y.
      • Ko G.T.
      • Lau I.T.
      • Tsang M.W.
      • et al.
      Effects of structured versus usual care on renal endpoint in type 2 diabetes: The SURE study: A randomized multicenter translational study.
      ,
      • Ko G.T.
      • So W.Y.
      • Tong P.C.
      • Le Coguiec F.
      • Kerr D.
      • Lyubomirsky G.
      • et al.
      From design to implementation--the Joint Asia Diabetes Evaluation (JADE) program: A descriptive report of an electronic web-based diabetes management program.
      ] using innovative and collaborative approaches (Fig. 1).
      Figure thumbnail gr1
      Fig. 1A multipronged strategy using both bottom up and top down approaches to raise awareness, detect early cases and prevent diabetes and its complications proposed by the Western Pacific Declaration on Diabetes
      [
      • Western Pacific Declaration on Diabetes Steering Committee
      Plan of Action (2006–2010) for the Western Pacific Declaration on Diabetes: from evidence to action.
      ]
      .
      According to the WHO, health is defined as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. To this end, government leaderships, intersectoral partnerships and community empowerment will be needed to reduce poverty, health illiteracy and social disparity as well as create a health-promoting environment, encourage self-management and strengthen the health care system to reduce the burden of diabetes and make health a reality [
      • WHO. WHO definition of health
      ].

      Acknowledgements

      Due to limitation of space, only a sample of scholastic work could be included in this discussion paper. The authors wished to thank all researchers and care professionals for contributing toward this vast body of knowledge on the epidemiology, pathophysiology and management of diabetes and its comorbidities in the Western Pacific Region.

      References

        • Chan J.C.
        • Malik V.
        • Jia W.
        • Kadowaki T.
        • Yajnik C.S.
        • Yoon K.H.
        • Hu F.B.
        Diabetes in Asia Epidemiology, risk factors, and pathophysiology.
        JAMA. 2009; 301: 2129-2140
        • Tajiman N.
        • La Porte R.E.
        • Hibi I.
        • Kitagawa T.
        • Fujita H.
        • Drash A.L.
        A comparison of the epidemiology of youth-onset insulin-dependent diabetes mellitus between Japan and the United Sates (Allegheny County, Pennsylvania).
        Diabetes Care. 1985; 8: 17-23
        • Morrish N.J.
        • Wang S.
        • Stevens L.K.
        • Fuller J.H.
        • Keen H.
        Mortality and causes of death in the WHO Multinational Survey of Vascular Diseases in Diabetes.
        Diabetologia. 2001; 44: S14-S21
        • Yoon K.H.
        • Lee J.H.
        • Kim J.W.
        • Cho J.H.
        • Choi Y.H.
        • Ko S.H.
        • et al.
        Epidemic of obesity and type 2 diabetes in Asia.
        Lancet. 2006; 368: 1681-1688
        • Ramachandran A.
        • Ma R.C.W.
        • Snehalatha C.
        Diabetes in Asia.
        Lancet. 2010; 375: 408-418
      1. International Diabetes Federation International Diabetes Atlas. 2013
        • Guariguata L.
        • Beagley J.
        • Linnenkamp U.
        • Hambleton I.
        • Shaw J.
        • Cho N.H.
        • et al.
        Global estimates of prevalence of diabetes in adults for 2013 and projections to 2035 from the IDF diabetes Atlas.
        Diabetes Res Clin Pract. 2013; ([in press])
        • Stevens G.A.
        • Singh G.M.
        • Lu Y.
        • Danaei G.
        • Lin J.K.
        • Finucane M.M.
        • et al.
        Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group. National, regional, and global trends in adult overweight and obesity prevalences.
        Population health metrics. 2012; 10: 22https://doi.org/10.1186/1478-7954-10-22
        • DeCODA Study Group
        Prevalence of the metabolic syndrome in populations of Asian origin. Comparison of the IDF definition with the NCEP definition.
        Diabetes Res Clin Pract. 2007; 76: 57-67
        • Khambalia A.
        • Phongsavan P.
        • Smith B.J.
        • Keke K.
        • Dan L.
        • Fitzhardinge A.
        • Bauman A.E.
        Prevalence and risk factors of diabetes and impaired fasting glucose in nauru.
        BMC Public Health. 2011; 11: 719https://doi.org/10.1186/1471-2458-11-719
        • Dancause K.N.
        • Dehuff C.
        • Soloway L.E.
        • Vilar M.
        • Chan C.
        • Wilson M.
        • et al.
        Behavioral changes associated with economic development in the South Pacific: Health transition in Vanuatu.
        American Journal of Human Biology. 2011; 23: 366-376
        • Xu Y.
        • Wang L.
        • He J.
        • Bi Y.
        • Li M.
        • Wang T.
        • et al.
        • On behalf of the 2010 China Non-communicable Disease Surveillance Group
        Prevalence and control of diabetes in Chinese adults.
        JAMA. 2013; 310: 948-959
        • Yang W.
        • Lu J.
        • Weng J.
        • Jia W.
        • Ji L.
        • Xiao J.
        • et al.
        Prevalence of diabetes among men and women in China.
        N Engl J Med. 2010; 362: 1090-1101
        • Jia W.
        • Xiang K.
        • Chen L.
        • Lu J.
        • Wu Y.
        Epidemiological study on obesity and its comorbidities in urban Chinese older than 20 years of age in Shanghai, China.
        Obes Rev. 2002; 3: 157-165
        • Laakso M.
        • Pyorala K.
        Age of onset and type of diabetes.
        Diabetes Care. 1985; 8: 114-117
        • Kong A.P.S.
        • Chan J.C.N.
        Other disorders with type 1 phenotype.
        in: Holt R. Goldstein B. Flyvbjerg A. Cockram C.S. Textbook of Diabetes. Wiley-Blackwell, a John Wiley & Son Ltd. publication, Chichester, UK2010: 152-159
        • Haynes A.
        • Bower C.
        • Bulsara M.K.
        • Jones T.W.
        • Davis E.A.
        Continued increase in the incidence of childhood Type 1 diabetes in a population-based Australian sample (1985–2002).
        Diabetologia. 2004; 47: 866-870
        • Tajima N.
        • Morimoto A.
        Epidemiology of childhood diabetes mellitus in Japan.
        Pediatr Endocrinol Rev. 2012; 10: 44-50
        • Morimoto A.
        • Onda Y.
        • Nishimura R.
        • Sano H.
        • Utsunomiya K.
        • Tajima N.
        Diabetes Epidemiology Research International Mortality Study Group. Cause-specific mortality trends in a nationwide population-based cohort of childhood-onset type 1 diabetes in Japan during 35 years of follow-up: The Deri Mortality Study.
        Diabetologia. 2013; 56: 2171-2175
        • Kobayashi T.
        • Tamemoto K.
        • Nakanishi K.
        • Kato N.
        • Okubo M.
        • Kajio H.
        • et al.
        Immunogenetic and clinical characterization of slowly progressive IDDM.
        Diabetes Care. 1993; 16: 780-788
        • Zhou Z.
        • Xiang Y.
        • Ji L.
        • Jia W.
        • Ning G.
        • Huang G.
        • et al.
        Frequency, immunogenetics, and clinical characteristics of latent autoimmune diabetes in China (LADA China Study Group): A nationwide, multicenter, clinic-based cross-sectional study.
        Diabetes. 2013; 62: 543-550
        • Shaw J.E.
        • Sicree R.A.
        • Zimmet P.Z.
        Global estimates of the prevalence of diabetes for 2010 and 2030.
        Diabetes Res Clin Pract. 2010; 87: 4-14
        • Ma R.C.
        • Chan J.C.
        • Diabetes:
        incidence of childhood type 1 diabetes: a worrying trend.
        Nat Rev Endocrinol. 2009; 5: 529-530
        • Alberti G.
        • Zimmet P.
        • Shaw J.
        • Bloomgarden Z.
        • Kaufman F.
        • Silink M.
        • et al.
        • Consensus Workshop Group
        Type 2 diabetes in the young: The evolving epidemic: The International Diabetes Federation Consensus Workshop.
        Diabetes Care. 2004; 27: 1798-1811
        • Seshasai S.R.
        • Kaptoge S.
        • Thompson A.
        • Di Angelantonio E.
        • Gao P.
        • SarwarF N.
        • et al.
        Diabetes mellitus, fasting glucose, and risk of cause-specific death.
        N Engl J Med. 2011; 364: 829-841
        • Luk A.O.Y.
        • Lau E.
        • So W.Y.
        • Ma R.C.W.
        • Kong A.P.S.
        • Ozaki R.
        • Chow F.C.C
        • et al.
        Prospective study on the incidences of cardiovascular-renal complications in Chinese patients with young-onset type 1 and type 2 diabetes mellitus.
        Diabetes Care. 2014; 37: 1-9https://doi.org/10.2337/dc13-1336
        • Zhao W.
        • Zhai Y.
        • Hu J.
        • Wang J.
        • Yang Z.
        • Kong L.
        • et al.
        Economic burden of obesity-related chronic diseases in Mainland China.
        Obesity reviews. 2008; 9: 62-67
        • Lee C.M.
        • Colagiuri R.
        • Magliano D.J.
        • Cameron A.J.
        • Shaw J.
        • Zimmet P.
        • et al.
        The cost of diabetes in adults in Australia.
        Diabetes Res Clin Pract. 2013; 99: 385-390
        • Chang T.J.
        • Jiang Y.D.
        • Chang C.H.
        • Chung C.H.
        • Yu N.C.
        • Chuang L.M.
        Accountability, utilization and providers for diabetes management in Taiwan, 2000–2009: an analysis of the National Health Insurance database.
        J Formos Med Assoc. 2012; 111: 605-616
        • Wang W.
        • Fu C.
        • Zhuo H.
        • Luo J.
        • Xu B.
        Factors affecting costs and utilization of type 2 diabetes healthcare: a cross-sectional survey among 15 hospitals in urban China.
        BMC Health Serv Res. 2010; 10: 244
        • Goldhaber-Fiebert J.D.
        • Li H.
        • Ratanawijitrasin S.
        • Vidyasagar S.
        • Wang X.Y.
        • Aljunid S.
        • et al.
        Inpatient treatment of diabetic patients in Asia: Evidence from India, China, Thailand and Malaysia.
        Diabetic Medicine. 2010; 27: 101-108
        • Li R.
        • Zhang P.
        • Barker L.E.
        • Chowdhury F.M.
        • Zhang X.
        Cost-effectiveness of interventions to prevent and control diabetes mellitus: a systematic review.
        Diabetes Care. 2011; 33: 1872-1894
        • Li G.
        • Zhang P.
        • Wang J.
        • Gregg E.W.
        • Yang W.
        • Gong Q.
        • et al.
        The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: A 20-year follow-up study.
        Lancet. 2008; 371: 1783-1789
        • Yang W.
        • Lin L.
        • Qi J.
        • Yu Z.
        • Pei H.
        • He G.
        • et al.
        The preventive effect of acarbose and metformin on the progression to diabetes mellitus in the IGT population: A 3-year multicentre prospective study.
        Chinese Journal of Endocrinology and Metabolism. 2001; 17: 131-136
        • Kawamori R.
        • Tajima N.
        • Iwamoto Y.
        • Kashiwagi A.
        • Shimamoto K.
        • Kaku K.
        Voglibose for prevention of type 2 diabetes mellitus: a randomised, double-blind trial in Japanese individuals with impaired glucose tolerance.
        Lancet. 2009; 373: 1607-1614
        • Luk A.O.
        • Yang X.
        • Ma R.C.
        • Ng V.W.
        • Yu L.W.
        • Lau W.W.
        • et al.
        Association of statin use and development of renal dysfunction in type 2 diabetes - the Hong Kong Diabetes Registry.
        Diabetes Res Clin Pract. 2010; 88: 227-233
        • Ting R.Z.
        • Yang X.
        • Yu L.W.
        • Luk A.O.
        • Kong A.P.
        • Tong P.C.
        • et al.
        Lipid control and use of lipid-regulating drugs for prevention of cardiovascular events in Chinese type 2 diabetic patients: A prospective cohort study.
        Cardiovascular diabetology. 2011; 9https://doi.org/10.1186/475-2840-9-77
        • So W.Y.
        • Chan N.
        • Tong P.C.Y.
        • Chow C.C.
        • Chan W.B.
        • Ng M.C.Y.
        • et al.
        Effect of RAAS inhibition on survival and renal outcomes in 3737 Chinese type 2 diabetic patients.
        Hypertension. 2004; 44: 294-299
        • Ohkubo Y.
        • Kishikawa H.
        • Araki E.
        • Miyata T.
        • Isami S.
        • Motoyoshi S.
        • et al.
        Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: A randomized prospective 6-year study.
        Diabetes Res Clin Pract. 1995; 28: 103-117
        • Leung W.Y.S.
        • So W.Y.
        • Tong P.C.Y.
        • Chan N.N.
        • Chan J.C.N.
        Effects of structured care by a pharmacist-diabetes specialist team in patients with type 2 diabetic nephropathy.
        Am J Med. 2005; 118: e421-e427
        • Chan J.C.
        • So W.Y.
        • Yeung C.Y.
        • Ko G.T.
        • Lau I.T.
        • Tsang M.W.
        • et al.
        Effects of structured versus usual care on renal endpoint in type 2 diabetes: The SURE study: A randomized multicenter translational study.
        Diabetes Care. 2009; 32: 977-982
        • So W.Y.
        • Yang X.
        • Ma R.C.
        • Kong A.P.
        • Lam C.W.
        • Ho C.S.
        • et al.
        Risk factors in V-shaped risk associations with all-cause mortality in type 2 diabetes - the Hong Kong Diabetes Registry.
        Diabetes Metabolism Research and Reviews. 2008; 24: 238-246
        • Li H.Y.
        • Jiang Y.D.
        • Chang C.H.
        • Chung C.H.
        • Lin B.J.
        • Chuang L.M.
        Mortality trends in patients with diabetes in Taiwan: a nationwide survey in 2000–2009.
        J Formos Med Assoc. 2012; 111: 645-650
        • Win Tin S.T.
        • Gadabu E.
        • Iro G.
        • Tasserei J.
        • Colagiuri R.
        Diabetes related amputations in Pacific Islands countries: a root cause analysis of precipitating events.
        Diabetes Res Clin Pract. 2013; 100: 230-234
        • Wu A.Y.
        • Kong N.C.
        • de Leon F.A.
        • Pan C.Y.
        • Tai T.Y.
        • Yeung V.T.
        • et al.
        An alarmingly high prevalence of diabetic nephropathy in Asian type 2 diabetic patients: The microalbuminuria prevalence (MAP) study.
        Diabetologia. 2005; 48: 1674-1675
        • Luk A.O.
        • So W.Y.
        • Ma R.C.
        • Kong A.P.
        • Ozaki R.
        • Ng V.S.
        • et al.
        Metabolic syndrome predicts new onset of chronic kidney disease in 5,829 patients with type 2 diabetes: A 5-year prospective analysis of the Hong Kong Diabetes Registry.
        Diabetes Care. 2008; 31: 2357-2361
        • Cheng A.Y.
        • Kong A.P.
        • Wong V.W.
        • So W.Y.
        • Chan H.L.
        • Ho C.S.
        • et al.
        Chronic Hepatitis B viral infection independently predicts renal outcome in type 2 diabetic patients.
        Diabetologia. 2006; 49: 1777-1784
        • Wen C.P.
        • Cheng T.Y.
        • Tsai M.K.
        • Chang Y.C.
        • Chan H.T.
        • Tsai S.P.
        • et al.
        All-cause mortality attributable to chronic kidney disease: A prospective cohort study based on 462 293 adults in Taiwan.
        Lancet. 2008; 371: 2173-2182
        • Williams E.D.
        • Magliano D.J.
        • Tapp R.J.
        • Oldenburg B.F.
        • Shaw J.E.
        Psychosocial stress predicts abnormal glucose metabolism: the Australian Diabetes, Obesity and Lifestyle (AusDiab) study.
        Ann Behav Med. 2013; 46: 62-72
        • Kaur G.
        • Tee G.H.
        • Ariaratnam S.
        • Krishnapillai A.S.
        • China K.
        Depression, anxiety and stress symptoms among diabetics in Malaysia: a cross sectional study in an urban primary care setting.
        BMC Fam Pract. 2013; 14: 69
        • Zhang Y.
        • Ting R.
        • Lam M.
        • Lam J.
        • Nan H.
        • Yeung R.
        • et al.
        Measuring depressive symptoms using the Patient Health Questionnaire-9 in Hong Kong Chinese subjects with type 2 diabetes.
        Journal of affective disorders. 2013; 151: 660-666
        • Ting R.Z.
        • Lau E.S.
        • Ozaki R.
        • Lau W.W.
        • Kong A.P.
        • Luk A.O.
        • et al.
        High risk for cardiovascular disease in Chinese type 2 diabetic patients with major depression--a 7-year prospective analysis of the Hong Kong Diabetes Registry.
        Journal of Affective Disorders. 2013; 149: 129-135
        • Ting R.Z.
        • Nan H.
        • Yu M.W.
        • Kong A.P.
        • Ma R.C.
        • Wong R.Y.
        • et al.
        Diabetes-related distress and physical and psychological health in Chinese type 2 diabetic patients.
        Diabetes Care. 2011; 34: 1094-1096
        • Cong J.Y.
        • Zhao Y.
        • Xu Q.Y.
        • Zhong C.D.
        • Xing Q.L.
        Health-related quality of life among Tianjin Chinese patients with type 2 diabetes: a cross-sectional survey.
        Nurs Health Sci. 2012; 14: 528-534
        • Sheu W.H.
        • Ji L.N.
        • Nitiyanant W.
        • Baik S.H.
        • Yin D.
        • Mavros P.
        • Chan S.P.
        • et al.
        Hypoglycemia is associated with increased worry and lower quality of life among patients with type 2 diabetes treated with oral antihyperglycemic agents in the Asia-Pacific region.
        Diabetes Res Clin Pract. 2012; 96: 141-148
        • Nguyen Q.N.
        • Pham S.T.
        • Do L.D.
        • Nguyen V.L.
        • Wall S.
        • Weinehall L.
        • et al.
        Cardiovascular disease risk factor patterns and their implications for intervention strategies in Vietnam.
        International Journal of Hypertension. 2012; 2012: 560397https://doi.org/10.1155/2012/560397
        • Otgontuya D.
        • Oum S.
        • Palam E.
        • Rani M.
        • Buckley B.S.
        Individual-based primary prevention of cardiovascular disease in Cambodia and Mongolia: early identification and management of hypertension and diabetes mellitus.
        BMC Public Health. 2012; 12: 254
        • Deurenberg-Yap M.
        • Schmidt G.
        • van Staveren W.A.
        • Deurenberg P.
        The paradox of low body mass index and high body fat percentage among Chinese, Malays and Indians in Singapore.
        Int J Obes. 2000; 24: 1011-1017
        • King G.L.
        • McNeely M.J.
        • Thorpe L.E.
        • Mau M.L.
        • Ko J.
        • Liu L.L.
        • et al.
        Understanding and addressing unique needs of diabetes in Asian Americans, native Hawaiians, and Pacific Islanders.
        Diabetes Care. 2012; 35: 1181-1188
        • Dickinson S.
        • Colagiuri S.
        • Faramus E.
        • Petocz P.
        • Brand-Miller J.C.
        Postprandial hyperglycemia and insulin sensitivity differ among lean young adults of different ethnicities.
        J Nutr. 2002; 132: 2574-2579
        • Nishi Y.
        • Fukushima M.
        • Suzuki H.
        • Mitsui R.
        • Ueda N.
        • Taniguchi A.
        • et al.
        Insulin secretion and insulin sensitivity in Japanese subjects with impaired fasting glucose and isolated fasting hyperglycemia.
        Diabetes Res Clin Pract. 2005; 70: 46-52
        • Kuroe A.
        • Fukushima M.
        • Usami M.
        • Ikeda M.
        • Nakai Y.
        • Taniguchi A.
        • et al.
        Impaired beta-cell function and insulin sensitivity in Japanese subjects with normal glucose tolerance.
        Diabetes Res Clin Pract. 2003; 59: 71-77
        • Suraamornkul S.
        • Kwancharoen R.
        • Ovartlarnporn M.
        • Rawdaree P.
        • Bajaj M.
        Insulin clamp-derived measurements of insulin sensitivity and insulin secretion in lean and obese Asian type 2 diabetic patients.
        Metab Syndr Relat Disord. 2010; 8: 113-118
        • Kong A.P.S.
        • Xu G.
        • Brown N.
        • So W.Y.
        • Ma R.C.
        • Chan J.C.N.
        Diabetes and its comorbidities – where East meets West.
        Nat Rev Endocrinol. 2013; https://doi.org/10.1038/nrendo.2013.102
        • Ma R.C.
        • Chan J.C.N.
        Type 2 diabetes in East Asians: similarities and differences with populations in Europe and the United States.
        Ann N Y Acad Sci. 2013; 1281: 64-91
        • Ng M.C.
        • Park K.S.
        • Oh B.
        • Tam C.H.
        • Cho Y.M.
        • Shin H.D.
        • et al.
        Implication of genetic variants near TCF7L2, SLC30A8, HHEX, CDKAL1, CDKN2A/B, IGF2BP2, and FTO in type 2 diabetes and obesity in 6,719 Asians.
        Diabetes. 2008; 57: 2226-2233
        • Cho Y.S.
        • Chen C.H.
        • Hu C.
        • Long J.
        • Hee Ong R.T.
        • Sim X.
        • et al.
        Meta-analysis of genome-wide association studies identifies eight new loci for type 2 diabetes in East Asians.
        Nature Genetics. 2011; 44: 67-72
        • Yamauchi T.
        • Hara K.
        • Maeda S.
        • Yasuda K.
        • Takahashi A.
        • Horikoshi M.
        • et al.
        A genome-wide association study in the Japanese population identifies susceptibility loci for type 2 diabetes at UBE2E2 and C2CD4A-C2CD4B.
        Nature Genetics. 2010; 42: 864-868
        • Ma R.C.
        • Hu C.
        • Tam C.H.
        • Zhang R.
        • Kwan P.
        • Leung T.F.
        • et al.
        Genome-wide association study in a Chinese population identifies a susceptibility locus for type 2 diabetes at 7q32 near PAX4.
        Diabetologia. 2013; 56: 1291-1305
        • Li J.K.Y.
        • Ng M.C.Y.
        • So W.Y.
        • Chiu C.
        • Ozaki R.
        • Tong P.C.Y.
        • et al.
        Phenotypic and genetic clustering of diabetes and metabolic syndrome in Chinese families with type 2 diabetes mellitus.
        Diabetes Metabolism Research and Reviews. 2006; 22: 46-52
        • Tam C.H.
        • Lam V.K.
        • So W.Y.
        • Ma R.C.
        • Chan J.C.
        • Ng M.C.
        Genome-wide linkage scan for factors of metabolic syndrome in a Chinese population.
        BMC Genet. 2010; 11: 14https://doi.org/10.1186/1471-2156-11-14
        • Xiang K.
        • Wang Y.
        • Zheng T.
        • Jia W.
        • Li J.
        • Chen L.
        • et al.
        Genome-wide search for type 2 diabetes/impaired glucose homeostasis susceptibility genes in the Chinese: significant linkage to chromosome 6q21-q23 and chromosome 1q21-q24.
        Diabetes. 2004; 53: 228-234
        • Ng M.C.
        • So W.Y.
        • Cox N.J.
        • Lam V.K.L.
        • Cockram C.S.
        • Bell G.I.
        • et al.
        Genome wide scan for metabolic syndrome and related quantitative traits in Hong Kong Chinese and confirmation of a susceptibility locus on chromosome 1q21-25.
        Diabetes. 2004; 53: 2676-2683
        • Diamond J.M.
        Diabetes running wild.
        Nature. 1992; 357: 362-363
        • Gluckman P.D.
        • Hanson M.A.
        • Cooper C.
        • Thornburg K.L.
        Effect of in utero and early-life conditions on adult health and disease.
        N Engl J Med. 2008; 359: 61-73
        • Kim C.
        • Newton K.M.
        • Knopp R.H.
        Gestational diabetes and the incidence of type 2 diabetes: a systematic review.
        Diabetes Care. 2002; 25: 1862-1868
        • Jang H.C.
        • Min H.K.
        • Lee H.K.
        • Cho N.H.
        • Metzger B.E.
        Short stature in Korean women: a contribution to the multifactorial predisposition to gestational diabetes mellitus.
        Diabetologia. 1998; 41: 778-783
        • Cheung N.W.
        • Byth K.
        Population health significance of gestational diabetes.
        Diabetes Care. 2003; 26: 2005-2009
        • Tam W.H.
        • Ma R.C.
        • Yang X.
        • Ko G.T.
        • Tong P.C.
        • Cockram C.S.
        • et al.
        Glucose intolerance and cardiometabolic risk in children exposed to maternal gestational diabetes mellitus in utero.
        Pediatrics. 2008; 122: 1229-1234
        • Ma R.C.
        • Chan J.C.
        • Tam W.H.
        • Hanson M.A.
        • Gluckman P.D.
        Gestational diabetes, maternal obesity, and the NCD Burden.
        Clin Obstet Gynecol. 2013; 56: 633-641
        • Djousse L.
        • Driver J.A.
        • Gaziano J.M.
        • Buring J.E.
        • Lee I.M.
        Association between modifiable lifestyle factors and residual lifetime risk of diabetes.
        Nutr Metab Cardiovasc Dis. 2013; 23: 17-22
        • Willi C.
        • Bodenmann P.
        • Ghali W.A.
        • Faris P.D.
        • Cornuz J.
        Active smoking and the risk of type 2 diabetes: a systematic review and meta-analysis.
        JAMA. 2007; 298: 2654-2664
        • Cho N.H.
        • Chan J.C.
        • Jang H.C.
        • Lim S.
        • Kim H.L.
        • Choi S.H.
        Cigarette smoking is an independent risk factor for type 2 diabetes: a four-year community-based prospective study.
        Clin Endocrinol (Oxf). 2009; 71: 679-685
        • Hansen A.L.
        • Wijndaele K.
        • Owen N.
        • Magliano D.J.
        • Thorp A.A.
        • Shaw J.E.
        • et al.
        Adverse associations of increases in television viewing time with 5-year changes in glucose homeostasis markers: The AusDiab study.
        Diabetic Medicine. 2012; 29: 918-925
        • Yu R.
        • Woo J.
        • Chan R.
        • Sham A.
        • Ho S.
        • Tso A.
        • et al.
        Relationship between dietary intake and the development of type 2 diabetes in a Chinese population: The Hong Kong Dietary Survey.
        Public Health Nutrition. 2011; 14: 1133-1141
        • Malik V.S.
        • Willett W.C.
        • Hu F.B.
        Sugar-sweetened beverages and BMI in children and adolescents: reanalyses of a meta-analysis.
        Am J Clin Nutr. 2009; 89 (author reply 9–40): 438-439
        • Harding J.L.
        • Backholer K.
        • Williams E.D.
        • Peeters A.
        • Cameron A.J.
        • Hare M.J.
        • et al.
        Psychosocial stress is positively associated with body mass index gain over 5 years: Evidence from the longitudinal AusDiab study.
        Obesity. 2013; https://doi.org/10.1002/oby.20423
        • Cappuccio F.P.
        • D’Elia L.
        • Strazzullo P.
        • Miller M.A.
        Quantity and quality of sleep and incidence of type 2 diabetes: a systematic review and meta-analysis.
        Diabetes Care. 2010; 33: 414-420
        • International Diabetes Federation
        Diabetes Atlas.
        3rd ed. 2006
        • Ko G.T.C.
        • Chan J.C.N.
        • Cockram C.S.
        A low socioeconomic class is associated with diabetes and metabolic syndrome in Hong Kong Chinese.
        Eur J Epidemiol. 2001; 17: 289-295
        • Ko G.T.
        • Chan J.C.
        • Chan A.W.
        • Wong P.T.
        • Hui S.S.
        • Tong S.D.
        • et al.
        Low levels of awareness of suboptimal health conditions in a high-risk working population: The “Better Health For Better Hong Kong” health promotion campaign.
        Int J Behav Med. 2007; 14: 63-69
        • Wong M.C.
        • Leung M.C.
        • Tsang C.S.
        • Lo S.V.
        • Griffiths S.M.
        The rising tide of diabetes mellitus in a Chinese population: a population-based household survey on 121,895 persons.
        Int J Public health. 2013; 58: 269-276
        • Lao T.T.
        • Chan B.C.
        • Leung W.C.
        • Ho L.F.
        • Tse K.Y.
        Maternal hepatitis B infection and gestational diabetes mellitus.
        J Hepatol. 2007; 47: 46-50
        • Cani P.D.
        • Delzenne N.M.
        • Amar J.
        • Burcelin R.
        Role of gut microflora in the development of obesity and insulin resistance following high-fat diet feeding.
        Pathol Biol. 2008; 56: 305-309
        • Lim S.
        • Cho Y.M.
        • Park K.S.
        • Lee H.K.
        Persistent organic pollutants, mitochondrial dysfunction, and metabolic syndrome.
        Ann NY Acad Sci. 2010; 1201: 166-176
        • Pickup J.C.
        Inflammation and activated innate immunity in the pathogenesis of type 2 diabetes.
        Diabetes Care. 2004; 27: 813-823
        • Fisher E.B.
        • Chan J.C.N.
        • Nan H.
        • Sartorius N.
        • Oldenburg B.
        Co-occurrence of diabetes and depression: conceptual considerations for an emerging global health challenge.
        J Affect Disord. 2012; 142: S56-S66
        • Holman R.R.
        • Paul S.K.
        • Bethel M.A.
        • Matthews D.R.
        • Neil H.A.
        10-year follow-up of intensive glucose control in type 2 diabetes.
        N Engl J Med. 2008; 359: 1577-1589
        • Gaede P.
        • Valentine W.J.
        • Palmer A.J.
        • Tucker D.M.
        • Lammert M.
        • Parving H.H.
        • et al.
        Cost-effectiveness of intensified versus conventional multifactorial intervention in type 2 diabetes: Results and projections from the Steno-2 study.
        Diabetes Care. 2008; 31: 1510-1515
        • Kong A.P.
        • Yang X.
        • Ko G.T.
        • So W.Y.
        • Chan W.B.
        • Ma R.C.
        • et al.
        Effects of treatment targets on subsequent cardiovascular events in Chinese patients with type 2 diabetes.
        Diabetes Care. 2007; 30: 953-959
        • Chan J.C.N.
        • Gagliardino J.J.
        • Baik S.H.
        • Chantelot J.M.
        • Ferreirae S.R.G.
        • Hancuf N.
        • et al.
        • on behalf of the IDMPS investigators
        Multi-faceted determinants for achieving glycaemic control: The international Ddiabetes Management Practice Study (IDMPS).
        Diabetes Care. 2009; 32: 227-233
        • Chuang L.M.
        • Soegondo S.
        • Soewondo P.
        • Young-SeolF K.
        • Mohamed M.
        • Dalisay E.
        • et al.
        Comparisons of the outcomes on control, type of management and complications status in early onset and late onset type 2 diabetes in Asia.
        Diabetes Res Clin Pract. 2006; 71: 146-155
        • David A.M.
        • Rubio J.M.
        • Luces P.S.
        • Zabala R.V.
        • Roberto J.P.
        Getting the patients’ perspective: a survey of diabetes services on Guam.
        Hawaii Med J. 2010; 69: 45-49
        • Popkin B.M.
        Is the obesity epidemic a national security issue around the globe?.
        Curr Opin Endocrinol Diabetes Obes. 2011; 18: 328-331
        • Mackay J.
        • Ritthiphakdee B.
        • Reddy K.S.
        Tobacco control in Asia.
        Lancet. 2013; 381: 1581-1587
        • Inzucchi S.E.
        • Sherwin R.S.
        The prevention of type 2 diabetes mellitus.
        Endocrinol Metab Clin North Am. 2005; 34 (viii): 199-219
        • Brown N.
        • Critchley J.
        • Bogowicz P.
        • Mayige M.
        • Unwin N.
        Risk scores based on self-reported or available clinical data to detect undiagnosed Type 2 Diabetes: a systematic review.
        Diabetes Res Clin Pract. 2012; 98: 369-385
        • CDC Diabetes Cost-effectiveness Study Group
        The cost-effectiveness of screening for Type 2 diabetes.
        JAMA. 1998; 280: 1757-1763
        • Gong Q.
        • Gregg E.W.
        • Wang J.
        • An Y.
        • Zhang P.
        • Yang W.
        • et al.
        Long-term effects of a randomised trial of a 6-year lifestyle intervention in impaired glucose tolerance on diabetes-related microvascular complications: The China Da Qing diabetes prevention outcome study.
        Diabetologia. 2011; 54: 300-307
        • Laatikainen T.
        • Dunbar J.A.
        • Chapman A.
        • Kilkkinen A.
        • Vartiainen E.
        • Heistaro S.
        • et al.
        Prevention of type 2 diabetes by lifestyle intervention in an Australian primary health care setting: Greater Green triangle (GGT) diabetes prevention project.
        BMC Public Health. 2007; 7: 249https://doi.org/10.1186/1471-2458-7-249
        • Sukala W.R.
        • Page R.
        • Cheema B.S.
        Targeting the type 2 diabetes epidemic in Polynesia: historical perspective and rationale for exercise intervention trials.
        Ethn Dis. 2012; 22: 123-128
        • Weng J.
        • Li Y.
        • Xu W.
        • Shi L.
        • Zhang Q.
        • Zhu D.
        • et al.
        Effect of intensive insulin therapy on beta-cell function and glycaemic control in patients with newly diagnosed type 2 diabetes: A multicentre randomised parallel-group trial.
        Lancet. 2008; 371: 1753-1760
        • Urakami T.
        • Suzuki J.
        • Mugishima H.
        • Amemiya S.
        • Sugihara S.
        • Kawamura T.
        • et al.
        Screening and treatment of childhood type 1 and type 2 diabetes mellitus in Japan.
        Pediatr Endocrinol Rev. 2012; 10: 51-61
        • Wei J.
        • Sung F.
        • Lin C.
        • Lin R.
        • Chiang C.
        • Chuang L.
        National surveillance for type 2 diabetes mellitus in Taiwanese children.
        JAMA. 2003; 290: 1345-1350
        • Norris S.L.
        • Lau J.
        • Smith S.J.
        • Schmid C.H.
        • Engelgau M.M.
        Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control.
        Diabetes Care. 2002; 25: 1159-1171
        • Zhang X.
        • Norris S.L.
        • Gregg E.W.
        • Cheng Y.J.
        • Beckles G.
        • Kahn H.S.
        Depressive symptoms and mortality among persons with and without diabetes.
        Am J Epidemiol. 2005; 161: 652-660
        • Campbell S.M.
        • Reeves D.
        • Kontopantelis E.
        • Sibbald B.
        • Roland M.
        Effects of pay for performance on the quality of primary care in England.
        N Engl J Med. 2009; 361: 368-378
        • Farmer S.A.
        • Black B.
        • Bonow R.O.
        Tension between quality measurement, public quality reporting, and pay for performance.
        JAMA. 2013; 309: 349-350
      2. Institute of Medicine Crossing the quality chasm: a new health system for the 21st century. 2001: http://www.nap.edu/books/0309072808/html/.

        • Ellrodt G.
        • Cook D.J.
        • Lee J.
        • Cho M.
        • Hunt D.
        • Weingarten S.
        Evidence-based disease management.
        JAMA. 1997; 278: 1687-1692
        • IDF Clinical Guidelines Task Force
        Global guideline for type 2 diabetes: recommendations for standard, comprehensive, and minimal care.
        Diabet Med. 2006; 23: 579-593
        • Tricco A.C.
        • Ivers N.M.
        • Grimshaw J.M.
        • Moher D.
        • Turner L.
        • Galipeau J.
        • et al.
        Effectiveness of quality improvement strategies on the management of diabetes: A systematic review and meta-analysis.
        Lancet. 2012; 379: 2252-2261
        • Chan J.C.
        What have we learnt from recent blood glucose lowering megatrials.
        J Diabetes Invest. 2011; https://doi.org/10.1111/j.2040-1124.2010.00063.x
        • Wu J.Y.
        • Leung W.Y.
        • Chang S.
        • Lee B.
        • Zee B.
        • Tong P.C.
        • et al.
        Effectiveness of telephone counselling by a pharmacist in reducing mortality in patients receiving polypharmacy: Randomised controlled trial.
        BMJ. 2006; 333: 522
        • Ko G.T.
        • So W.Y.
        • Tong P.C.
        • Le Coguiec F.
        • Kerr D.
        • Lyubomirsky G.
        • et al.
        From design to implementation--the Joint Asia Diabetes Evaluation (JADE) program: A descriptive report of an electronic web-based diabetes management program.
        BMC medical informatics and decision making. 2010; 10: 26https://doi.org/10.1186/1472-6947-10-26
        • So W.Y.
        • Raboca J.
        • Sobrepena L.
        • Yoon K.H.
        • Deerochanawong C.
        • Ho L.T.
        • et al.
        Comprehensive risk assessments of diabetic patients from seven Asian countries: The Joint Asia Diabetes Evaluation (JADE) program.
        Journal of diabetes. 2011; 3: 109-118
        • World Health Organization
        Updated revised draft global action plan for the prevention and control of noncommunicable diseases 2013–2020.
        2013
        • Pan X.R.
        • Li G.W.
        • Hu Y.H.
        • et al.
        Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance.
        Diabetes Care. 1997; 20: 537-544
        • WHO. WHO definition of health
        Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June 1946, and entered into force on 7 April 19481948
        • Western Pacific Declaration on Diabetes Steering Committee
        Plan of Action (2006–2010) for the Western Pacific Declaration on Diabetes: from evidence to action.
        World Health Organization Western Pacific Regional Office, Manila, Philippines2008 (available at www.wpdd.org)