Diabetes mellitus and Obesity: The Hong Kong Scenario

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Diabetes mellitus and Obesity The Hong Kong
Scenario
(Dr Hok-cheung MA) Hospital Chief Exeucitve
Cheshire Home Chung Hom Kok, Ruttonjee Tang
Shiu Kin Hospitals 2 August 2007
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Overall Picture

• Apparently an increasing trend in prevalence over
  recent years
• Both reaching the extent of epidemics
• Central obesity recognised as causative factor
  for Diabetes mellitus
• Leading to high burden of morbidity to society
• Important causes of mortality as well

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Definitions

• Overweight
• BMI values for Asians (IOTF, IASO and WPRO of
  WHO)
• Underweight lt 18.5
• Normal range 18.5 22.9
• Overweight 23
• At risk 23 24.9
• Obese I 25 29.9
• Obese II 30

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Definitions

• Overweight for Children
• gt 120 of median weight for height

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Definitions

• Central Obesity
• Has been shown in epidemiological studies
  equivalent to excessive total body fat as a risk
  factor for diseases
• Central obesity reflects increase in visceral fat
  which is important in the pathogenesis of
  obesity-related diseases
• Can be conveniently measured by waist
  circumference which showed good correlation to
  abdominal or visceral fat
• Can also be represented by the waist-to-hip ratio

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Recommended cut-off points of waist
circumferences by WHO and WHO WPRO
DefinitionsCentral Obesity

• Severe Central Obesity is defined as having waist
  circumferences 100cm for males and 90cm for
  females

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Definitions

• Diabetes mellitus
• Impaired fasting glucose fasting glucose 6.1
  6.9mmol/l
• Impaired glucose tolerance fasting glucose
  lt7mmol/l and 2-h oral glucose tolerance test
  value between 7.8 and 11.1mmol/l
• Diabetes mellitus fasting glucose gt7mmol/l and/
  or a value gt11.1mmol/l either at 2-h during an
  oral glucose tolerance test or in a random sample

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Prevalence

• Obesity
• 1990
• Obesity II (BMI gt 30) among Hong Kong Chinese
• Males 2.2
• Females 4.8
• IASO and WPRO of WHO

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Prevalence

• Obesity
• 1995

Janus ED et al, 1997
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Prevalence

• Obesity
• 2003-2004
• People aged 15 or above
• Overweight (BMI 23 24.9)
• Males 20.1
• Females 15.9
• Obese I (BMI 25)
• Males 22.3
• Females 20.0
• Department of Health, HKSAR

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PrevalenceObesity among Children
Trends of percentage of overweight primary and
secondary students in Hong Kong
Faculty of Sports Science, School of Education,
CUHK
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PrevalenceCentral Obesity among working class
KO GT et al, 2007
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Prevalence

• Diabetes mellitus
• No comprehensive population screening programme,
  thus no reliable prevalence figures of the three
  Diabetes-related conditions for Hong Kong
• 1995 population-based survey of 2,900 subjects
  aged between 25 and 74 showed an age-adjusted
  prevalence of 8.5
• A more recent demographic survey estimated that
• Overall prevalence 10
• Type I 4
• Type II 96

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Prevalence

• Diabetes mellitus
• It was estimated that 55 of Diabetes-related
  conditions are not diagnosed
• Diabetes mellitus ranked 13th as the principal
  diagnosis for hospital admissions of the public
  hospitals of Hong Kong
• A morbidity study in 2006 found that Diabetes
  mellitus was present in
• 34.7 of patients with of cardiovascular diseases
• 27.2 of patients with stroke
• 38 of patients newly recruited into regular
  renal replacement therapy

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Overall Regional Strategies

• Obesity
• No government initiated integrative programme for
  fighting obesity
• Most people of Hong Kong do not recognize
  overweight or obesity as disease
• There is a trend for ladies to get slim, but
  mainly for aesthetic purposes
• The results of most weight management programmes
  are transient and the weight loss achieved of
  small magnitude

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Overall Regional Strategies

• Diabetes mellitus
• Main approach of management is for optimal
  glycaemic control using self-measured blood
  glucose and HbA1c as monitors and reduction of
  long-term complications
• Hospital Authority of Hong Kong is the major
  care-provider for the majority of diabetic
  patients in Hong Kong
• Most medications, including insulin, are provided
  practically free of charge to patients as
  long-term maintenance
• Diabetology is a recognised sub-specialty for
  physician training

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Life Style Adjustments

• Diet Control
• Mainstream diet westernized with average number
  of servings for vegetables and fruits 3.3 per
  day, which is lower than the recommended figure
  of 5
• The Department of Health (DoH) published
  pamphlets on healthy diet through its Central
  Health Education Unit and distributed to people
  free of charge
• A lot of TV programmes advocate healthy diet with
  talks given by qualified dietitians
• Many NGOs organise healthy diet lectures for the
  public at nominal charge

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Diet Advisory Session ?????????
Courtesy of Hong Kong Tuberculosis, Chest Heart
Diseases Association
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Life Style Adjustments

• Diet Control
• Many healthy diet recipe books in the market
• With more and more people choose to dine out, the
  DoH shift the focus to restaurants, encouraging
  them to have healthy menus for customers (the Eat
  Smart at Restaurant Campaign)
• The three popular fast food chains also make
  available healthy or light dishes for
  customers choice
• An Eat Smart at School movement by DoH in which
  thousands of schools are requested to provide
  healthy lunches to their pupils and students
• Most hospitals have dietitians attending to
  patients with Diabetes mellitus or significant
  overweight to provide professional dietetic
  advices
• All diabetic patients are prescribed special
  diabetic diet, but compliance is a problem

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Life Style Adjustments

• Regular Exercise
• Children in Hong Kong exercise less than those in
  other developed countries
• A 2003-04 survey showed one-third of Hong Kong
  people aged 15 64 were physically inactive
• Most primary care physicians lack training in
  exercise prescription
• Compliance to medical advices for regular
  exercise is poor
• However, regular exercise is practiced by many
  retirees and senior citizens as part of their
  social life in the form of self-initiated groups
  but health impact not evaluated

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Life Style Adjustments

• Regular Exercise
• Some exercise programmes tailor-made for high
  risk groups
• Overall shortage in public facilities for sports
  and exercise, although many private residential
  communities have their own gymnasiums
• Most commercial gymnasiums are for body building
  and aesthetic purposes and used by the younger
  generations
• The overall percentage of people having regular
  exercise is low

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Medical Therapies

• Obesity
• No dedicated body weight management centre in the
  public health care sector
• For severe obesity patients, many are cared for
  their medical complications with body weight
  reduction as part of their treatment programme,
  but the result is unsatisfactory in most
  situations
• Weight reducing medications are rarely used,
  although there are a lot of commercial products
  in the market claiming effectiveness in weight
  reduction, with occasional discovery of
  containing withdrawn western medicines such as
  Fenfluramine and Dexfenfluramine
• Other agents such as Fluoxitene and Sibutamine
  are occasionally used for indicated patients

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Medical Therapies

• Diabetes mellitus
• For diabetic patients, the major health care
  burden (76 of diagnosed patients) lies on the
  public sector because of financial incentive
• 17 DM centres under Hospital Authority and 8 DM
  centres in the private sector
• Regular diabetic complication screening is
  performed in ? 20 patients in the public sector
  and ? 5 in the private sector
• The focus of diabetic care is on secondary
  prevention, especially on micro-vascular
  complications
• Oral hypoglycaemic agents will be used according
  to algorithm, and if glycaemic control proven to
  be suboptimal, then put on insulin
• Early use of ACEI ? ARB to prevent renal
  complications

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Surgical Interventions

• Obesity (Bariatric Surgery)
• Bariatric surgery is only considered when all
  conservative treatment modalities fail to achieve
  desirable weight loss in severely obese patients
• Bariatric surgery is still in its infancy in Hong
  Kong and not widely available
• No additional resources committed by the
  Government for this purpose
• The most common procedure is the intra-gastric
  balloon followed by adjustable gastric banding
• Gastric bypass surgery is very rarely employed

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Surgical Interventions

• Diabetes mellitus
• Renal replacement therapy for patients suffering
  from end-stage chronic renal failure
• PCI and surgery for macro-vascular complications
  such as CABG and amputation of gangrenous foot
• Laser therapy for retinal complications

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Traditional Chinese Medicine and Diabetes mellitus

• Diabetes mellitus first described in the classic
  Nei Jing(??)which was compiled between 400 to
  200 BC
• The ancient Chinese term for Diabetes mellitus is
  ??, which means consumption and thirsty
  literally
• The earliest description of sweet urine
  appeared in the Tang Dynasty
• The disease was mentioned in many famous Chinese
  medical classics over two millennium

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Traditional Chinese Medicine and Diabetes mellitus

• Role of Chinese Medicine in diabetic care today
  is not certain
• Around 10,000 Chinese Medicine practitioners in
  Hong Kong, with more than half legally registered
• Number of diabetic patients receiving Chinese
  Medicine as the sole treatment is very few
• Most receive Orthodox Western Medicine for
  disease management and seek treatment from
  Chinese Medicine practitioners for special
  purposes, such as diabetic ulceration of the foot
  or general wellness
• Some patients take Chinese patent medicines which
  might also contain hypoglycaemic agents of
  Western Medicine

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Concluding Remarks

• Obesity
• Obesity is common among working class and
  increases in prevalence with age
• There is an overall rising trend over the pass
  few years, especially in children
• Females have more severe obesity prevalence than
  males
• Most government-initiated campaigns for fighting
  obesity are short-lived and transient in effect
• More resources and effort needed for fighting
  obesity

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Concluding Remarks

• Diabetes mellitus
• Diabetes mellitus is common among Hong Kong
  Chinese
• No population-wide diabetic screening programme
  available except during antenatal care
• The onus of secondary prevention programmes for
  Diabetes mellitus falls on the public sector
• Patient self-help groups have been an active
  component of alliance against Diabetes mellitus
  at the society level

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Thank You??
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