Series

Diabetes in China 1
Diabetes in China: a societal solution for a personal challenge
Juliana C N Chan, Yuying Zhang, Guang Ning

China has a large burden of diabetes: in 2013, one in four people with diabetes worldwide were in China, where
116% of adults had diabetes and 501% had prediabetes. Many were undiagnosed, untreated, or uncontrolled. This
epidemic is the result of rapid societal transition that has led to an obesogenic environment against a backdrop of
traditional lifestyle and periods of famine, which together puts Chinese people at high risk of diabetes and multiple
morbidities. Societal determinants including social disparity and psychosocial stress interact with factors such as lowgrade infection, environmental pollution, care fragmentation, health illiteracy, suboptimal self-care, and insucient
community support to give rise to diverse subphenotypes and consequences, notably renal dysfunction and cancer. In
the China National Plan for Non-Communicable Disease Prevention and Treatment (201215), the Chinese
Government proposed use of public measures, multisectoral collaborations, and social mobilisation to create a healthenabling environment and to reform the health-care system. While awaiting results from these long-term strategies,
we advocate the use of a targeted and proactive approach to identify people at high risk of diabetes for prevention, and
of privatepubliccommunity partnerships that make integrated care more accessible and sustainable, focusing on
registry, empowerment, and community support. The multifaceted nature of the societal and personal challenge of
diabetes requires a multidimensional solution for prevention in order to reduce the growing disease burden.

Introduction
An epidemic is deemed to occur when the number of
new cases of a disease in a given human population and
during a given period substantially exceeds that expected
from past experience. It is typically caused by rapid
changes in the ecology of the host population resulting in
biological maladaptation with clinical manifestation.
Although this concept is widely recognised of
communicable diseasesfor example, overcrowding
and tuberculosis, water contamination and cholera
outbreaksthe eects of environments and settings on
the cognitivepsychologicalbehavioural responses of an
individual resulting in biological changes and disease
manifestation must be taken into account in pursuit of a
holistic solution to tackle the current epidemic of type 2
diabetes and non-communicable diseases (NCDs).1
China is home to 20% of the worlds population.
Extreme hardship was experienced in the rst 30 years of
establishment of the present government.2 With
globalisation and political changes, the increasing east
west exchanges have led to rapid socioeconomic,
technological, and cultural transitions in China. Although
these transitions have alleviated poverty, they have had
substantial health consequences. Compared with a rate of
09% in 1980,3 the prevalence of diabetes had increased to
116% in the 2010 national survey (table).4 That survey
used the 2010 American Diabetes Association diagnostic
criteria (75 g oral glucose tolerance test and HbA1c) and
included nearly 100 000 people representative of the
Chinese adult population. All ages were aected, with
808% of people older than 60 years and 486% of those
aged 1839 years having diabetes or prediabetes. Only
301% of those with diabetes had been previously
diagnosed; of them, only 258% had been treated, and
diabetes was controlled in only 397% of those treated.4
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In a prospective community-based survey in Shanghai,5

prediabetes was associated with ten times higher risk of
incident diabetes than was normal glucose tolerance. In
that 3-year follow-up study, the annual incidence of
diabetes by 1997 American Diabetes Association
diagnostic criteria was less than 1% in individuals with
normal glucose tolerance, 8% in those with prediabetes,
10% in those with isolated impaired fasting glucose
(IFG), 6% in those with isolated impaired glucose
tolerance (IGT), and 18% in those with IFG plus IGT.5
Given the high prevalence of diabetes and prediabetes in
China, and the close associations between glycaemic
indexes (HbA1c and plasma glucose) and multiple
morbidities, these gures herald an epidemic of NCDs
including but not limited to heart disease, renal failure,
and cancer.6
In this Series paper, we provide a historical overview of
Chinese peoples traditional lifestyle and the rapid
societal transition that has culminated in an obesogenic
environment, putting many people, especially the young,
old, and socially deprived, at high risk of type 2 diabetes.
In the China National Plan for NCD Prevention and
Treatment,7 the government advocated the use of policies
and mandates to create a health-enabling environment
(eg, tobacco control), reform the health-care system (eg,
family medicine), and adopt a life-course strategy to
prevent NCDs (eg, maternal and child health
programmes). While we wait for the results of these
long-term strategies, we can learn from the success of
introducing midwives to reduce maternal and perinatal
mortality and using public notication to control
tuberculosis during the period after World War 2. Given
the personal and public health implications of diabetes,
the use of registries and collaborative care have long
been proposed by the International Diabetes Federation

Lancet Diabetes Endocrinol

2014; 2: 96979
Published Online
September 11, 2014
http://dx.doi.org/10.1016/
S2213-8587(14)70144-5
See Comment page 930
This is the rst in a Series of
three papers about diabetes in
China
Department of Medicine and
Therapeutics, The Chinese
University of Hong Kong,
Prince of Wales Hospital,
Shatin, Hong Kong, China
(Prof J C N Chan FRCP,
Y Zhang MBBS); Li Ka Shing
Institute of Health Sciences,
Hong Kong Institute of
Diabetes and Obesity, and
International Diabetes
Federation Centre of
Education, The Chinese
University of Hong Kong,
Prince of Wales Hospital,
Shatin, Hong Kong, China
(Prof J C N Chan); and Key
Laboratory for Endocrine and
Metabolic Diseases of Ministry
of Health, Shanghai Clinical
Center for Endocrine and
Metabolic Disease, National
Clinical Research Center for
Metabolic Diseases, E-Institute
of Shanghai Universities, RuiJin Hospital, Shanghai Jiao
Tong University School of
Medicine, Shanghai, China
(G Ning MD)
Correspondence to:
Prof Juliana C N Chan,
Department of Medicine and
Therapeutics, The Chinese
University of Hong Kong, Shatin,
New Territories, Hong Kong SAR,
China
jchan@cuhk.edu.hk

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Area

Age (years)

19803

14 provinces/areas

107 954

30

199419*

19 provinces/areas

213 515

20000120

10 provinces/areas

15 540

20070821

14 provinces/areas

46 239

20

97%

20104

National

98 658

18

116%

2564
3574

Diabetes (%)

IGT (%)

IFG (%)

HbA1c 5765% Prediabetes (%)

09%

08%

..

..

..

25%

32%

..

..

..

55%

..
129% (men),
126% (women)
83%

73%
51% (men),
39% (women)
272%

..
..
354%

..
155%
501%

Data are percentages unless otherwise stated. IGT=impaired glucose tolerance. IFG=impaired fasting glucose. *Diabetes was diagnosed according to 1985 WHO criteria:
self-reported history of diabetes or fasting plasma glucose (FPG) 78 mmol/L or 2 h plasma glucose 111 mmol/L on 75 g oral glucose tolerance test; IGT was dened as
FPG <78 mmol/L and 2 h plasma glucose 78110 mmol/L. Data are from the International Collaborative Study of Cardiovascular Disease in Asia (InterASIA): diabetes was
dened as self-reported history of diabetes and/or FPG 70 mmol/L; IFG was dened as FPG 6169 mmol/L. Diabetes was diagnosed according to 1999 WHO criteria
(history of diabetes, FPG 70 mmol/L and/or 2 h plasma glucose 111 mmol/L on 75 g oral glucose tolerance test); IFG was dened as FPG 6169 mmol/L; IGT as 2 h plasma
glucose 78110 mmol/L; diabetes was dened according to 2010 American Diabetes Association criteria. Diabetes was diagnosed as history of diabetes, FPG 70 mmol/L,
and/or 2 h plasma glucose 111 mmol/L on 75 g oral glucose tolerance test, or HbA1c 65%. Prediabetes was dened as FPG 5669 mmol/L (IFG), 2 h plasma glucose
78110 mmol/L (IGT), or HbA1c 5764% in participants without a previous diagnosis of diabetes.

Table: Summary of national surveys for prevalence of type 2 diabetes in China in the past three decades

to improve diabetes care.8 In light of the large number of

people and processes involved in diabetes management,
in this digital era, information technology can be used to
improve communication among various health-care
providers and at-risk individuals to motivate behavioural
changes and promote informed decision making. Here,
we discuss the rationale and evidence for these
multidimensional strategies, including the use of
community-based care coordinating centres to set up
registries for quality assurance and provide empowerment with continuing support.911

Mismatch between biology and modernisation

Since the early 1980s, anthropologists, epidemiologists,
and clinical researchers have highlighted the potential
mismatch between biology and modernisation and its
eects on human health. Each of the theories had its own
features, but they shared a common theme: genetic traits
and phenotypes characterised by ecient energy storage,
plus prompt stress and inammatory responses, might
confer survival advantages in a food-deprived, physically
strenuous, and pathogen-rich environment, but in
societies undergoing rapid nutritional and lifestyle
transition with food abundance, psychosocial stress, and
physical inactivity, these genetic traits might substantially
increase the risk of diabetes and obesity. Activation of the
sympathetic nervous system, the hypothalamuspituitary
adrenal (HPA) axis, the renin angiotensin system (RAS),
and innate immunological responses together with ageing,
characterised by reduced secretion of growth hormone,
insulin growth factor-1 (IGF-1), and sex steroids, could
contribute to the multiple subphenotypes of obesity,
metabolic syndrome, cardiovascularrenal dysfunction,
and possibly cancer, all of which share common biological
pathways.1217
The rapid economic growth and acculturation in China
has taken on special signicance in light of these
theories. Traditionally, people in China led a lifestyle
characterised by strenuous physical activity and a lowcalorie, carbohydrate-rich diet with little animal fat. After
970

World War 2, especially between 1959 and 1962, China

experienced a period of extreme hardship during the
Cultural Revolution, when food scarcity, extreme physical
labour, and psychological stress were common.2 Since
economic reform in 1978, China has experienced rapid
and exponential increases in both national and personal
incomes; the gross domestic product (GDP) increased
from 365 billion RMB in 1978 to 56 885 billion RMB in
2013.18 This rapid transition has left people born in the
1950s and 1960s at high risk of diabetes and obesity.2
Only 21% of mainland Chinese lived in urban areas in
1982, but the proportion had increased to 53% by 2012.
Accompanying these socioeconomic changes, the
prevalence of diabetes also increased from 09% in 1980
to 116% in 2010 (table),3,4,1921 and the trends of wealth18
and health indicators ran almost in parallel (gure 1). In
the 2010 national survey, with 162 participating sites,
diabetes prevalence was 99% in underdeveloped regions
of China compared with 143% in more developed
regions, dened by the regions GDP per person in 2009.4
Between 1992 and 2002, the Chinese National Nutrition
Survey reported that the proportion of energy intake
from animal foods had increased from 93% to 137%,
whereas the proportion from fat rose from 220% to
298%.22 These changes were accompanied by increased
consumption of sugar-sweetened drinks,22 now viewed as
a major driver of the global epidemic of obesity, especially
in genetically predisposed individuals.23 Between 1991
and 2006, weekly physical activity had declined by 32%,
partly because use of cars increased.22,24 In a prospective
study in eight provinces in China,22,25 14% of households
acquired a car between 1989 and 1997. Men who acquired
a vehicle experienced an average 18 kg greater weight
gain, with doubling of the rate of obesity, than those who
did not acquire a vehicle. With rapid industrialisation
and greater use of cars, emission of carbon dioxide as an
index of environmental pollutants had also increased
over 25 times in 2006 compared with 1990.26 Several
reports from China have indicated possible associations
of type 2 diabetes and insulin resistance with exposure to
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environmental pollutants, some of which are known to

be endocrine disruptors, such as bisphenol A.27,28

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Diabetes prevalence (%)

Despite the rapid growth in national wealth, GDP per

person varies widely between rural provinces and auent
cities (eg, in 2012, 19 710 RMB in Guizhou and 93 173 RMB
in Tianjin).18 Disposable household income per person rose
from 2476 RMB in 2002 to 7917 RMB in 2012 in rural areas
compared with 7703 RMB in 2002 and 24 565 RMB in 2012
in urban areas.18 The Gini coecient, which measures the
degree of inequality in the distribution of household
income in a country, rose from 0333 in 1980 to 0473 in
2013.18,29 A Gini coecient above 0400 indicates alarming
inequality, which has also been reported in other highly
urbanised countries such as Singapore (0478, 2012), the
USA (0477, 2011), and Hong Kong (0537, 2011).30
Against this background, recognition that an individuals
behaviours are progressively framed by his or her
environment throughout the life course is important;
behaviour is strongly inuenced by education, experiences,
cognition, psychology, social norm, and peer inuence.
From conception, factors such as maternal stress,
perinatal deprivation, lack of education, low socioeconomic
status, subcultures, and psychosocial stress (work, family,
and interpersonal) can interact in a multiplicative way to
give rise to myriad health-related behaviours and biological
responses with dierent consequences. These clinical
presentations can be further inuenced by external
stressors, self-management, and quality of care; the last is
in turn commonly determined by health-care provision
and payment systems (gure 2).31
In areas undergoing rapid acculturation, disfranchised
subpopulations such as ethnic minorities and groups with
low socioeconomic status are especially vulnerable to the
consequences of social disparity. Han is the majority
ethnic group in China, although more than 50 subethnic
groups live in the northwestern and southwestern parts of
China where rapid urbanisation is occurring. Many
surveys have detected high rates of unhealthy lifestyles,
diabetes, cardiovascular risk factors, and premature
mortality and morbidity in minority groups from other
global regions (eg, Pima Indians) or migrants who
underwent rapid acculturation.32,33 Despite having no
shortage of food, many minority groups in China continue
to live in disease-prone environments characterised by
poor hygiene, chronic low-grade infections (notably viral
hepatitis B and C), and industrial pollution, with lowquality food and unbalanced nutrition. Rural to urban
migration and social mobilisation, especially in the young,
is commonly accompanied by erce competition,
unemployment, psychosocial stress, and depression,
culminating in risk-conferring behaviours such as use of
tobacco and binge drinking.34 Several large-scale surveys of
minority ethnic groups in China have revealed high rates
of obesity, hypertension, dyslipidaemia, and prediabetes.3537

12

Diabetes
GDP

2007
97

10
6
2

0
455
1978
1983

30 000

1993

20 000

26 581

10 000

9921

4820
1988

40 000

40 151

1994
25

1980
09

60 000
50 000

2000
55

8
4

2010
116

1998

2003

2008

GDP (million RMB)

Social disparity, obesogenic environment, and

psychological stress

14

0
2013

Year

Figure 1: Near-parallel trend lines of indicators of health (diabetes prevalence) and wealth (GDP) in China in
the past three decades
Prevalence data for any diabetes from the table and GDP data from the National Bureau of Statistics of the Peoples
Republic of China.18

Strategies and solution

Consequences
Perpetuating factor
Precipitating factor
Predisposing factor

Traditional subsistence lifestyle

Periods of famine
Low-grade infections
Genetic and epigenetic factors

Rapid urbanisation
Socioeconomic development

Community empowerment
Environmental protection

Poor adherence
Care fragmentation

Ageing
Small families

Obesogenic environment
Environmental pollution
Social disparity and isolation

Premature diabetes and NCDs

Unhealthy lifestyles
Health illiteracy

Community support
Social protection

Psychosocial stress
Poor quality of life

Premature mortality and morbidity

Loss of societal productivity
Unsustainable health-care system
Access to integrated care
and education
Registry and audit

Universal health-care
coverage
Health-care reform
Financial protection

Figure 2: The possible predisposing, precipitating, and perpetuating factors in a Chinese population leading a
traditional subsistence lifestyle in a pathogen-rich environment who undergo rapid transition with changes
in socioeconomic and demographic structures

Other researchers have reported independent associations

of obesity and diabetes with low educational attainment
and socioeconomic status.38 Although low educational
attainment might interact with high personal income to
increase the risk of diabetes among the newly auent,19
within the workforce, long working hours, poor sleep
hygiene, and shift work have been associated with
increased risk of obesity and diabetes,39,40 commonly
accompanied by low levels of awareness.41

Asian diabetes phenotype: a phenotype of

transition
During the past two decades, evidence has been increasing
that despite low BMI, Asian people have a high prevalence
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of diabetes and metabolic syndrome, characterised by low

-cell function, high insulin resistance, and propensity to
develop renal disease and cancer, in contrast to the
preponderance of obesity, insulin resistance, and
cardiovascular disease in white people with type 2
diabetes.42 In the early 1990s, researchers proposed that
ageing and rapid acculturation could lead to decline in
production of growth hormone and sex steroids and
activation of stress hormones, notably the HPA axis,
leading to changes in body composition, insulin
resistance, and increased cardiometabolic risk.12,14,43 Hong
Kong, one of the most auent cities in China, has
undergone rapid socioeconomic changes since 1990, not
dissimilar to the present situation in mainland China. In
the 1990s, researchers from Hong Kong rst reported
1030% prevalence of prediabetes, diabetes, and metabolic
syndrome despite relatively low BMI and waist
circumference.44,45 These ndings have subsequently been
conrmed in many Asian populations, with low BMI
associated with low -cell function, and large waist
circumference associated with insulin resistance.45
In the WHO Multinational Study of Vascular Disease
in Diabetes conducted in the early 1980s, Asian (including
Chinese) patients with diabetes had low prevalence of
coronary heart disease but high prevalence of chronic
kidney disease and stroke, whereas white patients were
more likely to have coronary heart disease.46,47 These
interethnic dierences have also been reported in
randomised clinical trials involving dierent ethnic
groups.48,49 Apart from genetic factors, Asian patients
might be more likely to develop renal disease due to the
co-occurrence of insulin deciency and resistance, low
risk of coronary heart disease, chronic viral infections,
environmental toxins, dietary factors (eg, high salt
intake), delayed treatment, and use of unregulated drugs
and herbal medications.50
In the Hong Kong Diabetes Registry, established in 1995
as a continuous quality improvement programme, much
has been learnt by tracking the clinical course of nearly
10 000 patients with type 2 diabetes, with an accrual of 7000
clinical events up to 2009. In the early 1990s, before the
introduction of near universal health coverage in Hong
Kong, the leading causes of death in patients with diabetes
were stroke and renal failure. With improved health-care
coverage including essential medications, the stroke rate
declined; however, with increasing personal auence and
westernised lifestyles, coronary heart disease became a
common clinical event in the early 2000s. Owing to
improved survival through coronary interventions and
dialysis, coupled with an ageing population, in 2007, one
in four patients with type 2 diabetes in the registry died
from cancer, mainly liver, colorectal, lung, and breast
cancers, followed by cardiovascular disease (coronary heart
disease, stroke, heart failure) and renal failure.51,52
The risk of cancer-related mortality is two times higher
in rapidly developing countries such as China than in
more developed countries such as the UK or the USA.
972

Some of the contributing factors to this increase include

ageing, westernisation, poor access to care, social
disparity, environmental contamination, uncontrolled
cancer-causing communicable infections, and delayed
treatment, partly due to use of alternative medicine.53 In
the prospective REACTION study,54 which examined the
link between diabetes and cancer in China, diabetes was
associated with increased risk of all cancers, especially in
women (mainly cancers of the breast, endometrium, and
thyroid). In the USA, population-based surveys have
detected higher prevalence of liver and gastric cancers in
Asian migrants than in white individuals, probably owing
to the high prevalence of chronic infections and exposure
to environmental toxins in their countries of origin.55
One possible mechanism linking diabetes and cancer is
chronic low-grade inammation and lipoglucotoxicity,
which can increase oxidative stress and cause dysregulation
of the insulingrowth hormoneIGF-1 axis and pathways
involving sterol-regulating binding-element proteins,
3-hydroxy-3-methyl-glutaryl-CoA reductase, and RAS,
resulting in abnormal cell cycles and cancer formation.
Pharmacoepidemiological studies have shown reduced
risk of cancer in patients with diabetes treated with
antidiabetic drugs, statins, and RAS inhibitors, but more
mechanistic and randomised studies are needed to
elucidate the causal nature of the diabetescancer link.56,57
In summary, complex interactions between the individual
and external stressors highly prevalent in developing areas
such as Chinasuch as environmental pollutants,58
psychosocial stress,59 low-grade infections,15 and tobacco60
could precipitate diabetes and obesity in predisposed
people, a situation perpetuated by multisystem dysfunction
with competing causes of mortality including stroke, renal
failure, coronary heart disease, heart failure, cancer, sepsis,
cognitive dysfunction, and dementia.44

Health and economic implications of ageing and

young-onset diabetes
With general improvement in living conditions, declining
rates of infectious disease, introduction of vaccination
programmes, and near-eradication of extreme poverty,
life expectancy in China has increased from 68 years to
73 years in the past 30 years, and infant and maternal
mortality rates are the lowest among less developed
nations.61 Given the high prevalence of diabetes in elderly
people, ageing of the population will continue to increase
the number of people with diabetes in China.62 However,
with increasing westernisation and rising rates of
childhood obesity, the most rapid rate of increase in
diabetes prevalence is occurring in the young to middleaged population.44 Thus, the double burden of ageing,
commonly associated with poor health and social
isolation, as well as rising rates of young-onset diabetes
and NCDs, will have an enormous toll on the social
fabric, societal productivity, health-care systems, and
quality of life in China, especially in rural populations
undergoing rapid urbanisation.
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The frailty and comorbidities associated with ageing are

well known, but the public and personal health implications
of young-onset diabetes have not been suciently
emphasised. In the early 1990s, high rates of microvascular
complications were reported, notably chronic kidney
disease in young Pima Indian63 and Japanese64 patients with
type 2 diabetes diagnosed before the age of 30 years. In an
analysis of the Hong Kong Diabetes Registry,65 one in ve
patients with diabetes diagnosed before the age of 40 years
had risks of all-cause death and cardiovascularrenal events
1520 times higher than those diagnosed after that age.
By the age of 60 years, one in three patients with youngonset diabetes had died or suered at least one major event.
In a subsequent analysis of 2363 Chinese people diagnosed
before the age of 40 years, 9% had type 1 diabetes; of the
remaining patients with type 2 diabetes, 64% were
overweight and 27% were of normal weight. After 9 years of
follow-up, overweight patients with type 2 diabetes had the
worst metabolic prole; their risk of cardiovascular disease
was 15 times higher and that of kidney failure ve times
higher than for people with type 1 diabetes, who had the
lowest event rates.66 In Hong Kong, where there is easy
access to insulin treatment and diabetes education, patients
with type 1 diabetes had a much better prognosis than
those with type 2 diabetes, many of whom experienced
major complications during the prime of life. These young
patients pose major therapeutic challenges owing to
phenotypic heterogeneity and lack of clinical guidelines.
Partly because they experienced no symptoms, young
patients with type 2 diabetes had high rates of medical visit
default, poor drug adherence, and low rates of attainment
of treatment targets, disease-modifying drugs were also
underprescribed to young patients.67,68

Reaching out to high-risk subjects for early

detection and empowerment
In 1993, the cost of diabetes treatment in China was
22 billion RMB, which accounted for 196% of national
health-care expenditure.69,70 In 2007, the cost had risen to
200 billion RMB, mainly used for the treatment of
diabetic complications and end-stage diseases, which
accounted for 182% of health-care expenditure. The
projected cost for 2030 is 360 billion RMB.69,70 Thus,
prevention is of crucial economic importance for China
to curb this escalating health-care cost. The evidence that
diabetes is preventable by means of structured lifestyle
modication is now irrefutable; this approach was rst
conceptualised, tested, and proven in China in the late
1980s. In the landmark Da Qing Study, the risk of
progression to diabetes for people with IGT was
decreased by 40% after 6 years of lifestyle intervention,
irrespective of obesity status at baseline, and on average
participants had 46% weight loss. After 23 years, the
positive benets of lifestyle modication were translated
to reduced risk of cardiovascular and all-cause mortality. 71
Despite the long-term benets on mortality, 8090% of
people with IGT in the Da Qing Study went on to develop
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diabetes in both intervention and control groups after

23 years,71 which shows the relentless deterioration of
-cell function.72,73 Thus, for these high-risk individuals,
early detection, regular surveillance, and possibly early
medical treatment to improve the metabolic milieu and
prevent disease progression would be needed. In the
early 1990s, Chinese researchers rst showed the benets
of using metformin and -glucosidase inhibitors to
prevent diabetes in people with IGT.74 Similar results
have been obtained in other Asian75 and white
populations.76,77
The next challenge is to translate this trial evidence to
daily clinical practice. By use of two prospective cohorts,
Chinese researchers have developed and validated the New
Chinese Diabetes Risk Score, which includes age, sex,
waist circumference, BMI, systolic blood pressure, and
family history of diabetes. It has 8692% sensitivity and
3538% specicity at a cut-o value of 25, of a maximum
of 51.78 Other researchers in China have reported the high
prevalence of diabetes in people with a history of coronary
heart disease79 and gestational diabetes.80 Simple point-ofcare tests, such as capillary blood glucose, remain a useful
way to identify individuals for early intervention.81 These
screening strategies are especially cost eective in young
people because they have a high life-time risk of diabetes
and its complications.82 However, since these risk factors
are silent and non-urgent, outreach programmes in special
settings, such as the workplace, schools, and clinics, might
be needed to identify high-risk individuals and to allow
follow-up actions including education, empowerment, and
intervention by relevant care professionals. The feasibility
of using trained community workers and graduate
students to implement these prevention programmes has
been shown in rural areas of less developed countries,
such as India.83

Quality of diabetes care: reality versus ideality

Apart from primary prevention, early intensive control of
blood glucose, blood pressure, and blood cholesterol
have been proven to reduce the risks of major clinical
outcomes, including death, in diabetes.84 In China, both
observational studies and randomised trials have
conrmed the benecial eects of team-based and
protocol-driven care to improve adherence and attain
several treatment targets; the interventions include RAS
inhibitors and statins to reduce the incidence of
cardiovascularrenal disease and cancer in patients with
diabetes in real-world settings.5257,8587 Furthermore, metaanalyses, and clinical and experimental studies suggest
the potential usefulness of traditional Chinese medicine,
widely used in Chinese populations, in the management
of obesity and diabetes.8891
Despite this evidence, large-scale national surveys in
China have revealed low rates of attainment of treatment
targets and use of these potentially life-saving
medications. In a multicentre study of more than
25 000 patients with type 2 diabetes, the proportions who
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achieved the individual targets were 477% for control of

blood glucose (HbA1c <7%), 284% for blood pressure
(<130/80 mm Hg), and 361% for total cholesterol
(<45 mmol/L), but only 56% achieved all three targets.92
In another study, only 2050% of patients with diabetes
had regular blood-pressure measurement, laboratory
tests, and examination of eyes or feet, and many did not
have regular medical follow-up or drug treatment.93

Education and support to promote selfmanagement

Diabetes is a challenging disease that necessitates
substantial self-learning and self-discipline.94 Lack of
awareness and education, compounded by clinical inertia

and care fragmentation, can lead to suboptimal self-care,

poor adherence, delayed intervention, frequent default,
hospital admission, and premature mortality (panel).95
Several meta-analyses have shown that diabetes education96
and self-monitoring of blood glucose97 independently lower
HbA1c. Contact with health-care professionals are crucial
for motivating and maintaining behavioural changes. In a
meta-analysis,98 self-management education reduced HbA1c
by 076% more than the control group at immediate followup, which decreased to 026% at 13 months and thereafter.
Contact time between patients and educators was the main
factor in maintaining HbA1c: a 1% decrease was associated
with every additional 236 h of contact time. This contact
time contrasts starkly with the actual average consultation

Panel: Interlinking of host, environmental, and system factors in precipitating and perpetuating the epidemic of diabetes
and obesity in predisposed individuals and possible strategies for a multidimensional solution
Demographic factors
Challenges
Ageing, frailties, and social isolation
One-child policy with small families
Early onset of diabetes and NCDs
Rising disease burden and health-care expenditures
Shrinking working force and reduced societal productivity
Strategies
Emphasise prevention and practice of evidence-based
medicine with community support
Regular national surveillance of social, medical,
psychological, and behavioural risk factors, health-care
needs, and access to care
Establishment of national disease registries (eg, death,
diabetes, cancer, stroke, dialysis) to monitor trends for
service planning
Ensure access to and equity of health care, including
essential laboratory assessments, technologies (eg, insulin
needles and test strips) and medications
Provide safety net for emergencies and catastrophic illness
Societal factors
Challenges
Rapid economic growth with social disparity
Population migration and acculturation
Rapid urbanisation with overconsumption of resources,
over-use of cars, environmental pollution, etc
Changes in food technology with high consumption of
energy-dense food
Lack of city planning with overcrowding and lack of space
for leisure and physical activity
Strategies
Intersectoral policies to provide a health-enabling
environment
Intersectoral policies to ensure sustainability of economic
development, to protect the environment, and to avoid
widening the gap between rich and poor

974

Food and environmental policies to ensure safety of air,

food, water, and drugs (including traditional Chinese
medicine) with adequate sanitation
Universal education to improve health literacy
Host factors
Challenges
Genetic predisposition
Previous hardships and famine
Epigenetic changes and transgenerational diabetes
Suboptimal maternal health
High prevalence of gestational diabetes and childhood obesity
Strategies
Universal screening for gestational diabetes with follow-up
plan for high-risk women
Maternity and child health programmes to reduce rates of
childhood obesity and young-onset diabetes and NCDs
Targeted approach to identify high-risk individuals for early
intervention
Self-managment
Challenges
Obesogenic environment with unhealthy lifestyle
Psychosocial stress
Poor sleep hygiene
Lack of awareness and health information
Low self-ecacy to change behaviour
Strategies
Tobacco control and policy on alcohol use
Multisectoral partnerships to create a health-enabling
environment, including city planning and trading policies
Community empowerment through early health education,
social marketing, and outreach health-promotion
programmes
Information transparency and encouragement of regular
self-assessment and monitoring, including use of mobile
technology
(continues on next page)

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Series

(Panel continued from previous page)

Care delivery
Challenges
Heterogeneity in phenotypes
Complex care protocols
Clinical inertia
Poor treatment adherence
Suboptimal care standards
Care fragmentation
Unwillingness to pay for preventive care
Low incentives to provide education and preventive care
because of time constraints, insucient remuneration, and
poor job satisfaction
Strategies
Build capacity with accreditations and career path to
promote preventive medicine
Improve workow and use team approach, augmented by
information technology to stratify risk, reinforce care
protocols, and establish registries for public reporting
Set up nurse-led diabetes centres supported by specialists to
provide education, regular assessments, care coordination,
and quality assurance
Provide incentive schemes to encourage provision and
subscription of health promotion and disease prevention
programmes

time of 10 min for each medical visit.99 On average, a patient

visits a clinic three to six times per year, equating to less
than 1 h with his or her care team, and therefore must cope
with their disease in the remaining 8765 h (36525 24 1),
often with little support.94
In a survey of nearly 6000 Chinese patients with type 2
diabetes,100 80% claimed to have received diabetes education,
which was associated with better self-care and glycaemic
control. In a randomised study,101 patients who received
education had improved signicantly more in self-care,
HbA1c, and drug compliance. Notably, 1050% of patients
with diabetes had mental health disorders such as
depression, distress, and anxiety, which were often associated
with poor cardiometabolic control. The close associations
detected between diabetes, depression, and stroke in young
people emphasise the complexity of these chronic diseases.102
Misconceptions, uncertainties, and demands associated
with treatment can cause substantial anxiety and stress both
to the individual and their family.34 Encouragingly, apart
from professional education,103 several studies have shown
the usefulness of peer support in improving cardiometabolic
control, psychological health, self-ecacy, and self-care,
highlighting the resource of involving people with diabetes
to improve quality of care (panel).104

Information technology for integrated care and

shared decision-making
The clinical inertia, non-adherence with treatment, and
care fragmentation that put strain on the care system,
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Community support
Challenges
Lack of motivation to change with relapse of risk behaviours
Negative emotions including depression and distress
Insucient contact time with care team
Lack of continuing support for day-to-day management
Excessive and unnecessary use of health-care resources
including hospital admission and attendance at emergency
departments
Strategies
Encourage formation of networks of community and peer
support groups including non-governmental organisations
and social enterprises to provide continuing support with
linkage to clinical care
Use private-public partnerships to encourage competition
in developing innovative ambulatory care models with clear
mandates from government (eg, infrastructure, care
components, personnel, treatment targets, outcome
measures and costs) together with information disclosure
for bench marking

carers, and patients are the result of the lifelong nature of

diabetes, complex care protocols, and short contact
times.105 In a 2012 meta-analysis,9 initiatives targeting the
system (eg, team change, task delegation, case
management, electronic patient registers, continuous
quality improvement), patients (eg, promotion of selfmanagement, reminders to patients), and doctors (eg,
audits, feedback, education, reminders to clinicians,
nancial incentives) all lowered HbA1c, blood pressure,
and LDL-cholesterol. Education, promotion of self-care,
task delegation, and case management had the largest
eect size.9 Use of nurses as educators and care
coordinators, guided by protocols and information
technology to provide decision support, improves selfecacy and reduces clinical inertia and non-adherence.8,11
Data collection by standard protocols can help to identify
unmet clinical needs, conrm treatment eectiveness,
reveal unexpected side-eects or benets, and track
performance indices for public reporting and
benchmarking.8,11,106

Coordination of care and provision of quality

assurance
To deliver this integrated care, health-care experts have
proposed changes to the clinical setting and reorganisation
of workows to facilitate education of patients, group
medical review, systematic data collection, and coordinated
care.107 For example, trained nurses, with medical
supervision, can successfully run diabetes centres that
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coordinate outreach and assessment programmes,

establish registries, and provide education and peer
support.11,108 In Italy, patients jointly managed by family
doctors and specialist-led diabetes centres had 17% lower
risks of all-cause and cardiovascular mortality than those
managed by family doctors alone over a 5-year follow-up.109
In 2000, motivated by results from research and pilot
programmes on the benets of team-based, protocoldriven care,85 the Hospital Authority in Hong Kong set up
diabetes centres and pilot schemes to create career paths
for diabetes nurses. With supervision by endocrinologists,
highly trained nurses in these diabetes centres served as
liaisons between patients and other care professionals,
including family doctors, specialists, dieticians, and
podiatrists, to provide regular comprehensive assessments
and education programmes. These comprehensive
assessments, modied from the St Vincents Declaration
EuroDiab protocol,110 enabled establishment of a territorywide registry for risk stratication and triage of patients
into various shared-care models which were reviewed
periodically at the centres for quality assurance.111 In 2009,
the Hong Kong Government adopted this care model into
the framework for management of diabetes in the primary
care setting.112

How to make care in China more accessible and

sustainable
In China, primary care is a relatively new concept to the
public and health-care community, and is still in its
infancy. As a result, hospital-based acute and episodic
care remain the predominant practices. In an interview
published in The Lancet in 2008, Chen Zhu, Chinas
Minister of Health, highlighted the challenges in
introducing major health-care reforms given the size of
the country, the large number of people needing
education and health care, and vested interests of many
stakeholders. The over-emphasis by hospitals on
generating income by providing high-technology

Search strategy and selection criteria

We searched PubMed, Google Scholar, and international and
national databases between January, 1978, and January, 2014
with the key words epidemiology, obesity, cancer,
mortality, morbidities, social disparity, globalisation,
ethnic minorities, economics, health literacy,
infection, environment, pollution, modernisation,
acculturation, transition, quality improvement, public
health, patient education, empowerment, chronic care
model, and national policies in combination with
diabetes. We gave priority to publications in English and
government data sources. We particularly focused on original
articles, reviews, and meta-analyses relevant to Chinese
populations. We included the literature and other data
sources that we judged to be important and timely
contributions to this topic.

976

medicine and earning commissions on drug sales is of

particular concern. Although the Chinese Government
has taken steps to gradually increase the state share of
hospital budgets from 68% to 2530% to promote good
clinical practice and bring justice and equality to basic
health care,61 these major reforms will take time to
realise. Similarly, in the China National Plan for NCD
Prevention and Treatment (20122015),7 the Government
proposed to use public measures including tobacco
control, food safety, clean drinking water, environmental
protection, and occupational safety to create a healthenabling environment through multisector collaborations
and broad social participation. Other proposed policies
and practices included universal vaccination, maternal
and child health programmes, health promotion
demonstration projects, targeted screening programmes,
and large-scale training of health-care professionals with
particular emphasis on community and primary health
care (panel).113
While we await the outcomes of these major healthcare reforms and national policies, what can society do to
address the rising burden of type 2 diabetes and its
comorbidities? Although each country will have its own
challenges in introducing health-care reform, some
broad principles based on supply and demand are
universally applicable. First and foremost, prevention of
avoidable harm to individuals must be the top priority for
all concerned. Second, all parties must recognise that
various care models need to be developed to make care
for diabetes and other chronic diseases more accessible,
sustainable, and aordable. Third, given the proven cost
eectiveness of diabetes prevention and control
programmes,114 mandates, audits, and incentives are
needed to discourage oversupply of technologies and
services with uncertain benets. In addition, the
provision and subscription of evidence-based prevention
programmes, including access to education, medications,
and laboratory assessments, should be encouraged.
Fourth, since health is a basic human right, governments
must provide a safety net so that health care for acute
emergencies and catastrophic disease is universally
available. Fifth, to meet the varying needs of people with
dierent backgrounds, privatepublic partnerships can
be used to promote competition and innovation to
provide less expensive services, such as communitybased risk assessment and education centres. To increase
information transparency, the public should be educated
about the benets to health of early intervention, regular
follow-ups, and self-management, as well as about
recommended care protocols, tasks of dierent
individuals in a multidisciplinary team (eg, specialists,
family doctors, nurses, dietitians, pharmacists,
community health workers, peer supporters), treatment
targets, and the range of treatment costs. Governments,
health-care experts, and private partners can specify the
nancial, operational, and clinical standards of these
programmes, and reimbursement of patients or care
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Series

providers could be based on specied performance

attainment. By leveraging private investment and using
competition to drive eciency and innovation,
governments can focus on professional training,
implementation of public-health measures, treatment of
emergencies and catastrophic diseases, and provision of
care for the sick and disadvantaged (panel, gure 2).10,115

The way forward: prevent the preventables

The diabetes epidemic that aected indigenous
populations such as Pima Indians in the mid 1970s116 is
now occurring on a massive scale in China. The complex
interactions between nature and nurture in populations
undergoing rapid transition from an energy-scarce to
energy-rich environment have resulted in a high
prevalence of obesity, metabolic syndrome, type 2
diabetes, and associated comorbidities, particularly renal
disease and cancer. With diering combinations and
permutations of external stressors and circumstances,
predisposed individuals might acquire dierent
behaviours and receive dierent patterns of care, giving
rise to heterogenous outcomes in the population aected
by diabetes.
The epidemic of obesity and diabetes in China is a wakeup call in terms of the price to society if rapid
socioeconomic development is not balanced by counter
measures for health, environment, and social protection.
That said, during the past two decades, many
stakeholdersincluding government, professional and
non-governmental organisations, researchers, care
providers, and industryhave made substantial progress
in advancing our understanding of the nature of this
epidemic, and in developing technologies and validating
programmes for prevention and control of diabetes and its
comorbidities.
This epidemic has revealed the intertwining nature of
knowledge, health, and wealth, and the importance of
research and education to shift the balance from adversity
to hope through leadership, partnership, and innovation.
As the Chinese saying goes, Whoever tied the knot on
the bell is the one to untie it (Jie ling hai xu ji ling ren).
Thus, as this epidemic continues to unfold, every
individual must join in the grand challenge of creation of
a multidimensional solution to minimise its negative
eects on societal, family, and personal health.
Contributors
JCC wrote the Series paper, YYZ searched and summarised various
databases. YYZ and NG reviewed, edited, and provided intellectual input
to the content and structure.
Declaration of interests
JCNC is the Chief Executive Ocer of the Asia Diabetes Foundation on
a probono basis. The Asia Diabetes Foundation is a charitable
organisation registered in Hong Kong, governed by the Chinese
University of Hong Kong Foundation to promote translation of evidence
to practice and to conduct pragmatic research in real world setting
through privatepublic partnerships. She is also the Director of the Yao
Chung Kit Diabetes Assessment Centre, a non-prot making nurse-led
diabetes centre, established under the Chinese University of Hong
Kong. The other authors declare no competing interests.

www.thelancet.com/diabetes-endocrinology Vol 2 December 2014

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