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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

Overall Picture: 

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

Definitions: 

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

Definitions: 

Definitions Overweight for Children > 120% of median weight for height

Definitions: 

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

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

Recommended cut-off points of waist circumferences by WHO and WHO WPRO Severe Central Obesity is defined as having waist circumferences ≥ 100cm for males and ≥ 90cm for females Definitions Central Obesity

Definitions: 

Definitions Diabetes mellitus Impaired fasting glucose: fasting glucose 6.1 – 6.9mmol/l Impaired glucose tolerance: fasting glucose <7mmol/l and 2-h oral glucose tolerance test value between 7.8 and 11.1mmol/l Diabetes mellitus: fasting glucose >7mmol/l and/ or a value >11.1mmol/l either at 2-h during an oral glucose tolerance test or in a random sample

Prevalence: 

Prevalence Obesity 1990 Obesity II (BMI > 30) among Hong Kong Chinese Males: 2.2% Females: 4.8% IASO and WPRO of WHO

Prevalence: 

Prevalence Obesity 1995 Janus ED et al, 1997

Prevalence: 

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

Prevalence Obesity among Children: 

Prevalence Obesity among Children Trends of percentage of overweight primary and secondary students in Hong Kong Faculty of Sports Science, School of Education, CUHK

Prevalence Central Obesity among working class: 

Prevalence Central Obesity among working class KO GT et al, 2007

Prevalence: 

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%

Prevalence: 

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

Overall Regional Strategies: 

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

Overall Regional Strategies: 

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

Life Style Adjustments: 

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

Slide19: 

Diet Advisory Session 食得健康、吃得有營 Courtesy of Hong Kong Tuberculosis, Chest & Heart Diseases Association

Life Style Adjustments: 

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

Life Style Adjustments: 

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

Life Style Adjustments: 

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

Medical Therapies: 

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

Medical Therapies: 

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

Surgical Interventions: 

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

Surgical Interventions: 

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

Traditional Chinese Medicine and Diabetes mellitus: 

Traditional Chinese Medicine and Diabetes mellitus Diabetes mellitus first described in the classic “Nei Jing”(內經)which was compiled between 400 to 200 BC The ancient Chinese term for Diabetes mellitus is 消渴, 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

Traditional Chinese Medicine and Diabetes mellitus: 

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

Concluding Remarks: 

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

Concluding Remarks: 

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

Thank You 謝謝: 

Thank You 謝謝

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