ISBN 978-988-17464-2-9 · 2014. 12. 10. · 3.2.2 Blood glucose measurement results and...
Transcript of ISBN 978-988-17464-2-9 · 2014. 12. 10. · 3.2.2 Blood glucose measurement results and...
ISBN 978-988-17464-2-9
Trends of Disease Burden Consequent to Diabetes in Older Persons in Hong Kong: Implications of Population Ageing
Authors: Prof.SarahM.McGhee Ms.WaiLingCheung Prof.JeanWoo Dr.PuiHingChau Ms.JingChen Ms.KamCheChan Mr.SaiHeiCheung
Publishedby: TheHongKongJockeyClubTel: 29668111Fax: 25042903Website: http://www.hkjc.org.hk
ISBN: 978-988-17464-2-9
Publishedin2009
Thecopyrightofthisbookbelongstotheoriginalauthors.Interestedpartiesarewelcometoreproduceanypartofthispublicationfornon-commercialuse.Acknowledgementofthispublicationisrequired.
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CADENZA: A Jockey Club Initiative for Seniors
CADENZA:AJockeyClubInitiativeforSeniorsisa$380millionprojectinitiatedandfundedbyTheHongKongJockeyClubCharitiesTrustinlightofarapidlyageingpopulation.FacultyofSocialSciences,TheUniversityofHongKongandFacultyofMedicine,TheChineseUniversityofHongKongaretheprojectpartners.Itaimsatcreatinganelder-friendlycommunitywhichfosterspositivecommunityattitudetowardsolderpeopleandcontinuouslyimprovesthequalityofcareandqualityoflifeforHongKong’selderly.
CADENZAisanacronymfor"CelebratetheirAccomplishments:DiscovertheirEffervescenceandNever-endingZestastheyAge."Inclassicalmusic,a'Cadenza'isanextendedvirtuosicsection,usuallyneartheendofamovementinaconcerto.Thewordisusedfigurativelytodescribetheapexofone'slifeandthecelebrationofalifetime'saccomplishments.
CADENZAismadeupof6majorcomponents:
1. Community Projectsareinnovativeandsustainableservicemodelstocopewiththechangingneedsofseniors.
2. Research Training Workshopistobuildandnurtureacademicleadershipinthefieldofgerontology.
3. ResearchistoadvancegerontologicalknowledgeandtoevaluatetheoutcomesofdifferentCADENZAprojects.
4. Public Awarenessseekstopromotepositiveageingandhighlightimportantissuespertainingtotheelderlypopulation,covering6majorthemes:(i)healthpromotionandmaintenance,(ii)healthandsocialservicesinHongKong,(iii)livingenvironment,(iv)financialandlegalissues,(v)qualityoflifeandqualityofdying,and(vi)agedisparities.
5. Symposiumistoprovideaplatformwhereoverseasandlocalexpertscanexchangenewinsightsintheunderstandingofageingissues.
6. Trainingincludeson-linecourses,workshopsandpublicseminarstotraindifferentlevelsofprofessionalfront-lineworkers,care-giversandthegeneralpublic.
Thefindingscoveredbythisreportarepartoftheseries"Challengesofpopulationageingondiseasetrendsandburden"carriedoutbyCADENZAincollaborationwiththeDepartmentofCommunityMedicine,SchoolofPublicHealth,TheUniversityofHongKong.Thisseriesutilisesexistingdatatoestimatetheimpactofvariouschronicdiseasesontheageingpopulationaswellassocietyasawhole.Thefirstoftheseriesfocusesondiabetesmellitus.ThisreportismadeavailabletothepublicwiththecomplimentsofTheHongKongJockeyClubCharitiesTrust.
CADENZA
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Acknowledgement
TheauthorswishtothankTheHongKongJockeyClubCharitiesTrustinsupportingthe
publicationofthisreport. WealsowishtoexpressheartfeltthankstotheElderlyHealth
Service,DepartmentofHealthoftheHongKongSpecialAdministrativeRegion,theHong
KongHospitalAuthorityandtheHongKongDepartmentofHealthforpermissiontouse
datatoprovidesomeoftheinformationinthisreport.Lastbutnotleast,wearegratefultoall
theofficialsandresearcherswhocompiledtheusefulstatisticsthatarequotedinthisreport.
Withouttheirefforts,thisreportwouldnothavebeenpossible.
Acknowledgement
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Contents
Contents
Executive Summary 7
1 Introduction 15
1.1 Overview 16 1.2 TypesofDiabetes 16 1.3 DiagnosticClassification 17 1.4 InternationalClassificationofDiseases(ICD) 18 1.5 DataQuotedinthisReport 18
2 Global Trends and Burden 19
2.1 Prevalence 20 2.1.1 Global 20 2.1.2 UnitedStates 20 2.1.3 UnitedKingdom 21 2.1.4 Australia 22 2.1.5 China 22 2.1.6 Singapore 23 2.1.7 Japan 24
2.2 Incidence 25 2.2.1 Global 25 2.2.2 UnitedStates 25 2.2.3 UnitedKingdom 26 2.2.4 Australia 27 2.2.5 China 27 2.2.6 Singapore 27 2.2.7 Japan 28
2.3 Mortality 28 2.3.1 Global 28 2.3.2 UnitedStates 29 2.3.3 UnitedKingdom 29 2.3.4 Australia 30 2.3.5 China 30 2.3.6 Singapore 31 2.3.7 Japan 31
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3 Trends and Burden of Diabetes in Hong Kong 33
3.1 Introduction 34
3.2 Prevalence 34
3.2.1 Self-reporteddiabetes 34 3.2.2 Bloodglucosemeasurementresultsandself-reporteddiabetes 37 3.2.3 Estimatednumberofpeoplewithknowndiabetesandfutureprojection 38 3.2.4 ComparisonbetweenHongKongandotherplaces 40 3.2.5 Pre-diabetes 42
3.3 Incidence 44
3.4 DiseaseBurden 45
3.4.1 Mortality 45 3.4.2 Morbidity 50 3.4.2.1 Hospitaladmissionatpublichospitals 50 3.4.2.2 Out-patientvisitsrelatedtodiabetes 50 3.4.2.3 Complicationsofdiabetes 51 3.4.3 Disability 52 3.4.4 Cognitiveimpairment 53 3.4.4.1 Cognitivefunction 53 3.4.4.2 Dementia 55 3.4.5 Qualityoflife 56
3.5 EconomicBurden 58
3.5.1 Hospitalcosts 58 3.5.2 Generalout-patientclinics(GOPC)visits 59 3.5.3 AccidentandEmergencyDepartment(A&E)visits 60 3.5.4 Specialistout-patientclinics(SOPC)visits 62 3.5.5 Currentandfutureeconomicburdeninpublicsectors 63
3.6 BehaviourinManagingDiabetes 64
4 Discussion and Conclusion 67
5 References 71
Contents
Executive Summary
� Executive Summary
Theprevalenceofdiabetesisincreasingworld-wideinbothdevelopedanddevelopingcountries.Oneoftheriskfactorsfordiabetesisbeingolder.InHongKong,theprevalenceofdiabetesamongtheolderpopulation(aged65andabove)wassixtimesthatamongtheyoungerpopulation(aged18to64)in2003-2004.Evenifthereisnoincreasingtrendintheage-specificprevalenceofdiabetes,thenumberofolderpeoplewhohavediabetescanbeexpectedtoincreaseowingtothelargernumberofolderpeoplewhoaremostatriskofdevelopingthedisease.Asaresult,HongKongwillexperienceincreasinglylargernumbersofolderpeoplewithdiabetesinthefuture.Anexaminationofthetrendinprevalence,incidence,mortalityandmorbiditywouldenableestimatesoftheconsequencesoftheageingpopulationinHongKong.Thisreport
estimatesthecurrentandfutureburdenofthediseaseforolderpeople.
Prevalence
Accordingtoself-reportedpastdoctordiagnosis,thereisnoclearevidenceofeitheranincreasingordecreasingtrendintheprevalenceofdiabetesamongolderpeopleinHongKongbetween1995and2004.Thelatestfindingsshowedthattheprevalenceofself-reporteddiabetesinthecommunity-dwellingpopulationaged65andabovewas13.5%in2003-2004.However,thisestimatewaslikelyunder-reported.Accordingtoself-reporteddata,plustheoralglucosetolerancetest(OGTT),about21.4%ofpeopleaged65to84haddiabetesin2004-2005,ofwhich28.6%(45.0%men,13.3%women)wereunawarethattheyhaddiabetes.Theprevalenceofdiabetesamongthepopulationaged65andaboveinHongKongwascomparabletothatintheUnitedStates,theUnitedKingdomandAustralia.
Peopleaged65andabovemadeup50%ofthediagnosedadultcasesofdiabetesin2006.Basedontheprevalenceofself-reporteddiabetes,thenumberofcasesforpeopleagedover65wasestimatedtoincreasebetween2000and2004from0.09millionto0.11millionmainlyduetotheincreaseinthenumberofolderpeople.Thisnumberwouldbeexpectedtoincreaseto0.30millionby2036,morethandoublethenumberofcases,andto0.42millionincludingundiagnosedcases.
Executive Summary
Oneoftheriskfactorsfordiabetesisbeingolder.
TheprevalenceofdiabetesinHongKongisnotdecreasing.
About1in5peopleaged65to84inHongKonghaddiabetesin2004-2005,ofwhich28.6%wereunawarethattheyhaddiabetes.
�Executive Summary
Peoplewiththeconditionofpre-diabetes(definedashavingimpairedglucosetolerance(IGT)orimpairedfastingglucose(IFG))areatsubstantiallyhigherriskofdevelopingdiabetesthanthosewithnormalglucosetolerance.Olderpeoplehaveahigherprevalenceofpre-diabetesthanyoungerpeople.Asurveyidentified17.9%ofthoseaged65to84ashavingpre-diabetesin2004-2005.Actionmustbetakentopreventthesepre-diabetescasesfrombecomingdiabetescases.
Incidence
There isnotmuch informationon the local trend inincidenceofdiabetes.Basedonself-reporteddoctor-diagnoseddiabetes,acohortstudyin1991-1992found37.3per1,000subjectsaged70andolderreporteddiabetesover3years,i.e.anannualincidenceof12.4per1,000peryear.Thisestimatewashigherthanothercountries.
Mortality
Diabetesistheninthmostcommoncauseofmortalityamongthepopulationagedover65inHongKong,accountingfor1.4%ofdeathsamongtheolderpopulationin2007.In2007,mortalityratesfromdiabeteswere43.2per100,000formalesand56.5forfemalesaged65andabove.However,thesedonotincludeallpotentialcomplications.Theage-standardisedmortalityrateswerequitestablebetween1981and1998,increasingsharplyinthelate1990’sbutgenerallydecreasingfrom2001to2007.ThisisdifferentfromtheUnitedStateswhichhashadanincreasingtrendsince1981.
Asmanypeoplewouldhavebeenrecordedasdyingfromanothercausewhichwasitselfacomplicationofdiabetes,theindirectcostofdiabeteswouldbebettermeasuredbydeathsattributabletodiabetes.Therelativerisk(fromoverseas)ofall-causemortalityamongpeoplewithdiabetescomparedtothosewithout
was1.38formalesand1.40forfemalesaged60to69,and1.13formalesand1.19forfemalesaged70andabove.Thistranslatesintoaround673deathsattributable todiabetes inolderpeopleinHongKongin2006(thatis,arateof79.0per100,000population).
ThenumberofolderpeoplewhohavediabetesinHongKongisprojectedtoincreasefrom0.11millionin2004to0.30millionin2036.
From a 1991-1992 cohort, theincidencerateofdiabetesinHongKong was about 12.4 per 1,000population.
ThemortalityrateattributabletodiabetesinHongKongwasabout79.0per100,000populationin2006.
10 Executive Summary
Morbidity
In2006,amongthediabetesrelatedhospitaldischargesforallages,56%wereforpeopleaged65andabove.Ingeneral,olderpeoplehadalongerlengthofstaythanyoungerpeople.Forout-patientvisits,olderpeoplewithdiabeteshadan81%higherlikelihoodofhavingdoctorconsultationsthanthosewithout.
Complicationsrelatedtodiabetesarecommon.Between2002and2006,morethanhalfofthepublichospitaladmissionsfordiabetesinvolvedcomplications.Olderpeoplehadahigherproportion(58%)ofcomplicationsthanyoungeradults(46%).Surveydatarevealedthatin2004-2005,overhalfofthoseaged65
to84withknowndiabeteshadelevatedfastingbloodglucose implyingthat therewaspoorcontrolofdiabeteswhichcouldleadtofurthercomplications.Thesecomplications,inparticularvisionproblemsandamputation,affectactivitiesofdailyliving(ADL).
Disability
Olderpeoplewithdiabeteswere1.8to4.1times(dependingondifferenttasks)morelikelythanthosewithoutdiabetestoreportsomedifficultywithADL.Moreolderpeoplewithdiabetesreporteddifficultyinatleastoneofthethreefunctionaldomains(26.0%comparedwith14.8%ofthosewithout).Thoseagedover70withdiabeteshada50%to70%greaterchanceofmildtoseverefunctionallimitationthanthosewithoutdiabetes.
Cognitive impairment
Thereisevidencefromoverseasthatolderpeoplewithdiabetesaremorelikelytohaveimpairedcognitivefunctionthanthosewithoutdiabetes.InHongKong,someevidencehassupportedsuchan
associationamongcommunity-dwellingolderpeople.However,theevidencesupportingarelationshipbetweendiabetesanddementiaisinconclusive.
Executive Summary
Morethanhalfofolderpeoplewith diabetes in Hong Konghavecomplications.
In2004-2005,overhalfofthoseaged65to84withknowndiabetesinHongKonghadelevatedfastingbloodglucoseimplyingthattherewaspoorcontrolofdiabetes.
Olderpeoplewithdiabetesaremorepronetofunctionalandcognitiveimpairment, inadditiontothewell-knowncomplications.
11Executive SummaryExecutive Summary
Quality of life
Olderpeoplewithdiabetesgenerallyhadpoorerqualityoflifethanthosewithout,regardlessofthemeasurementtool.Basedonself-ratedhealth,moreolderpeoplewithdiabetesreportedtheirhealthtobepoorerthanotherpeopleofthesameage.Inaddition,theprobabilityofhavingdepressivesymptomswashigheramongolderpeoplewithdiabetescomparedtothosewithout.
Economic burden
Aswellascostsduetoincreasedriskofotherdiseasesandcomplications,therearealsohealthcarecostsassociatedwithdiabetes.Directcostsincludemedicalcostssuchashospitalisation,doctorconsultationsandmedicines.Indirectcostsincludecostsofdealingwithdisability,costsfromlossofworkandcostsofprematuremortality.
TheattributabledirectcostofdiabetesinHongKongwasestimatedataboutHK$1.4billionin2006forthoseaged65andabove.Thisisaconservativeestimatewhichdoesnotincludeprivatesectorcare.Thecostofhospitalcarecontributedtomostofthecostsamounting
toHK$1.2billionin2006,whichwasnear80%ofthetotaldiabetesattributablehospitalcostfortheadultpopulation.Theeconomicburdeninthepublicsectorduetodiabetesinthepopulationaged65andabovewillincreasetoHK$3.5billionin2036(at2006prices)whichismorethandoublethecurrentcost.
Althoughthedollarvaluewasnotestimated,therewillbeeconomicimplicationsfordealingwithfunctionalandcognitiveimpairmentresultingfrompoorlycontrolleddiabetesinolderpeople.Theresultingdisabilitycostwouldbehigherintheolderpopulationthanintheyoungerone.
Olderpeoplewithdiabetesgenerallyhavepoorerqualityoflifeandaremorelikelytohavedepressivesymptomsthanthosewithout.
TheattributabledirectcostofdiabetesinHongKongwasestimatedataboutHK$1.4billionin2006forthoseaged65andabove.
Becauseofanincreasednumberofolderpeople,theeconomicburdeninthepublicsectorduetodiabetesinthoseaged65andabovewillincreasetoHK$3.5billionin2036(at2006prices).
12 Executive Summary
Conclusion1. Diabetesexertshighcostsonthehealthcaresystemandthe
population,especiallyolderpeoplewhoareatthehighestriskofdevelopingthedisease.Allofthesecostswillpredictablyincreaseinthefutureasthepopulationages.Theincreasingnumberofolderpeoplewillincreasethenumberofcasesandtheageprofileofpeoplewithdiabeteswillalsoincreaseleadingtoahigherdegreeofdependencyandmoreco-morbidities.Accordingtothedataexamined,alargenumberofexistingolderpeoplewithdiabetesarenotbeingdiagnosedand,amongthosediagnosed,alargenumberdonothaveadequatecontroloftheirbloodsugarlevels.
Everyopportunityshouldbetakenbyhealthcareproviderstofindcasesofdiabetesamongolderpeople,toensurethatalldiagnosedcasesarewellcontrolledandmonitoredforthedevelopmentofcomplications.
2. Apartfromunderscoringtheimportanceofthepreventionofdiabetesanditscomplications,thefindingshavespecificimplicationsforcaringforolderpeoplewithdiabetes,andforadoptinganelder-orientedapproach:
ο Comprehensivegeriatricassessmentcoveringphysical,functional,psychological,nutritionalandsocialdomainsneedstobecarriedouttoguidethemanagementplan,inviewoftheincreasedpredispositiontofunctionalandcognitiveimpairment,dementia,depressionandpoorqualityoflifeofolderpeoplewithdiabetes,inadditiontothecurrentdiabetescomplicationsscreening.
ο Thereisaneedtoconsidercareinthecontextofasocialunit,recognizingthataproportionoftheolderpopulationislessabletoachievelifestylemodification;lessabletomanagecomplexdrugregimes(andthereforemorepronetoadversedrugeffects);lessabletocopewithmultipleserviceprovidersatmultiplesites;andlessabletohandlegadgetsandinformationtechnology.Carewouldideallybeprovidedinauserfriendlyandconvenientcommunitysettingintegratingmedicalandsocialactivitiesformanagementandmaintenance.
Diabetesexertshighcostsonthehealthcaresystemandthepopulation,especiallyolderpeople.
Weshouldensurethatalldiabetescasesareidentified,wellcontrolledandmonitoredforthedevelopmentofcomplications.
1�Executive Summary
ο Theneedforeyecareandmonitoringforretinopathyisparticularlyimportantsincevisionaffectsindependenceandqualityoflife.
ο Thereisaneedtoconsiderthetrajectoryofthediseaseinthecontextofincreasingfrailtyandtheproximitytoendoflife,inmanagementofthediseaseversustheusual‘static’systembasedapproachgovernedbyguidelines.
Itisrecommendedtoadoptanelder-orientedapproachincareofolderpeoplewithdiabetesasacornerstoneinhealthandsocialservicesinadditiontoprevention,screeningandoptimizingdiseasecontrol.
1� Executive Summary
IntroductionChapter 1
1�
1.1 Overview
Diabetesmellitus(Diabetes)isachronicmetabolicdiseasewherethepancreasdoesnotproduceenoughinsulinorthebodycannoteffectivelyusetheinsulintolowerbloodglucose(WorldHealthOrganization(WHO),2008b).Oneoftheriskfactorsfordiabetesisbeingolder.Otherriskfactorsfordiabetesincludebeingoverweightorobesity,physicalinactivity,certaindrugsordiseasesthataffectthefunctioningofthepancreasandfamilyhistory(DepartmentofHealthofHongKongSpecialAdministrativeRegion,2006).Theriskfactorsofdiabeteshaveadditiveeffects,suchthatthepresenceofmoreriskfactorsisassociatedwithincreasedoddsofhavingdiabetes(Koetal.,2000).
Commonsymptomsofdiabetesincludefrequenturination,abnormalthirst,fatigue,weightloss,blurredvisionandpoorwoundhealing.Diabetescanoftenbeasymptomaticandpeopleaffectedmayremainunawareoftheconditionuntilcomplicationsdevelop(DepartmentofHealthofHongKongSpecialAdministrativeRegion,2006).Diabetescanalsoleadtovariousadverseconsequences,includingretinopathy,neuropathy,limbamputation,kidneyfailure,heartdiseaseandstroke(WHO,2008b).Thesecomplications,inparticularretinopathyandamputation,affectactivitiesofdailyliving(ADL).
Diabetesisachronicmedicalconditionthatcanbecontrolledbutnotcured.Combinedwiththeincreasingriskassociatedwithadvancingage,theprevalenceofdiabetesinthepopulationincreaseswithage.Withtheglobalageingtrend,theprevalenceofdiabetesisincreasingworld-wideinbothdevelopedanddevelopingcountries.
1.2 Types of Diabetes
AccordingtotheWHO,therearethreecommontypesofdiabetes:Type1,Type2andgestationaldiabetes(WHO,2008b).
IntroductionChapter 1
17Introduction
ο Type1diabetes:usuallydevelopsinchildhoodandadolescence.Patientsrequirelifelonginsulininjectionsforsurvival.
ο Type2diabetes:usuallydevelopsinadulthoodandisrelatedtoobesity,lackofphysicalactivityandunhealthydiet.Thisisthecommonesttypeofdiabetes(representing90%ofdiabeticcasesworld-wide).Treatmentmayinvolvelifestylechangesandweightloss,andoralmedicationsorinsulininjections.
ο Gestationaldiabetes:usuallydevelopsinpregnantwomenwhohaveneverhaddiabetesbeforebutwhohavehighbloodsugar(glucose)levelsduringpregnancy.
1.3 Diagnostic Classification
AccordingtotheWHOandInternationalDiabetesFederation(IDF)(2006),theWHODiagnosticClassificationcriteriadefinesdiabetes,impairedglucosetolerance(IGT)andimpairedfastingglucose(IFG)asfollows:
ο Diabetesisdefinedasafastingplasmaglucoselevel≥7.0mmol/Lor2-hourplasmaglucose≥11.1mmol/L.
ο Impairedglucosetolerance(IGT)isdefinedasfastingplasmaglucoselevel<7.0mmol/Land2-hourplasmaglucoseof7.8to11.1mmol/L.
ο Impairedfastingglucose(IFG)isdefinedasafastingplasmaglucoselevelof6.1to6.9mmol/Land(ifmeasured)2-hourplasmaglucose<7.8mmol/L.
Two-hourplasmaglucosemeasurementisbasedonoralglucosetolerancetest(OGTT)with75goralglucoseload.IGTandIFGareoftentermed"pre-diabetes",whichimplyahigherriskofdevelopingdiabetes.
1� Chapter 1
1.4 International Classification of Diseases (ICD)
TheInternationalStatisticalClassificationofDiseaseandRelatedHealthProblems(ICD)ispublishedbytheWHOfortheinternationalstandarddiagnosticclassificationofdisease.TheICDiscommonlyusedtoclassifydiseasesandotherhealthproblemsonrecordsincludingdeathcertificatesandhospitaldischargerecords.TheICDcodesfordiabetesare:
ο ICD9thversion(ICD-9): 250
ο ICD10thversion(ICD-10): E10-E14
1.5 Data Quoted in this Report
Thisreporttreatsalltypesofdiabetestogetherbecausemostdatasourcesuseddonotdistinguishbetweentypesofdiabetesinadults.Inmostofthesurveydataincludedinthisreport,thedefinitionofdiabetesisaself-reportedpastdiagnosisofdiabetesbyadoctor.Inmostcases,thiswasnotverifiedfromclinicalrecords.Nevertheless,someofthesurveysdidusethediagnosticclassificationbasedonglucosetestsandithasbeenstatedexplicitlywheneverclinicaldataisquoted.
Formortalityandhealthcareutilisationstatistics,theICDiswidelyusedforclassifyingdiabetes.InHongKong,theclassificationofdiseaseandcausesofdeathwasbasedonICD-9fortheyears1979to2000,andthenICD-10from2001onwards.Hence,thefiguresfrom2001onwardsmaynotbecomparablewithfiguresforpreviousyearsandcautionshouldbeexercisedwheninterpretingthetrendofdiseaseacross2000and2001inHongKong.
As the statistics quoted in this report were compiled from different sources, theconceptualizationandcompilationmethodscouldvaryconsiderablyacrossstudies.Thecomparisonspresentedinthisreport,therefore,canonlybeinterpretedinabroadsense.Itisrecommendedthatreadersconsultthecitedreferencesforthemeta-dataofthestudies.
Global Trends and BurdenChapter 2
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2.1 Prevalence
2.1.1 Global
UsingtheWHOdiagnosticcriteriafordiabetes,itisestimatedthattheworld-wideprevalenceandnumberofcasesofdiabetesinallage-groupsisincreasing.Evenassumingthatage-specificprevalenceremainsconstant,thenumberofpeoplewithdiabeteswillapproximatelydoublebetween2000and2030(Wildetal.,2004)(Table2.1).
Table2.1World-wideprevalenceofdiabetesfortheyear2000andprojectionfor2030
2000 2030 % changePrevalence 2.8% 4.4% 57%increaseNumber of people with diabetes 171million 366million 114%increase
Wildetal.(2004)pointedoutthattheexpandingolderpopulationhascontributedmosttothisincreasingprevalence.Sincetheprevalenceofdiabetesisslightlyhigherinmenthaninwomenundertheageof60,butthereverseisobservedforolderages,theexpandingolderfemalepopulationleadstoagreaternumberofwomenwithdiabetes,despitetheprevalencebeinghigherinmen.
Whilepeoplewithdiabetesindevelopingcountriesweremainlymiddle-aged,thoseindevelopedcountriesweremainlyaged65andabove.
2.1.2 United States
IntheUnitedStates,theprevalenceofself-reportedpastdoctordiagnosisofdiabetesincreasedinallagegroupsbetween1980and2006(CentersforDiseaseControlandPrevention,DepartmentofHealthandHumanServicesoftheUnitedStates,2008).Itwasprojectedthatthenumberof
Global Trends and BurdenChapter 2
21Global Trends and Burden
peoplewithdiabetesintheUnitedStateswouldincreasefrom17.7millionin2000to30.3millionin2030(Wildetal.,2004).
Between1980and2006,peopleaged65to74hadthehighestprevalenceofself-reportedpastdiagnosisofdiabetesfollowedbypeopleaged75orolder,peopleaged45to64,andpeopleunder45.In1980,theprevalenceofself-reportedpastdoctordiagnosisofdiabetesamongpeopleaged65to74was9.1%andamongpeopleaged75andaboveitwas8.9%;whilsttherespectivefiguresincreasedto18.4%and16.6%in2006(CentersforDiseaseControlandPrevention,DepartmentofHealthandHumanServicesoftheUnitedStates,2008)(Table2.2).Itwasestimatedthatbetween1999and2002,amongthoseaged65andabove,26.9%ofpersonswithdiabeteswereunawareoftheircondition(Cowieetal.,2006).
Table2.2Prevalenceofself-reporteddiabetes,byagegroup,UnitedStates,1980-2006
Age groups 1980 1990 2000 200665-74 9.1% 9.9% 15.4% 18.4%75+ 8.9% 8.6% 13.0% 16.6%Whole population (age-adjusted*) 2.8% 2.9% 4.5% 5.6%
*Theage-adjustedprevalenceusedtheestimated2000U.S.populationasthestandard.
2.1.3 United Kingdom
IntheUnitedKingdom,theprevalenceofself-reportedpastdiagnosisofdiabetesbyadoctoramongthepopulationaged16andabovenearlydoubledfrom2.4%in1994to4.5%in2006.Theprevalenceofdiabetesincreasedwithageingeneral.From1994to2006,theprevalenceincreasedinallagegroups.In1994,theprevalenceofdiabetesamongthoseaged65to74yearswas5.3%andthatamongthoseaged75yearsandabovewas6.0%;whilstin2006,therespectivefiguresincreasedto12.8%and11.8%(TheNHSInformationCentreoftheUnitedKingdom,2008)(Table2.3).
Table2.3Prevalenceofself-reportedpastdiagnosisofdiabetesbyadoctor,byagegroup,UnitedKingdom,1994-2006
Age groups 1994 1998 2003 200665-74 5.3% 6.8% 9.9% 12.8%75+ 6.0% 7.4% 9.2% 11.8%Whole population (16+) 2.4% 2.8% 4.1% 4.5%
22 Chapter 2
2.1.4 Australia
InAustralia,theage-adjustedprevalenceofself-reportedpastdoctordiagnosisofdiabetesrosefrom2.4%in1995to3.0%in2001and3.5%in2004-2005(AustralianBureauofStatistics,2006).Between1995and2005,theprevalenceincreasedamongthoseaged55andabove,whilstthatamongtheyoungeragegroupsremainedmoreorlessthesame.In1995,theprevalenceofdiabetesamongthoseaged65to74yearswas8.4%andthatamongthoseaged75andabovewas8.9%;whilstin2004-2005,therespectivefiguresincreasedto13.9%and13.3%(Table2.4).
Table2.4Prevalenceofself-reporteddoctordiagnosisofdiabetes,byagegroup,Australia,1995-2005
Age groups 1995 2001 2004-200565-74 8.4% 11.4% 13.9%75+ 8.9% 10.0% 13.3%Whole population (age-adjusted*) 2.4% 3.0% 3.5%
*Theage-adjustedprevalenceusedtheestimatedresidentAustralianpopulationasof30June,2001asthestandard.
Basedonself-reportofpastdoctordiagnosisandOGTTusingtheWHOdiagnosticcriteria,itwasestimatedthattheoverallprevalenceofdiabetesamongpeopleaged75andabovewas23.0%in1999-2000,overhalfofwhomwereundiagnosed(Dunstanetal.,2002).Inaddition,another30.0%ofpeopleaged75andabovehadIGTorIFG,whichmightsuggestafurtherincreaseintheprevalenceofdiagnoseddiabetesinfuture.
2.1.5 China
InChina,theprevalenceofdiabetesappearstohaveincreasedamongthepopulationaged35to64.In1994,usingthe1985WHOcriteria,theprevalenceofdiabetesamongthepopulationaged35to44years,45to54yearsand55to64yearswas1.7%,4.1%and7.7%respectively(Panetal.,1997).UsingtheAmericanDiabetesAssociation(ADA)criteria,theprevalenceofself-reportedandundiagnoseddiabetesamongthepopulationaged35to44,45to54and55to64increasedto3.2%,5.6%and8.6%respectivelyin2000-2001(Guetal.,2003)(Table2.5).
23Global Trends and Burden
Table 2.5 Prevalence of diabetes (self-reported and undiagnosed), by age group, China, 1994-2001
Age groups 1994 2000-200135-44 1.7% 3.2%45-54 4.1% 5.6%55-64 7.7% 8.6%
According to official statistics, the prevalence of self-reported diabetes increased rapidly from 0.2% in 1993, to 0.3% in 1998 and to 0.6% in 2003 (Ministry of Health of the People's Republic of China, 2004). It was projected that the number of people with diabetes in China would more than double from 20.8 million in 2000 to 42.3 million in 2030 (Wild et al., 2004).
The percentage of undiagnosed diabetes was over 70% in 1994-1995 and 2000-2001 (Gu et al., 2003; Pan et al., 1997). In 2000-2001, the proportion of undiagnosed cases among those aged 65 to 74 with diabetes was as high as 73.8%. This high percentage implies that a majority of diabetes cases were not aware of their status.
The prevalence of pre-diabetes was also high in China. In 1994, the prevalence of IGT was 5.9% for people aged 45 to 54 and 8.0% for those aged 55 to 64 (Pan et al., 1997). In 2000-2001, the prevalence of IFG was 7.2% and 8.6% for the two age groups respectively (Gu et al., 2003). The prevalence of IFG reached 10.4% among those aged 65 to 74. The high prevalence might suggest an increasing trend in prevalence of diabetes in future.
2.1.6 Singapore
In Singapore, based on the WHO diagnostic criteria for diabetes, the prevalence of diabetes for the population aged 18 to 69 remained stable between 1998 and 2004, being 9.0% in 1998 and 8.2% in 2004 (Ministry of Health of Singapore, 1999, 2005). The prevalence of diabetes dropped slightly in the age groups 50 to 59 and 60 to 69 (Table 2.6). The proportion of undiagnosed cases among people aged 18 to 69 also decreased from 62.1% in 1998 to 49.4% in 2004 (Ministry of Health of Singapore, 2005).
Table 2.6 Prevalence of diabetes, by age group, Singapore, 1998 and 2004
Age groups 1998 200450-59 21.8% 16.7%60-69 32.4% 28.7%18-69 9.0% 8.2%
2� Chapter 2
Between1998and2004,theprevalenceofIGTdecreasedamongalltheagegroups.Amongthoseaged50to59,theprevalenceofIGTdecreasedfrom24.1%in1998to18.6%in2004;amongthoseaged60to69,itremainedatabout22%inbothyears(MinistryofHealthofSingapore,1999,2005).
Amongallraces,Chinesehadthelowestratesofdiabetes(8.0%in1998,7.1%in2004)andIGT(14.3%in1998,11.7%in2004).However,theproportionofundiagnosedcasesintheChinesepopulationwasamongthehighest(63.9%in1998,50.4%in2004)(MinistryofHealthofSingapore,1999,2005).
2.1.7 Japan
InJapan,theprevalenceofself-reporteddiabeteswasaround15.0%amongthepopulationaged60andabovein2000(MinistryofHealth,LabourandWelfareofJapan,2001).ItwasprojectedthatthenumberofpeoplewithdiabetesinJapanwouldincreasemoderatelyfrom6.8millionin2000to8.9millionin2030(Wildetal.,2004).
Adoptingdifferentcriteria,nationalstudieshaveusedtheself-reportedpreviousdoctordiagnosisofdiabetesandthelevelofstableglycatedhemoglobin(HbA1c)toestimatetheprevalenceofpossibleandprobablediabetes.PeoplewithHbA1cbeing6.1%andabove,orunderdiabetestreatmentwereregardedasprobablediabetescases,whilethosewithoutdiabetestreatmentandwithaHbA1cbetween5.6%and6.1%weredefinedaspossiblediabetescases(MinistryofHealth,LabourandWelfareofJapan,2004,2008b).
Theprevalenceofprobablediabetesforthepopulationaged20andabovehasincreasedslightlyoverthepastdecade(8.2%in1997ascomparedto10.5%in2007).Theprevalenceofprobablediabetesforthepopulationaged70andaboveslightlyincreasedfrom13.8%in1997to16.2%in2007(MinistryofHealth,LabourandWelfareofJapan,2004,2008b)(Table2.7).
Table2.7Prevalenceofprobablediabetes,byagegroup,Japan,1997-2007
Age groups 1997 2002 200760-69 13.7% 14.4% 17.7%70+ 13.8% 15.7% 16.2%Whole population (20+) 8.2% 9.0% 10.5%
2�Global Trends and Burden
Theprevalenceofpossiblediabetesforthepopulationaged20andabove increaseddramaticallyfrom7.9%in1997to21.1%in2007.Between1997and2007,theprevalenceofpossiblediabetesforthepopulationaged60to69increasedfrom9.5%to25.1%andforthoseaged70andabovefrom12.0%to29.4%(MinistryofHealth,LabourandWelfareofJapan,2004,2008b)(Table2.8).
Table2.8Prevalenceofpossiblediabetes,byagegroup,Japan,1997-2007
Age groups 1997 2002 200760-69 9.5% 14.8% 25.1%70+ 12.0% 16.5% 29.4%Whole population (20+) 7.9% 10.6% 21.1%
2.2 Incidence
2.2.1 Global
Statisticsontheincidenceofdiabetesaresparsewhencomparedwiththeprevalencestatistics.Theworld-widenumberofcasesincreasedfrom11.1millionin2000to11.6millionin2002(WHO,2002a,2002b,2004).Meanwhile,theincidenceratewasmoreorlessthesame,with1.9per1,000populationin2002(WHO,2004)(Table2.9).
Table2.9World-wideincidenceofdiabetes,2000-2002
2000 2001 2002Number of cases 11.1million 11.3million 11.6millionIncidence rate (per 1,000) 1.8 1.9 1.9
2.2.2 United States
IntheUnitedStates,theincidenceofself-reporteddiagnoseddiabetesinallagegroupswasincreasingfrom1980to2006(CentersforDiseaseControlandPrevention,DepartmentofHealthandHumanServicesoftheUnitedStates,2009b).Amongthoseaged65to79,theincidenceratenearlydoubledfrom6.9per1,000populationin1980to12.8per1,000populationin2006,withmorerapidincreasesincethe1990s(Table2.10).
2� Chapter 2
Table2.10Incidenceofdiagnoseddiabetes(per1,000),byagegroup,UnitedStates,1980-2006
Age groups 1980 1990 2000 200645-64 5.2 6.0 10.1 12.165-79 6.9 6.0 11.6 12.8
Forbothmenandwomen,age-adjustedannualincidencewasabouttwiceashighin2006comparedwith1980,withmostoftheincreaseoccurringinthelatterhalfofthetimeperiod.In2006,theage-adjustedincidenceamongwomen(7.6per1,000)wassimilartothatofmen(7.9per1,000).Whiletheincidencefollowedsimilartrendsformenandwomenintheagegroup18to44,differenttrendswereobservedbetweenmenandwomenindifferentagegroups(CentersforDiseaseControlandPrevention,DepartmentofHealthandHumanServicesoftheUnitedStates,2009a,2009c).
2.2.3 United Kingdom
IntheUnitedKingdom,theage-adjustedincidenceofdiabetes,basedonbloodglucosemeasurement,nearlydoubledbetween1994and2003,from1.8to3.3per1,000person-years.Thepopulationaged60andabovehadthegreatestincrease.Amongthoseaged65to69,theincidenceratedoubledfrom5.2per1,000populationin1994to10.7per1,000populationin2003(QResearch,2007)(Table2.11).
Table2.11Incidenceofdiagnoseddiabetes(per1,000),byagegroup,UnitedKingdom,1994and2003
Age groups 1994 200365-69 5.2 10.7Whole population (age-adjusted*) 1.8 3.3
*Theage-adjustedincidenceusedtheUKCensus2001populationasthestandard.
27Global Trends and Burden
2.2.4 Australia
InAustralia,basedonself-reportandWHOcriteria,theannualincidenceofdiabetesamongthoseaged49andabovewasabout9.3per1,000in2002-2004(Cugatietal.,2007).Alsobasedonself-reportandWHOcriteria,butinayoungerpopulation(aged25to88),theannualincidenceofdiabeteswasabout7.7per1,000(unadjustedforage)in2004-2005(Maglianoetal.,2008).
2.2.5 China
InChina,basedonADAstandards,theannualincidenceofdiabetesofaShanghaisampleaged20to94was16.5per1,000person-yearsin1998-2001(Jiaetal.,2007).BasedonWHOdiagnosticcriteria,aDaqingstudyshowedtheannualincidenceofdiabetesamongpeopleaged25to74was1.3per1,000person-yearsin1986-1990(Huetal.,1993).
TherewasanincreasingtrendforclinicallydiagnosedType2diabetes.Between1999and2005,theincidenceratesofType2diabetes,basedonaregistryinHarbin,increasedby12%peryear(Liuetal.,2007).Therateinmetropolitanareasdoubledfrom0.5per1,000person-yearsin1999to1.1per1,000person-yearsin2005.Theincidencerateincreasedwithageuntil70years.Theincidencerateamongmalesaged55andabovewashigherthantheirfemalecounterparts,butthereversewastrueforthoseagedbelow55.Thesurroundingcountyareashadlowerincidenceratesthanthemetropolitanareas(Table2.12).
Table2.12Incidenceofdiabetes(per1,000),byarea,inHarbin,China,1999-2005
Areas 1999 2001 2003 2005Metropolitan 0.5 0.6 0.8 1.1Surrounding Counties 0.1 0.2 0.3 0.2
2.2.6 Singapore
InformationonincidenceofdiabetesinSingaporeisnotreadilyavailable.
2� Chapter 2
2.2.7 Japan
InJapan,basedonself-reportandWHOcriteria,theannualincidenceofdiabetesamongthoseaged30to59wasabout6.9per1,000formenand3.8per1,000forwomenin2001(Nagayaetal.,2005).BasedonADAcriteria,theannualincidenceofdiabetesamongthoseaged19to86wasabout1.2per1,000in2002-2006(Inoueetal.,2008).
2.3 Mortality
2.3.1 Global
Itwasestimatedthat1.1millionpeoplediedfromdiabetesin2004(WHO,2008a). Theproportionofdeathsduetodiabetesworld-wideincreasedfrom1.6%in2000to1.9%in2004(WHO,2002a,2008a).Itwasprojectedthatthenumberofdeathsduetodiabeteswouldnearlydoublefrom1.1millionin2004to2.2millionin2030(WHO,2008a,2008c)(Table2.13).
Table2.13World-widenumberofdeathsfromdiabetesforyear2004andprojectionfor2030
2004 2030 % changeNumber of deaths due to diabetes 1.1million 2.2million 95%increaseProportion of deaths due to diabetes among all deaths 1.9% 3.3% 74%increase
However,thesefiguresunderestimatethetrueburdenbecausetheunderlyingcauseofdeathisoftenrecordedasanotherconditionsuchasheartdiseaseorkidneyfailure.Ifdeathsforwhichdiabeteswascontributorywastakenintoaccount,itwasestimatedthattherewere2.9milliondeathsattributabletodiabetesannually(WHO,2008b).
Itwasestimatedthattheoverallriskofdyingamongpeoplewithdiabeteswasatleastdoubletheriskoftheircounterpartswithoutdiabetes(WHO,2008b).About29%ofalldeathsamongthepopulationaged65andabovewhohaddiabeteswereattributabletodiabetesin2000(Roglicetal.,2005).
Arecentstudyshowedthattherelativeriskofincreasedmortalitywas1.4formenandwomenaged60to69andthecorrespondingfigureswere1.1and1.2formenandwomenaged70andabove(Barnettetal.,2006).
2�Global Trends and Burden
2.3.2 United States
IntheUnitedStates,theage-standardiseddeathratesfordiabetesremainedstablebetween1999and2003anddecreasedslightlyfrom2004to2005(NationalCenterforHealthStatisticsoftheUnitedStates,2008).Thedeathratesincreasedsharplywithageandtheage-specificdeathratesfollowedsimilartrends.In2005,thedeathratefordiabetesamongthoseaged65to74was86.8per100,000(Table2.14).
Table2.14Deathratesfordiabetes(per100,000),byagegroup,UnitedStates,1999-2005
Age groups 1999 2001 2003 200565-74 91.8 91.4 90.8 86.875-84 178.0 181.4 181.1 177.285+ 317.2 321.8 317.5 312.1Whole population (age-adjusted*) 25.0 25.3 25.3 24.6
*Theage-adjusteddeathratesusedtheUSpopulationasof1April,2000asthestandard.
2.3.3 United Kingdom
IntheUnitedKingdom,theage-standardiseddeathratesfordiabetesslightlydecreasedfrom9.4(males)and6.5(females)per100,000populationin1999to7.9(males)and5.7(females)per100,000in2005(OfficeforNationalStatisticsoftheUnitedKingdom,2008).Thedeathratesincreasedwithageforbothgenders,andthemaleshadhigherdeathratesthanthefemalesatallages(Table2.15).In2005,thedeathratefordiabetesamongthoseaged65to74was27.9and19.0per100,000forthemalesandfemalesrespectively.
Table2.15Deathratesfordiabetes(per100,000),byagegroupandsex,UnitedKingdom,1999-2005
Age groups 1999 2002 2005 Male Female Male Female Male Female65-74 38.2 25.2 35.5 24.1 27.9 19.075-84 85.5 62.1 87.5 64.3 79.2 59.485+ 182.0 147.9 210.6 168.8 184.4 164.3Whole population (age-adjusted*) 9.4 6.5 9.1 6.5 7.9 5.7
*Theage-adjusteddeathratesusedtheEuropeanStandardPopulationasthestandard.
Age groups
�0 Chapter 2
2.3.4 Australia
InAustralia,theage-standardiseddeathratesfordiabetesremainedstablebetween1997and2005(AustralianBureauofStatistics,2008).Thedeathratesincreasedsharplywithage.Theage-specificdeathratesamongthoseaged85andaboveshowedanincreasingtrend.In2005,thedeathratefordiabetesamongthoseaged65to74was46.5per100,000(Table2.16).
Table2.16Deathratesfordiabetes(per100,000),byagegroup,Australia,1997-2005
Age groups 1997 1999 2001 2003 200565-74 57.7 53.9 51.5 56.8 46.575-84 140.9 134.2 129.1 129.2 141.685+ 263.8 282.6 286.6 335.4 336.5Whole population (age-adjusted*) 17.7 16.2 15.9 16.5 16.3
*Theage-adjusteddeathratesusedtheAustralianpopulationasof30June,2001asthestandard.
2.3.5 China
InChina,thedeathratesfordiabetesinurbanareasincreasedbytwo-thirdsfrom11.4per100,000in2003to19.0per100,000in2007;whilethecorrespondingfiguresfortheruralareasincreasedlessrapidlyfrom6.4to8.2per100,000(MinistryofHealthofthePeople'sRepublicofChina,2004,2008).Theage-specificdeathratesfordiabetesalsoincreasedforthoseaged75andabove(Table2.17).Malesgenerallyhavehigherdeathratesfordiabetesthanfemales,exceptfortheyoungeroldpeople.
Table2.17Deathratesfordiabetes(per100,000),byagegroup,China(urbanareas),2003-2007
Age groups 2003 2006 200760-64 29.1 25.5 26.065-69 61.9 58.4 51.670-74 118.8 110.2 106.975-79 162.7 187.4 198.280-84 169.7 265.2 268.585+ 171.2 356.6 361.6Whole population 11.4 15.5 19.0
�1Global Trends and Burden
2.3.6 Singapore
InSingapore,thedeathratesfordiabetesnearlydoubledinthepastdecade,from7.4per100,000populationin1997to13.3per100,000populationin2007(SingaporeDepartmentofStatistics,2008)(Table2.18).Nevertheless,thisincreaseincludedtheeffectduetoageing.
Table2.18Deathratesfordiabetes(per100,000),Singapore,1997-2007
1997 2002 2005 2007Whole population 7.4 10.2 12.0 13.3
2.3.7 Japan
InJapan,thedeathratesfordiabetesslightlydecreasedfrom11.4per100,000populationin1995to10.8per100,000in2006(MinistryofHealth,LabourandWelfareofJapan,2008a).Thedeathratesincreasedwithage.In2006,thedeathratefordiabetesamongthoseaged65to69was18.0per100,000whilethatamongthoseaged80to84was62.6per100,000(Table2.19).Themaleshadhigherdeathratesthanthefemalesatallages.Adjustingforage,thedeathratesfordiabetesfollowedthesametrend,thatisslightlydecreasedfrom10.1(males)and6.6(females)per100,000populationin1995to7.2(males)and3.7(females)per100,000in2006.
Table2.19Deathratesfordiabetes(per100,000),byagegroup,Japan,1995-2006
Age groups 1995 2000 2004 200660-64 17.8 13.4 11.2 11.765-69 26.3 19.9 18.8 18.070-74 39.6 30.8 27.5 27.975-79 68.4 45.9 40.7 41.680-84 114.4 74.6 63.1 62.6Whole population 11.4 9.8 10.0 10.8
�2 Chapter 2
Trends and Burden of Diabetes in Hong Kong
Chapter 3
��
Trends and Burden of Diabetes in Hong Kong
Chapter 3
3.1 Introduction
HongKonghasarapidlyageingpopulation.Thepopulationaged65andabovenearlydoubledduringthepasttwodecades,from455,800in1988to879,600in2008(CensusandStatisticsDepartmentofHongKongSpecialAdministrativeRegion,2009).Itisprojectedthatin2036,therewillbe2,261,000peopleaged65andaboveinHongKong(CensusandStatisticsDepartmentofHongKongSpecialAdministrativeRegion,2007b).
Evenifthereisnoincreasingtrendintheage-specificprevalenceofdiabetes,thenumberofolderpeoplewhohavediabetescanbeexpectedtoincreaseovertheyearsowingtothelargernumberofolderpeople,whoaremostatriskofdevelopingdiabetes.Asaresult,HongKongwillexperienceincreasinglylargernumbersofolderpeoplewithdiabetesinthefuture.
3.2 Prevalence
ThereareseveralestimatesoftheprevalenceofdiabetesinolderpeopleinHongKong.Thesecanbegroupedintotwosets(1)self-reportedpastdoctordiagnosisand(2)bloodglucosemeasurementsplusself-reportedpastdoctordiagnosis.
3.2.1 Self-reported diabetes
Datawerecollectedfromseveralhouseholdsurveys,whichaskedwhethertherespondenthadbeentoldbyadoctorthattheyhaddiabetes,hadbeendiagnosedwithdiabetesinthepastorwasreceivingmedicalcarefordiabetes(Table3.1andFigure3.1).Accordingtoself-reportedestimates,thereisnoclearevidenceofeitheranincreasingordecreasingtrendintheprevalenceofdiabetesamongolderpeopleinHongKongfrom1995to2004.Amongthecommunity-dwellingpopulationaged60andabove,theprevalenceofself-reportedpastdoctordiagnosisofdiabeteswas15.0%in2000and15.9%in2004(CensusandStatisticsDepartmentofHongKongSpecialAdministrativeRegion,2001,2005).
BasedonthePopulationHealthSurvey2003/2004,theprevalenceofdiabetesamongthepopulationaged65andabovewas13.5%,whilstthatforthepopulationaged18to64was2.2%in2003-2004.Theprevalenceofdiabetesamongtheolderpopulationwassixtimesthatamongtheyoungerpopulation
��Trends and Burden of Diabetes in Hong Kong
(DepartmentofHealthofHongKongSpecialAdministrativeRegionandDepartmentofCommunityMedicine,TheUniversityofHongKong,2005).
Table3.1Prevalenceofdiabetesinolderpeoplefromself-reporteddata,HongKong,1995-2004
Age groups 1995-1996 1 1998 2 1998-2001 3 2003-2004 4
Total65-74 11.2% 14.3% 12.4% 14.3%75+ -- 17.7% 11.9% 12.0%65+ -- 15.5% 12.3% 13.5% Male65-74 9.3% 12.7% 12.1% 13.1%75+ -- 18.1% 11.7% 11.1%65+ -- 14.4% 12.0% 12.5% Female65-74 13.6% 15.8% 12.5% 15.6%75+ -- 17.4% 12.1% 12.6%65+ -- 16.4% 12.4% 14.4%
Datasources:1. HongKongCardiovascularRiskFactorPrevalenceStudy1995-1996.Questionused"Haveyoueverbeendiagnosedby
adoctor(western-trained)thatyouhavediabetes?"2. HarvardHouseholdSurvey1998.Questionused"Haveyoueverbeentoldbyadoctorthatyouhavediabetes?"3. ElderlycohortfromElderlyHealthCentre,DepartmentofHealthofHongKong,1998-2001.Questionused"Active
Disease–bothreceivingregularhealthcareornot"4. PopulationHealthSurvey,2003/2004.Questionused"Haveyoueverbeentoldbyadoctororhealthprofessionalthat
youhavediabetes?"
Figure3.1Prevalenceofself-reporteddiabetes,HongKong,1995-2004
0
5
10
15
20
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Year
Prev
alen
ce(%
)
65-74 75+ 65+
Figure 3.1 Prevalence of self-reported diabetes, Hong Kong, 1995-2004
�� Chapter �
Afewmoreestimatesoftheprevalenceofdiabetesbasedonself-reportofpreviousdoctordiagnosesareshowninTable3.2.Theseestimatesarenotdirectlycomparablewiththepreviousestimatesduetospecificsampleselectioncriteria.
Table3.2Furtherestimatesofprevalenceofself-reporteddiabetesinolderpeople
Year Age Sample Characteristics Prevalence Source1988 55+ Olderpeoplenotliving 8.5% ChiandLee(1989) ininstitution 1991-1992 70+ Olderpeoplereceiving 10.3% Hoetal.(1994) allowancefromthe government 1997 65+ OlderpeoplelivinginCentral 13.5% Chuetal.(1998) andWesternDistrict1998-1999 65+ Ambulatoryolderpeople 12.4% Chuetal.(2005)2000 60+ Olderpeoplelivingin 15.0% CensusandStatistics community DepartmentofHongKong SpecialAdministrative Region(2001)2001-2003 65+ Olderpeopleattendinga 11.7% McGheeetal.(2007) mobileclinicinShamShuiPo forscreening2001-2003 65+ Ambulatoryolderpeoplewho 14.5% Leeetal.(2006) attendedahealthcheck2004 60+ Olderpeoplelivingincommunity 15.9% CensusandStatistics DepartmentofHongKong SpecialAdministrative Region(2005)2004 60+ Olderpeoplelivingininstitutions 20.8% CensusandStatistics DepartmentofHongKong SpecialAdministrative Region(2005)
Mostofthestudiescarriedouthavebeenonolderpeopleinthecommunityandmayunder-estimatetheprevalenceamongallolderpeoplewhichcoversthoseininstitutionswheretheprevalenceishigher.Itwasestimatedthattheprevalenceofself-reporteddiabetesamongtheinstitutionalpopulationaged60andabovewas20.8%in2004(CensusandStatisticsDepartmentofHongKongSpecialAdministrativeRegion,2005).
�7Trends and Burden of Diabetes in Hong Kong
3.2.2 Blood glucose measurement results and self-reported diabetes
Theprevalencebasedonself-reporteddatawaslikelytobeunderestimated.Afewstudiesestimatedtheprevalenceofdiabetesbycombiningself-reportedpastdoctordiagnoseddiabetesandmeasurementsofbloodglucosewithadefinitionofdiabetesbasedonWHOcriteria.ResultsofthesestudiesareshowninTable3.3.Accordingtoself-reporteddataplusOGTT,about21.4%ofthesubjectsaged65to84haddiabetesin2004-2005(DepartmentofHealthofHongKongSpecialAdministrativeRegion,2007).Again,thereisnoclearevidenceofeitheranincreasingordecreasingtrendintheprevalence.
Table3.3Prevalenceofdiabetesamongolderpeoplebasedonself-reporteddiagnosisplusbloodglucosemeasurement,
HongKong,1995-2005
Age groups 1995-1996 1 2001-2002 2 2004-2005 3
Total65-74 25.4% -- --75+ -- -- --65+ -- -- 21.4%#
Male65-74 21.7% 32.9% --75+ -- 33.3% --65+ -- 32.9% 19.8%#
Female65-74 29.3% 36.2% --75+ -- 44.4% --65+ -- 38.5% 23.3%#
#Refertotheagegroup65-84years.Datasources:1. HongKongCardiovascularRiskFactorPrevalenceStudy1995-1996.Diabetesdefinedbyself-report(onmedication)or
OGTT.2. PrevalenceofdiabetesmellitusintheHongKongCardiovascularRiskFactorPrevalenceStudycohort.Medicalhistory
obtainedand2-hourOGTT.3. HeartHealthSurvey2004/2005.Diabetesstatuswasbasedonself-reportorOGTT.
Theextentofunder-reportingofself-reporteddatacanbereflectedbythegapbetweenself-reporteddataandthatcombinedwithmeasurementdata.Table3.4showsanestimateofunder-reportingofdiabetesusingself-reporteddata.
�� Chapter �
Table3.4Under-reportingofdiabetesbasedonself-reporteddata,HongKong
Self-reported only Self-reported & Percentage of blood glucose diabetes cases measurement under-reported
Aged 65-74 1995-1996 1
Male 9.3% 21.7% 57.1%Female 13.6% 29.3% 53.6%Total 11.2% 25.4% 55.9%
Aged 65-84 2004-2005 2
Male 10.9% 19.8% 45.0%Female 20.2% 23.3% 13.3%Total 15.3% 21.4% 28.6%
Datasources:1. HongKongCardiovascularRiskFactorPrevalenceStudy1995-1996.2. HeartHealthSurvey2004/2005.
FromtheHongKongCardiovascularRiskFactorPrevalenceStudy,itwasestimatedthatoverhalf(55.9%)ofthepeopleaged65to74yearswithdiabeteswereunawareoftheirdiabetesstatus.FromtheHeartHealthSurvey2004/2005,amongthoseaged65to84yearswithdiabetes,28.6%wereunawarethattheyhaddiabetes.Theproportionofpeoplewithdiabeteswhowereunawareoftheirdiabetesstatuswashigherformenat45.0%comparedto13.3%forwomen(DepartmentofHealthofHongKongSpecialAdministrativeRegion,2007).
3.2.3 Estimated number of people with known diabetes and future projection
WeestimatethetotalnumbersofpeopleinHongKongwithknowndiabetesbymultiplyingtheprevalenceratesofself-reportedpreviousdoctordiagnosisofdiabeteswiththeHongKongdemographicdata.Self-reportedprevalencewasusedbecausethisindicatesthenumberofpeoplewhoarecurrentlybeingtreated.Ofcourse,thesenumbersdonotincludetheundiagnosedcases.
Basedonthesameseriesofsurvey,itwasestimatedthattheprevalenceofapreviousdiagnosisofdiabetesamongthoseaged60andabovewas15.0%in2000and15.9%in2004(CensusandStatisticsDepartmentofHongKongSpecialAdministrativeRegion,2001,2005).Itwasestimatedthatthenumberofpeopleaged60andabovewithdiabetesincreasedfrom0.15millionin2000to0.17millionin2004(Table3.5).Thiscorrespondstoanincreaseofaround12.4%.Thisincreaseispartlyduetotheincreasedprevalencein2004andanincreasednumberofolderpeopleinHongKong.
��Trends and Burden of Diabetes in Hong Kong
Table3.5Estimatednumberofpeopleaged60andabovewithknowndiabetesinHongKong,2000and2004
Aged 60+ 2000 2004Population 986,600 1,049,800Prevalence with diabetes 15.02% 1 15.87% 2Estimated population with diabetes 148,187 166,603
Datasources:1. ThematicHouseholdSurveyReportNo.21:Patternofstudyinhighereducation;Socio-demographicprofile,health
statusandlong-termcareneedsofolderpersons.2. SocialDataCollectedviatheGeneralHouseholdSurvey-SpecialTopicsReportNo.27:Casualemployment;Part-time
employment;Socio-demographic,healthandeconomicprofilesofelderlypeopleandsoon-to-beoldpeople.
Focusingonthepopulationaged65andabove,estimationsofthenumberofknowncasesofdiabeteshadtobebasedondifferentdatabases,namelytheElderlyHealthCentrecohort1998-2001andthePopulationHealthSurvey2003/2004.Itwasestimatedthat0.09millionpeopleaged65andabovehaddiabetesinHongKongin2000and0.11millionin2004.Thiscorrespondstoanincreaseofaround23.3%.Thisisconsistentwiththefindingsabove.
Assumingaconstantprevalenceratebetween2003/2004and2006,weestimatedthetotalnumberofpeopleinHongKongwithknowndiabetesin2006bythesamemethodology.Itwasestimatedthat0.23millionpeoplehavediabetesinHongKongofwhich50%areaged65andabove(Table3.6).
Table3.6EstimatednumberofpeoplewithknowndiabetesinHongKong,2006*
Age groups Male Female Total18-44 8,088 15,205 23,29345-64 46,872 43,031 89,90365-74 31,149 36,177 67,32675+ 17,334 28,617 45,95118-64 54,960 58,237 113,19765+ 48,483 64,794 113,277Total (18+) 103,443 123,031 226,474
*Estimatednumberofpeoplewithknowndiabetesin2006
=Populationinmid-2006byagegroupandsex×prevalenceofdiabetesbyagegroupandsex
�0 Chapter �
Usingthesamemethodology(2003/2004prevalence)andassumingthattheageandgenderspecificprevalenceremainsthesame,thenumberofpeopleaged65andabovewithknowndiabeteswouldbeexpectedtoincreasefrom0.11millionin2006to0.30millionby2036(Table3.7),whichis,morethandoubleover30years.By2036,peopleaged65andabovewouldmakeupabout70%ofthediagnosedadultcasesofdiabetes.AssumingthepercentageofundiagnoseddiabetescaseswasthesameasthatrevealedbytheHeartHealthSurvey(28.6%),theestimatednumberofpeopleaged65andabovewithdiabeteswouldbe0.42millionin2036.
Table3.7Estimatednumberofpeopleaged65andabovewithknowndiabetesinHongKong,2006and2036
Aged 65+ 2006 2036Estimated number with known diabetes 113,277 297,858% increase compared with 2006 -- 163%increase
Theaboveestimatesassumetheage-specificprevalenceofknowndiabetesremainsunchangeduntil2036.TheIDFpredictedthat,by2025,HongKongwillbeoneofthe10regionsintheworldwiththehighestprevalenceofdiabetesamongthoseaged20to79(IDF,2008).Iftheage-specificprevalenceisincreasing,thenumberofpeoplewithknowndiabeteswouldbelargerthanourestimatesabove.
3.2.4 Comparison between Hong Kong and other places
Owingtothedifferencesinconceptualizationandcompilationmethods, internationalcomparisonscanonlybeconductedinabroadsense.Fromtheprevioussections,theprevalenceofself-reporteddiabetesamongthepopulationaged65andaboveinHongKong,theUnitedStates,theUnitedKingdomandAustraliaaresimilar.ThesearecomparedinabroadsenseinFigure3.2.
�1Trends and Burden of Diabetes in Hong Kong
0
5
10
15
20
1992 1994 1996 1998 2000 2002 2004 2006 2008
Year
Prev
alen
ce(%
)
Hong Kong, 65-74 United States, 65-74 United Kingdom, 65-74 Australia, 65-74Hong Kong, 75+ United States, 75+ United Kingdom, 75+ Australia, 75+
Figure 3.2 Prevalence of self-reported diabetes among population aged 65 and above in selected places, 1994-2006
Figure3.2Prevalenceofself-reporteddiabetesamongpopulationaged65andaboveinselectedplaces,1994-2006
BasedontheIDFestimates,Table3.8andFigure3.3showthetrendsinprevalenceofdiabetes,includingundiagnosedcases,inHongKongandotherWesternPacificregionsforthoseaged20to79from2000to2003andprojectionsfor2025(IDF,2008).
Table3.8Prevalenceofdiabetes(diagnosedandundiagnosed)amongpopulationaged20-79inWesternPacificRegion,2000to2025
Country 2000 2001 2003 2025Australia 5.9% 6.1% 6.2% 7.7%China, Hong Kong 12.1% 12.1% 8.8% 12.8%China, Macau 10.7% 10.7% 8.2% 12.9%China, People’s Republic of 2.7% 3.0% 2.7% 4.3%Japan 7.4% 7.4% 6.9% 7.9%Korea, Democratic People’s Republic of - - 5.2% 6.3%Korea, Republic of 6.1% 6.1% 6.4% 8.3%New Zealand 8.0% 4.0% 7.6% 9.0%Singapore, Republic of 11.3% 11.3% 12.3% 19.5%Taiwan 9.1% 9.1% 5.6% 6.6%Thailand 3.7% 2.0% 2.1% 2.6%Vietnam - - 1.0% 1.4%
Datasource:DiabetesAtlas,InternationalDiabetesFederation(http://www.eatlas.idf.org/About_e_Atlas).
�2 Chapter �
Figure3.3Prevalenceofdiabetes(diagnosedandundiagnosed)amongpopulationaged20-79inWesternPacificRegion,2000-2003andprojectedfor2025
Theseresultsshowthattheprevalenceofdiabetesamongthepopulationaged20to79in2003inHongKongwascomparabletoAustralia,Japan,NewZealandandMacau,lowerthanSingapore,buthigherthanChina.TheIDFdidnotprojectanobviousincreasingtrendfortheprevalenceofdiabetes inHongKongin2025,whileanincreasingtrendwasprojectedforSingapore.Nevertheless,theprojectedprevalenceofdiabetesin2025inHongKongwouldbemuchhigherthaninAustralia,ChinaandJapan,thoughitisstillmuchlowerthaninSingapore.
3.2.5 Pre-diabetes
IGTandIFGrefertolevelsofbloodglucoseconcentrationabovethenormalrange,butbelowthosewhicharediagnosticfordiabetes.SubjectswithIGTorIFGareatsubstantiallyhigherriskofdevelopingdiabetesthanthosewithnormalglucosetolerance.Hence,theyaresaidtohavepre-diabetes.
UsingtheWHOcriteriaforIGT,theCardiovascularRiskFactorPrevalenceStudy1995-1996foundthattheprevalenceofIGTamongthepopulationaged25to74was15.7%(14.2%formenand17.1%forwomen)(DepartmentofClinicalBiochemistry,QueenMaryHospitalofHongKong,1997).TheprevalenceofIGTincreasedwithage,about1in4peopleaged65to74hadIGT(ascomparedto1in13forthoseaged24to34)(Table3.9).
0
5
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25
Australia China Hong Kong Japan Macau New Zealand Singapore
Year
Prev
alen
ce(%
)
2000 2001 2003 2025
Figure 3.3 Prevalence of diabetes (diagnosed plus undiagnosed) among population aged 20-79 in Western Paci�c Regions, 2000-2003 and projected 2025
��Trends and Burden of Diabetes in Hong Kong
Table3.9Prevalenceofpre-diabetes(IGT)inHongKong,1995-1996
Age groups Male Female Total25-34 6.2% 9.8% 8.0%35-44 13.5% 14.1% 13.8%45-54 15.0% 19.4% 17.3%55-64 17.4% 24.1% 20.4%65-74 24.8% 26.0% 25.4%Total (25-74) 14.2% 17.1% 15.7%
Datasource:TheHongKongCardiovascularRiskFactorPrevalenceStudy,1995-1996.
BasedonWHOcriteriaforIGTandIFG,theHeartHealthSurvey2004/2005foundthattheprevalenceofpre-diabetes(IGTorIFG)amongthepopulationaged15to84was7.5%(8.7%formenand6.4%forwomen)(DepartmentofHealthofHongKongSpecialAdministrativeRegion,2007).Again,theprevalenceofpre-diabetesincreasedsharplywithage,about1in6peopleaged65to84hadpre-diabetes(Table3.10andFigure3.4).
Table3.10Prevalenceofpre-diabetes(IGTorIFG)inHongKong,2004-2005
Age groups Male Female Total15-24 2.2% 1.2% 1.7%25-44 4.8% 3.9% 4.3%45-64 12.8% 8.0% 10.2%65-84 16.9% 18.9% 17.9%Total (15-84) 8.7% 6.4% 7.5%
Datasource:HeartHealthSurvey2004/2005.
Figure3.4Prevalenceofpre-diabetes(IGTorIFG)inHongKong,byagegroup,2004-2005
0
5
10
15
20
15-24 25-44 45-64 65-84
Age group
Prev
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Figure 3.4 Prevalence of pre-diabetes (IGT or IFG) in Hong Kong, by age group, 2004-2005
�� Chapter �
UsingtheHeartHealthSurveyprevalenceestimateasthemoreconservativeone,wecalculatedthenumberofpersonsinHongKongin2006whowerelikelytohavepre-diabetesandthuswereatriskofdevelopingdiabetes(Table3.11).Nearly0.14millionpeopleaged65to84wereestimatedtohavepre-diabetesin2006,thatisaround30.8%ofallthosewithpre-diabetes.
Table3.11Estimatednumberofpeoplewithpre-diabetesinHongKong,2006
Age groups Male Female Total15-24 9,854 5,528 15,38225-44 48,720 50,107 98,82745-64 119,040 74,192 193,23265-84 61,634 74,976 136,611Total (15-84) 239,248 204,804 444,052
AccordingtoIDF,itwaspredictedthatHongKongwillbeoneofthe10regionsintheworldwiththehighestprevalenceofpre-diabetesamongthoseaged20to79by2025.Itwaspredictedthatbythattimetheprevalenceofpre-diabeteswillbe14.6%(IDF,2008).Actionhastobetakentopreventthesepre-diabetescasesfrombecomingdiabetescases.
3.3 Incidence
AcohortstudyofChinesesubjectsaged70yearsandabovein1991-1992foundthattheincidencerateofself-reporteddoctordiagnosisofdiabeteswas37.3per1,000ina36-monthfollowupafterrecruitment(Wooetal.,2002).Thisworksouttoanannualincidenceof12.4per1,000.IntheCardiovascularRiskFactorPrevalenceStudy1995-1996,respondentswhoreportedbeingdiagnosedwithdiabetesbyawesterntraineddoctorwereaskedhowlongagotheywerediagnosedandthisdatewasusedtoidentifythosediagnosedwithinthelastyear.Thisgaveanestimateofincidenceofself-reporteddoctor-diagnoseddiabetesinthoseaged65to74of8.9per1,000.Theseestimates,especiallytheformer,seemtobehigherthaninothercountries.
Inanotherlocalstudy,PopulationHealthSurvey2003/2004,respondentswereaskedwhethertheyhadbeendiagnosedwithdiabetesbyadoctororhealthprofessionaland,ifso,whetheritwasinthepast12months.Theresultingestimateofincidenceamongthoseaged15andabovewas15.9per1,000(DepartmentofHealthofHongKongSpecialAdministrativeRegionandDepartmentofCommunityMedicine,TheUniversityofHongKong,2005).Theincidencerateincreasedwithage(Table3.12).Theincidencerateofdiabetesamongthoseaged65andabove(55.6per1,000)wasnearlysixtimesthatamongthoseaged15to64(9.5per1,000).
��Trends and Burden of Diabetes in Hong Kong
Table3.12Incidenceofdiabetesdiagnosedinthe12monthsprecedingthesurvey(per1,000)inHongKong,byagegroupandsex,2003-2004
Age groups Male Female Total18-44 3.1 3.1 3.145-64 24.4 18.7 21.365-74 50.9 59.6 55.075+ 29.9 75.0 56.715-64 10.7 8.5 9.565+ 44.7 65.9 55.6Total (15+) 15.9 16.0 15.9
Datasource:PopulationHealthSurvey,2003/2004
TheestimateofincidencefromthePopulationHealthSurveyishigherthanthatfromtheWooetal.(2002)studyandothercountries.Thismaybeduetothedifferentmethodologyandsurveyquestionover-estimatingtheactualincidence.
Thereisnotmuchinformationonthelocalincidenceofdiabeteseithercurrentlyorinthepast.WewereunabletoidentifyusefulinformationontheincidenceofdiabetesinolderpeopleinHongKongusingclinicalcriteria.
3.4 Disease Burden
3.4.1 Mortality
DiabetesistheninthmostcommoncauseofmortalityinHongKong(DepartmentofHealthofHongKongSpecialAdministrativeRegion,2008b).In2007,therewere506deathsfromdiabetes,accountingfor1.3%ofalldeaths(DepartmentofHealthofHongKongSpecialAdministrativeRegion,2008b).Thecrudedeathratesfromdiabetesincreasedslightlyfrom5.1per100,000in1981to7.3per100,000in2007(DepartmentofHealthofHongKongSpecialAdministrativeRegion,2005,2008a).Theage-standardiseddeathratesfordiabetesincreasedfrom9.7per100,000in1981to16.2per100,000in2000,thendecreasedto7.3per100,000in2007.Theage-standardisedmortalityrateswerequitestablebetween1981and1998,increasingsharplyinthelate1990’sbutgenerallydecreasingfrom2001to2007(Figure3.5).ThisisdifferentfromtheUnitedStateswhichhashadanincreasingtrendsince1981.
�� Chapter �
Figure3.5Crudeandage-adjusted*deathratesfordiabetesinHongKong,1981-2007
*Theage-adjusteddeathratesusedtheHongKongpopulationasofmid-2007asthestandard.
Datasource:VitalStatistics,DepartmentofHealth(http://www.healthyhk.gov.hk/phisweb/en/enquiry/index.html).
Thedeathratesincreasedsharplywithage(Table3.13).Thetrendinstandardisedmortalityfromdiabetesamongpeopleaged65andabovewassimilartothatforallages(Figure3.6).In2007,thestandardiseddeathratesfordiabetesamongthoseagedbelow65was1.1per100,000andamongthoseaged65andaboveitwas50.4per100,000(DepartmentofHealthofHongKongSpecialAdministrativeRegion,2008b).
0
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1981 1986 1991 1996 2001 2006
Year
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Figure 3.5 Crude and age-adjusted* death rate for diabetes in Hong Kong, 1981-2007
�7Trends and Burden of Diabetes in Hong Kong
0
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120
1981 1986 1991 1996 2001 2006
Year
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Figure 3.6 Age-adjusted* death rates for diabetes (per 100,000), by age groups, Hong Kong, 1981-2007
Table3.13Deathratesfordiabetes(per100,000),byagegroup,HongKong,1981-2007
Age groups 1981 1990 2000 2001 200765-74 34.4 27.1 55.9 53.0 22.675-84 94.8 67.0 147.6 102.0 64.185+ 54.9 105.3 249.1 169.3 141.0<65 (age-adjusted*) 2.7 1.6 2.5 1.9 1.165+ (age-adjusted*) 57.9 51.1 111.1 84.0 50.4Whole population (age-adjusted*) 9.7 7.8 16.1 12.2 7.3
*Theage-adjusteddeathratesusedtheHongKongpopulationasofmid-2007asthestandard.
Datasource:VitalStatistics,DepartmentofHealth(http://www.healthyhk.gov.hk/phisweb/en/enquiry/index.html).
Figure3.6Age-adjusted*deathratesfordiabetes(per100,000),byagegroup,HongKong,1981-2007
*Theage-adjusteddeathratesusedtheHongKongpopulationasofmid-2007asthestandard.
Datasource:VitalStatistics,DepartmentofHealth(http://www.healthyhk.gov.hk/phisweb/en/enquiry/index.html).
Amongthoseaged65andabove,thenumberofdeathsfromdiabetesincreasedfrom174in1981to716in2000,thendecreasedto439in2007(Figure3.7)(DepartmentofHealthofHongKongSpecialAdministrativeRegion,2005,2008a).Theproportionofdeathsfromdiabetesamongalldeathsofthoseaged65andabovefollowedasimilarpattern,being1.4%in2007(Figure3.8).
�� Chapter �
0%
1%
2%
3%
1981 1986 1991 1996 2001 2006
Year
Prop
ortio
nof
tota
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Figure 3.8 Proportion of deaths with diabetes as principal cause among the population aged 65 and above, 1981-2007
0
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1981 1986 1991 1996 2001 2006
Year
No.
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Aged 65-74 Aged 75+ Aged 65+
Figure 3.7 Number of deaths due to diabetes among the population aged 65 and above, 1981-2007Figure3.7Numberofdeathsduetodiabetesamongthepopulation
aged65andabove,1981-2007
Datasource:VitalStatistics,DepartmentofHealth(http://www.healthyhk.gov.hk/phisweb/en/enquiry/index.html).
Figure3.8Proportionofdeathswithdiabetesasprincipalcauseamongthepopulationaged65andabove,1981-2007
Datasource:VitalStatistics,DepartmentofHealth(http://www.healthyhk.gov.hk/phisweb/en/enquiry/index.html).
Whilethedeathratesfromdiabetesincreasedwithage,femaleshadhigherdeathratesthanmalesamongtheoldergroup(DepartmentofHealthofHongKongSpecialAdministrativeRegion,2005,2008a).In2007,mortalityratesfromdiabeteswere43.2per100,000formalesand56.5forfemalesaged65andabove(Table3.14).
��Trends and Burden of Diabetes in Hong Kong
Table3.14Deathratesfromdiabetes(per100,000)inHongKong,byagegroupandsex,2007
Age groups Male Female Total65-74 26.1 19.0 22.675-84 57.2 69.5 64.185+ 114.0 153.3 141.0<65 1.6 0.6 1.165+ 43.2 56.5 50.4
Datasource:VitalStatistics,DepartmentofHealth(http://www.healthyhk.gov.hk/phisweb/en/enquiry/index.html).
Asmanypeoplewouldhavebeenrecordedasdyingfromanothercausewhichwasitselfacomplicationofdiabetes,theindirectcostofdiabeteswouldbebettermeasuredbydeathsattributabletodiabetes.Hence,weusedtheattributableriskmethodologytoestimatethedeathsattributabletodiabetesinordertoshowtheactualburdenofdiabetes.Theattributablefraction(AF)istheproportionofcost(e.g.itsmortality,diseaseburdenordollarcost)thatiscausedbyariskfactoraftercontrollingforconfoundingfactors.Applyingthistothepopulationgivesthepopulationattributablefraction(PAF)ortheproportionofthecostforthepopulationthatiscausedbytheriskfactor.ThePAFisestimatedas:
PAF=Prevalence×(RelativeRisk-1)/[(Prevalence×(RelativeRisk-1))+1]
whereprevalencereferstotheprevalenceofdiabetesinthepopulationofinterestandrelativeriskistheriskofsomeonewithdiabetesincurringthiscostcomparedwithsomeonewithoutdiabetes.ThisPAFisthenappliedtothetotalcostforthepopulationofinterest.
Therelativeriskofall-causemortalityamongpeoplewithdiabetescomparedtothosewithoutis1.38formalesand1.40forfemalesaged60to69,whereas1.13formalesand1.19forfemalesaged70andabove(Barnettetal.,2006).InHongKong,673deathsamongolderpeople(302formaleand371forwomen)in2006couldbeattributedtodiabetes(thatis,arateof79.0per100,000population)usingtheprevalenceofdiabetesfromthePopulationHealthSurvey2003/2004(Table3.15).
�0 Chapter �
Table3.15Diabetes-attributabledeathsamongpopulationaged65andabove,HongKong,2006
Aged 65-69 Male FemaleRelative risk of mortality 1.38 1.40PAF% 4.93% 6.11%Deaths in Hong Kong in 2006 1,928 817Attributed deaths 95 50
Aged 70+ Male FemaleRelative risk of mortality 1.13 1.19PAF% 1.51% 2.52%Deaths in Hong Kong in 2006 13,669 12,741Attributed deaths 207 321
3.4.2 Morbidity
3.4.2.1 Hospital admission at public hospitals
BasedondataprovidedbytheHospitalAuthority,inpatientutilisationstatisticswerecompiled.In2006,therewereabout13,600inpatientdischargesanddeathsinpublichospitalswithaprincipaldischargediagnosisofdiabetes(ICD9250).Therewerearound7,700episodesforpeopleaged65yearsandabovewhichamountsto56%ofthetotalepisodesfordiabetesinpublichospitalsforallages.
Ingeneral,olderpeoplehavealongerlengthofstay(LOS)inhospitalthanyoungerpeople(6.7daysforthoseaged65andabovecomparedwith4.2daysforthoseaged45to64).Amongthoseaged65andabovewithdiabetes,theaverageLOSinhospitaltendstobelongerforthosewithcomplications(7.5days)comparedtothosewithout(5.6days).
3.4.2.2 Out-patient visits related to diabetes
TheHarvardHouseholdSurvey1998data(HarvardUniversityandTheUniversityofHongKong,1998)wereusedtoestimatethedifferenceinthelikelihoodofout-patientvisitsbetweenthosewithdiabetesandthosewithout.
Forgeneralout-patientclinics(GOPC),AccidentandEmergencyDepartment(A&E)andfamilydoctors,thosewithdiabetesweremorelikelytovisitthemforchronicillness,cold/flu/feveror
�1Trends and Burden of Diabetes in Hong Kong
otherhealthproblemthanthosewithout(Table3.16).Amongpeopleaged65andabove,thosewithdiabeteshadan81%higherlikelihoodofhavingdoctorconsultations,inthe14dayspriortointerview,thanthosewithout.
Table3.16Likelihoodofdoctorconsultationsinthe14dayspriortointerviewforthosewithdiabetesrelativetothosewithoutdiabetes
Age groups Odds Ratio (OR) p-value 95% Confidence Interval (CI)16-64 * 2.397 0.000 1.538-3.73565+ * 1.808 0.040 1.027-3.184Total (16+) * 2.237 0.000 1.578-3.173
* Adjustedbyagegroup,sex,otherchronicillness,martialstatus,personalincome,insurancecoverage,occupation,livingaloneandhealthstatus
Datasource:HarvardHouseholdSurvey1998.
Forspecialistout-patientclinics (SOPC),peoplewithdiabetesalsohadmoredoctorconsultationsforanydiseasethanthosewithout.Forexample,thoseaged16andabovewithdiabeteshadan81%higherlikelihoodofvisitinganSOPCinthe14dayspriortointerviewthanthosewithout(OddsRatio(OR)=1.81;95%CI:1.04-3.16).
3.4.2.3 Complications of diabetes
Complicationsofdiabetesarecommon.BasedonstatisticsfromtheHospitalAuthority,between2002and2006,over50%ofinpatientsdischargedfrompublichospitalshadcomplicationsasindicatedbytheICDcodesfordiabeteswithcomplications.Olderpeoplehadahigherproportion(58%forthoseaged65andabove)ofcomplicationsthanyoungeradults(46%forthoseunder65).
Peoplewithdiabetesareatgreaterriskofhavingretinopathy,neuropathy,limbamputation,kidneyfailure,heartdiseaseandstroke.AccordingtotheWHOfactsheet,overtime,about2%ofpeoplewithdiabetesbecomeblindandabout10%developseverevisualimpairmentafter15yearswithdiabetes.Upto50%ofpeoplewithdiabeteshavedamagednerves,10-20%dieofkidneyfailureandabout50%dieofcardiovasculardisease,mainlyheartdiseaseandstroke(WHO,2008b).
AnAustralianstudyestimatedthatonethirdofpeopleaged40andabovewithType2diabeteswouldexperienceaseriouscomplication(Colagiurietal.,2003).Of8,536peoplewithType2diabetes,eyeproblemsweremostcommon,experiencedby26.6%,followedbykidneyproblems(10.4%),footorlegulcers(9.0%),stroke(6.9%)andheartattack(8.9%).Amputation(4.9%)wasalesscommonbutimportantcomplicationaffectingactivitiesofdailyliving.
�2 Chapter �
InHongKong,onediabetescentrestudiedco-morbiditiesandcomplications in1990(QualigenicsDiabetesCentre,n.d.).Halfofthepatientswithdiabetesalsohadeitherco-existinghighbloodpressureorhighbloodcholesterollevel.About25%and20%ofthediabetespatientshadretinopathyandwereonrenaldialysisrespectively.Inaddition,about20-30%ofstroke,25%ofheartattacksand50%ofamputationswerecausedbydiabetes.
Wangetal. (1998)showedthatfrom1990to1996,theprevalenceofretinopathyandneuropathyamongpatientsfirstattendingadiabetesclinicwas21.9%and12.8%respectively.Anotherstudyfoundthatpeopleaged60andabovewithdiabeteshadahigherlikelihoodofheartdisease(23.2%comparedwith13.3%ofthosewithoutdiabetes),hypertension(58.9%comparedwith31.1%),stroke(8.9%comparedwith2.6%)andvisionproblem(33.3%comparedwith19.9%)(ChouandChi,2005a).
Diabeticretinopathyisacommonandseriousconditionwhichcanleadtoblindnessbutistosomeextenttreatableifdetectedearlyenough.However,surveydatarevealedthatin2004-2005,56.9%ofthoseaged65to84withknowndiabeteshadelevatedfastingbloodglucoseimplyingthattherewaspoorcontrolofdiabeteswhichcouldleadtofurthercomplications(DepartmentofHealthofHongKongSpecialAdministrativeRegion,2007).
3.4.3 Disability
IntheGlobalBurdenofDiseasestudy(GBD),WHOuseddisabilityweightsbytreatmentstatusforthosewithdiabetes(MurrayandLopez,1996).Table3.17showsthatahighdisabilityweightisgiventoblindness,bothtreatedanduntreated.Amputationalsohadahighdisabilityweightbutfortheuntreatedcasesonly.Forthetreatedcases,diabeticfoothadthesecondhighestdisabilityweight.
Table3.17DisabilityweightsbytreatmentstatusforGBDdiabetesmodels
Conditions Untreated TreatedDiabetes Cases 0.01 0.03Blindness due to retinopathy 0.60 0.49Neuropathy 0.08 0.06Diabetic foot 0.14 0.13Amputation 0.16 0.07
Datasource:Theglobalburdenofdisease:acomprehensiveassessmentofmortalityanddisabilityfromdiseases,injuries,andriskfactorsin1990andprojectedto2020.
��Trends and Burden of Diabetes in Hong Kong
InAustralia,itwasestimatedthatdiabeteswasresponsiblefor4.9%ofthetotaldisability-adjustedlifeyears(DALYs)sufferedbythepopulationin1996.Lifelostduetodisability(YLD)contributedtoover40%ofDALYsduetodiabetes.YLDfromdiabeteswerealsoresponsiblefor4.6%ofYLDfromallcauses(Mathersetal.,1999).Thusdiabetesisconsideredasamajorcauseofchronicdisability.
InHongKong,ChouandChi(2005a)usedstandardisedquestionnairesabout15tasksandshoweddiabetestobeassociatedwithdisabilitiesamongpeopleaged60andabove.Olderpeoplewithdiabeteswere1.8to4.1times(dependingondifferenttasks)morelikelythanthosewithoutdiabetestoreportsomedifficultyinADL.Moreolderpeoplewithdiabetesreporteddifficultyinatleastoneofthethreefunctionaldomainscoveringself-caretasks,mobilityandhigherfunctioning(26.0%comparedwith14.8%withoutdiabetes).Themostcommondifficultywasmealpreparation(14.2%comparedwith5.5%withoutdiabetes),followedbypersonalshopping(11.8%comparedwith5.2%withoutdiabetes)andclimbingstairs(9.3%comparedwith5.0%withoutdiabetes).
Wooetal.(1998)alsocarriedoutafunctionalassessmentoftenbasicADLusingtheBarthelIndex(BI)bymeansofinterviewandphysicalassessmentofpeopleaged70andaboveattheirplacesofresidence.Ascoreoflessthan15ontheBIscaleindicatesseverelimitation,15-19moderate-to-mildlimitationand20nolimitation.TheORadjustedforageandsexwas1.7(95%CI:1.0-3.0)forseverelimitationand1.5(95%CI:1.1-2.2)formoderate-to-mildlimitationforthosewithdiabetescomparedtothosewithout.
3.4.4 Cognitive impairment
Moststudiesoverseassuggestthatdiabetesisassociatedwithanincreasedriskofcognitiveimpairmentanddementia.Somedetailsarediscussedbelow.
3.4.4.1 Cognitive function
ArecentreviewshowedthatType2diabeteswaslikelytobeassociatedwithcognitiveimpairment(Pasquieretal.,2006).StewartandLiolitsa(1999)foundthat,whileusingdifferentassessmenttools,mostofthecasecontrolstudiessuggestedolderpeoplewithdiabetesperformedlesswellincognitivefunctionsthanthosewithout.AstudyinJapandemonstratedthatpeopleaged60andabovewithType2diabetesweremorelikely,thanthosewithoutdiabetes,tohavecognitiveimpairmentasindicatedbysignificantlylowerscoresontheMini-MentalStateExaminationandDigitSymbolTest(Mogietal.,2004).
�� Chapter �
However,StewartandLiolitsa(1999)concludedthatprospectivestudieshaveinconsistentfindings.InonelongitudinalcohortstudyintheUnitedStates,peopleaged65andabovewithType2diabeteshadsignificantlyhigherriskofmildcognitiveimpairmentaftercontrollingforallcovariates(Luchsingeretal.,2007).AstudyinFinland,meanwhile,foundthatType2diabeteswasnotasignificantriskfactorforcognitiveimpairmentorimpairedmemoryamongpeopleaged69to78(Vanhanenetal.,1999).
Ameta-analysisfoundthatpeoplewithType1diabeteshadloweredcognitiveperformance,ascomparedtothosewithoutdiabetes,invariouscognitivedomains(Brandsetal.,2005).
UsinglocaldatafromtheElderlyHealthCentrefortheperiodfrom1998to2001,weclassifiedanAbbreviatedMentalTest(AMT)scoreof0-3asseverecognitiveimpairmentand4-7asmoderateimpairment.Wefoundslightlymorepeopleaged65andabovewithdiabeteshadsevereormoderatecognitiveimpairmentandtherelationshipwassignificantusingachi-squaretestforassociation(P<0.001)(Table3.18).
Table3.18Cognitivefunction*ofpeopleaged65andaboveinElderlyHealthCentrecohort,bydiabetesstatus,1998-2001
Cognitive function N(%) Diabetes status Severe Moderate Normal Total impairment impairment
Have regular care for diabetes 68(1.0%) 485(7.0%) 6,368(92.0%) 6,921(100.0%)Without diabetes 522(0.9%) 3,064(5.2%) 55,002(93.9%) 58,588(100.0%)Total 590(0.9%) 3,549(5.4%) 61,370(93.7%) 65,509(100.0%)
* AbbreviatedMentalTest(AMT)asassessmenttoolandtheclassificationofthelevelofcognitiveimpairmentisbasedonthescores(0-3Severeimpairment;4-7Moderateimpairmentand8-10Normal)
Datasource:ElderlyHealthCentrecohort1998-2001.
Table3.19showsthattherewassomedifferenceinthefindingsdependingonwhethertheolderpersonlivedinaninstitution.Thelevelofcognitivefunctionwassignificantlyassociated(p-value<0.001)withthelivingarrangementofthepeoplewithdiabetes.Morepeoplewithdiabeteslivingininstitutionstendedtohavesevereormoderatecognitiveimpairmentthanthosewholivedinthecommunity.
��Trends and Burden of Diabetes in Hong Kong
Table3.19Cognitivefunction*ofpeopleaged65andaboveinElderlyHealthCentrecohortwithdiabetesunderregularcare,bylivingstatus,1998-2001
Cognitive function N(%) Living status Severe Moderate Normal Total impairment impairment
Living in institution 20(7.1%) 52(18.4%) 210(74.5%) 282(100.0%)Living in community 48(0.7%) 433(6.5%) 6,158(92.8%) 6,639(100.0%)Total 68(1.0%) 485(7.0%) 6,368(92.0%) 6,921(100.0%)
* AbbreviatedMentalTest(AMT)asassessmenttoolandtheclassificationofthelevelofcognitiveimpairmentisbasedonthescores(0-3Severeimpairment;4-7Moderateimpairmentand8-10Normal)
Datasource:ElderlyHealthCentrecohort1998-2001.
3.4.4.2 Dementia
Evidencetosupportarelationshipbetweendiabetesanddementiaisnotasclearasthatbetweendiabetesandcognitiveimpairmentthoughapositiveassociationhasbeenreportedinsomestudies(Pasquieretal.,2006).A6-yearfollowupstudyinSwedenfoundthatpeopleaged75andabovehadhigherriskfordementia,inparticularvasculardementia(Xuetal.,2004).A9-yearstudyonCatholicnuns,priestsandbrothersintheUnitedStatesfoundthatpeopleaged55andabovewithdiabeteshad65%higherriskofdementiacomparedwiththosewithoutdiabetes(Arvanitakisetal.,2004).However,somerecentstudiesdidnotshowasignificantincreaseinrisk.Forexample,astudyoftheFraminghamcohort(overanaverage12.7yearsoffollow-up)foundthatdiabeteswasaninsignificantriskfactorfordementia,yetitwasariskfactoramongthosewhooriginallyhadrelativelylowriskfordementia(Akomolafeetal.,2006).
InHongKong,weexaminedtherelationshipbetweendiabetesandself-reporteddementiausingthePopulationHealthSurvey2003/2004data(Table3.20). Diabetesstatuswasnotsignificantlyassociated(p-value=0.96)withdementiastatusamongthesurveyrespondentsaged65andabove.Aspeoplewithdementiawereunlikelytobeinterviewedinthesurvey,peoplewithdementiamaybeunder-representedinthesample.Hence,theresultsmaynotbeconclusive.
Table3.20Dementiastatusofpeopleaged65andaboveinPopulationHealthSurvey,bydiabetesstatus,2003-2004
Diabetes status Signs of dementia present?
Yes No Total
Have diabetes 1.8% 98.2% 100.0%Without diabetes 2.0% 98.0% 100.0%
Datasource:PopulationHealthSurvey2003/2004.
�� Chapter �
3.4.5 Quality of life
Toestimatequalityoflife(QOL)forpeoplewithdiabetesinHongKong,aspecificinstrument,HongKongChineseversionofdiabetes-specificqualityoflife(HKC-DQoL-37),hasbeentestedinHongKongandconsideredtobevalidandreliable(Shiuetal.,2008).Itconsistsofthreesubscaleswith37items(14itemsonsatisfaction,19itemsondiabetesimpactand4itemsonconcernaboutdiabetes).Shiuetal.(2008)showedthatthemeanHKC-DQoL-37scorewasabout2.2(SD=0.5)andthatyoungerage,complicationsofdiabetes,hospitaladmissionduetohypoglycaemiaandinsulintherapyworsenQOLofdiabetespatients.
ArecentstudyofType2diabetespatientsaged18to89in2003,usinga57-itemDiabetesStressQuestionnaire,foundthat33.6%couldbeclassedasbeinganxious-depressed(Leeetal.,2006).Thosewhohadcomplications,whodidnotdisclosetheirdiabetestotheirfamily,orwhoveryoftenorsometimesbelievedthatdiabetesrenderedthemaburdentothefamilyweremorelikelytobeanxious-depressed.
BasedontheGeriatricDepressionScale(GDS),alocalstudyofpeopleaged60andabovein1996foundthattheproportionofpeoplewhohaddepressivesymptoms(GDS≥8)wassignificantlyhigheramongthosewithdiabetes(26.0%)ascomparedwiththosewithout(19.7%)(ChouandChi,2005b).
UsingtheHarvardHouseholdSurveydatabase(HarvardUniversityandTheUniversityofHongKong,1998),wefoundthatolderpeople(aged65andabove)withdiabetesweremorelikelytoratetheirhealthaspoorcomparedtothosewithoutdiabetes(p-value=0.002)(Table3.21).
Table3.21Self-ratedhealthstatusofpeopleaged65andaboveinHarvardHouseholdSurvey,bydiabetesstatus,1998
Self-rated health compared with others of the same age
Diabetes status N(%)
Good# Poor* Total
Have Diabetes 21(23.4%) 70(76.7%) 91(100.0%)Without Diabetes 200(41.1%) 287(59.0%) 487(100.0%)Total 221(38.3%) 357(61.7%) 578(100.0%)
#Thecategory"Good"referstoexcellent,verygoodorgoodself-ratedhealthstatus.
*Thecategory"Poor"referstofairorpoorself-ratedhealthstatus.
Datasource:HarvardHouseholdSurvey1998.Questionused"Ingeneral,howisyourhealthatthistimecomparedtootherpeoplearoundyoursameage?"Numberswereweightedbyagegroupandsex.ThePercentageswerebasedontheweightednumbersbeforerounding.
UsingthebaselinehealthassessmentofacohortofmembersattendingElderlyHealthCentresinHongKong,wefoundthatthosewithdiabetesreportedpoorerself-ratedhealth(p-value<0.001)(Table3.22).
�7Trends and Burden of Diabetes in Hong Kong
Table3.22Self-ratedhealthstatusofpeopleaged65andaboveinElderlyHealthCentrecohort,bydiabetesstatus,1998-2001
Self-rated health compared with others of the same age Diabetes status N(%) Better Normal Worse Total
Have regular care for diabetes 1,307 4,782 840 6,929 (18.9%) (69.0%) (12.1%) (100.0%)
No diabetes 14,279 40,138 4,213 58,630
(24.4%) (68.5%) (7.2%) (100.0%)
Total 15,586 44,920 5,053 65,559 (23.8%) (68.5%) (7.7%) (100.0%)
Datasource:ElderlyHealthCentrecohort1998-2001.Questionsused"Isyourhealthconditionconsideredasbetter,normalorworsewhencomparedtothatofsimilaragegroup?"
SubjectswithdiabetesintheElderlyHealthCentrecohortweresignificantlymorelikelytoreportthattheiractivitieswerelimitedandtheyaccomplishedlessbutthesedatawerenotadjustedforconfounders.Theresultssuggestthatthereisasignificantdifferentbetweenthosewithandwithoutdiabetesinphysicalaspectsoftheirqualityoflife.
Again,usingtheElderlyHealthCentredata,itwasshownthat12.2%ofpeopleaged65andabovewithdiabeteshavedepressivesymptoms(GDSshort-form≥8)comparedto9.3%withoutdiabetes(p-value<0.001)(Table3.23).
Table3.23Depressionstatusofpeopleaged65andaboveinElderlyHealthCentrecohort,bydiabetesstatus,1998-2001
Depression Status N(%) Diabetes status GDS#<8 GDS#≥8 Total
Have regular care for diabetes 6,075(87.8%) 848(12.2%) 6,923(100.0%)No diabetes 53,121(90.7%) 5,458(9.3%) 58,579(100.0%)Total 59,196(90.4%) 6,306(9.6%) 65,502(100.0%)
#GDSshort-formscale(Range0-15)≥8indicatesdepressivesymptoms.
Datasource:ElderlyHealthCentrecohort1998-2001.
�� Chapter �
3.5 Economic Burden
Diabetescanresultinmanylongtermhealthconditions,especiallyifitisundetectedorpoorlycontrolled.Thesearereflectedinthediseaseburden.However,someoftheseconditionsresultineconomiclosses.Therearenotonlydirecthealthcostsassociatedwithdiabetesbutalsoindirecthealthcostsduetoincreasedriskofotherdiseaseandcomplicationsarisingfromdiabetes.Directcostsincludemedicalcostssuchashospitalisation,doctorconsultationandothercostssuchasmedicines.Indirectcostsincludecostsofdealingwithdisability,costsfromlossofworkandcostsofprematuremortality.
InHongKong,itwasestimatedthatin2004,theannualcostofaType2diabetespatientwasHK$13,457,ofwhich87.9%wasfromdirectcost(Chanetal.,2007).MedicalcostscontributedHK$11,638tothedirectcostofaType2diabetespatientperyear.AsthemedicalservicesareheavilysubsidisedbythegovernmentofHongKong,thepublicsectorhadbeenpaying90.6%ofthedirectmedicalcost,whichamountedto3.9%ofthetotalhealthcareexpenditureinHongKong.Ifcomplicationse.g.vascularwerepresent,thecostscouldbeupto30%higher.
IntheUnitedStates,itwasestimatedthatthetotalcostofdiabetesin2002wasUS$132billion,with69.5%indirectmedicalexpenditures(AmericanDiabetesAssociation,2003).TheannualmedicalcostofadiabetespatientintheUnitedStateswasUS$13,243.Itwasalsofoundthatmorethanhalf(51.8%)ofthedirectmedicalcostswereincurredbypeopleagedover65(AmericanDiabetesAssociation,2003).Over10years,thetotalcostofdiabetesintheUnitedStateshasincreasedby77.6%,fromUS$98billionin1997toUS$174in2007(AmericanDiabetesAssociation,1998,2008).
Here,usingtheattributableriskmethodology,thedirectcostsofdiabetes,inparticularamongolderpeople,inHongKongwereestimated.
3.5.1 Hospital costs
BasedonstatisticsprovidedbytheHospitalAuthority,populationaged18andaboveusedaround6million(6,033,541)beddaysatthepublicgeneralhospitalsforalldiseasesin2006.Thepopulationaged65andaboveusedapproximately60%ofthesebeddaysandnear30%ofthesebeddaysforolderpeoplewereusedbypatientswithdiabetes.
��Trends and Burden of Diabetes in Hong Kong
Theattributablecostofinpatientcarewasestimatedusing(i)thenumberofinpatientbeddaysbasedonstatisticsfromtheHospitalAuthority,(ii)theprevalenceofdiabetesfromPopulationHealthSurvey2003/2004,(iii)therelativeprevalenceofdiabetescomplicationsand(iv)aunitcostofaninpatientbeddaybasedonthechargefornon-eligiblepersonsinHongKong("S.S.No.4toGazetteNo.13/2003",2003).TheresultsbasedonattributableriskmethodologyareshowninTable3.24.
Table3.24Diabetes-attributablecostofinpatientcareinHongKong,2006
Age
18-64 years 65+ years(1)Estimatednumberofinpatientbeddaysin2006 2,431,372 3,602,169(2)Estimatednumbersofinpatientbeddays 105,443 368,993
attributabletodiabetes*(3)Costperinpatientbedday(HK$) 3,300 3,300
Estimatedattributablecost(HK$) 347,961,075 1,217,677,196
*AftertakingintoaccountthePAF%ofdifferentcomplicationsofdiabetesandgeneralmedicalcondition.
Theattributablecostofinpatientcarefordiabetesinpeopleaged65andabovewasaroundHK$1.2billionin2006,whichwasnear80%ofthetotalattributableinpatientcarecostofdiabetesforpeopleaged18andabove.
3.5.2 General out-patient clinics (GOPC) visits
In2006,therewerearound5millionattendances(5,557,700)attheGOPCforalldiseases(CensusandStatisticsDepartmentofHongKongSpecialAdministrativeRegion,2007a).UsingdatafromtheHarvardHouseholdSurvey,itwasestimatedthatthepopulationaged65andaboveusedapproximately18%ofthesevisits(Table3.25).
Table3.25EstimatednumbersofGOPCattendancesinHongKong,byagegroup,2006
Age groups Proportion of GOPC visits Estimated number
from Harvard Household Survey of GOPC visits≤15 19.0% 1,055,25916-64 62.9% 3,494,08165+ 18.1% 1,008,359Total 100.0% 5,557,700
�0 Chapter �
TheattributablecostofGOPCvisitswasestimatedusing(i)theestimatednumberofGOPCvisitsfromtheHarvardHouseholdSurvey,(ii)theprevalenceofdiabetesfromPopulationHealthSurvey2003/2004,(iii)therelativeriskestimatesofthelikelihoodofapersonwithdiabetesvisitingaGOPCascomparedtoapersonwithoutdiabetesfromtheHarvardHouseholdSurveyand(iv)aunitcostofaGOPCvisitbasedonthechargefornon-eligiblepersonsinHongKong("S.S.No.4toGazetteNo.13/2003",2003).TheresultsbasedonattributableriskmethodologyareshowninTable3.26.
Table3.26Diabetes-attributablecostofGOPCvisitsinHongKong,2006
Age 16-64 years 65+ years
(1)EstimatednumberofGOPCvisitsin2006 3,494,081 1,008,359
(2) PAF%=P(RR-1)/[P(RR-1)+1)] 3.15% 9.82% Prevalenceofdiabetes 2.33% 13.48% RelativeriskofvisitingGOPCgivendiabetes 2.397 1.808(3)EstimatednumbersofGOPCvisitsattributabletodiabetes 110,151 99,054
(1)*(2)(4) Costperattendance(HK$) 215 215
Estimatedattributablecost(HK$) 23,682,540 21,296,566
TheattributablecostofGOPCvisitsfordiabetesinpeopleaged65andabovewasaroundHK$21.3millionin2006,whichwasnearly50%ofthetotalattributableGOPCcostofdiabetesforpeopleaged16andaboveor1.8%ofallGOPCattendancesinthatyear.
3.5.3 Accident and Emergency Department (A&E) visits
In2006,therewerearound2millionattendances(2,028,569)totheA&Eforalldiseases(CensusandStatisticsDepartmentofHongKongSpecialAdministrativeRegion,2007a).Again,usingdatafromtheHarvardHouseholdSurvey,weestimatethenumberofA&EvisitsbyagegroupasshowninTable3.27.
�1Trends and Burden of Diabetes in Hong Kong
Table3.27EstimatednumbersofA&EattendancesinHongKong,byagegroup,2006
Age groups Proportion of A&E visits Estimated number of
from Harvard Household Survey A&E visits≤15 41.0% 832,23316-64 53.8% 1,092,30665+ 5.1% 104,029Total 100.0% 2,028,569
Thediabetes-attributablecostofA&Evisitswasestimatedusing(i)theestimatednumberofA&EvisitsfromtheHarvardHouseholdSurvey,(ii)theprevalenceofdiabetesfromthePopulationHealthSurvey2003/2004,(iii)therelativeriskestimatesofthelikelihoodofapersonwithdiabetesvisitingA&EascomparedtoapersonwithoutdiabetesfromtheHarvardHouseholdSurveyand(iv)theunitcostbasedonthechargeforanA&Evisittoanon-eligibleperson("S.S.No.4toGazetteNo.13/2003",2003).TheresultsbasedonattributableriskmethodologyareshowninTable3.28.
Table3.28Diabetes-attributablecostofA&EvisitsinHongKong,2006
Age 16-64 years 65+ years(1)Estimatedno.ofvisitsin2006 1,092,306 104,029(2)PAF%=P(RR-1)/[P(RR-1)+1)] 3.15% 9.82% Prevalenceofdiabetes 2.33% 13.48% RelativeriskofvisitingA&Egivendiabetes 2.397 1.808(3) EstimatednumbersofA&Evisitsattributabletodiabetes 34,435 10,219
(1)*(2)(4) Costperattendance(HK$) 570 570
EstimatedattributableburdeninA&E(HK$) 19,627,999 5,824,856
Thediabetes-attributablecostofA&Eforpeopleaged65andabovewasaroundHK$5.8millionin2006whichwasmorethan20%ofthetotaldiabetes-attributablecostofA&Eforpeopleaged16andaboveinthatyear.
�2 Chapter �
3.5.4 Specialist out-patient clinics (SOPC) visits
ApartfromGOPCandA&E,therewerearound6millionvisits(5,786,268)toSOPCforalldiseasesinHongKongin2006(CensusandStatisticsDepartmentofHongKongSpecialAdministrativeRegion,2007a).Usingthesamemethodologyasabove,weestimatedthenumberofSOPCvisitsbyagegroup(Table3.29)andattributablecostofSOPCvisits(Table3.30).
Table3.29EstimatednumbersofSOPCattendancesinHongKong,byagegroup,2006
Age groups Proportion of SOPC visits Estimated number of
from Harvard Household Survey SOPC visits≤15 11.7% 675,76916-64 62.0% 3,590,02065+ 26.3% 1,520,479
Total 100.0% 5,786,268
Table3.30Diabetes-attributablecostofSOPCvisitsinHongKong,2006
Age 16-64 years 65+ years
(1)EstimatednumberofSOPCvisitsin2006 3,590,020 1,520,479(2)PAF%=P(RR-1)/[P(RR-1)+1)] 1.86% 9.86% Prevalenceofdiabetes 2.33% 13.48% RelativeriskofaSOPCvisitgivendiabetes 1.811 1.811(3)EstimatednumbersinSOPCattributabletodiabetes 66,604 149,891
(1)*(2)(4)Costperattendance(HK$) 700 700
EstimatedattributablecostofSOPCvisits(HK$) 46,622,624 104,923,713
Thediabetes-attributablecostofSOPCforpeopleaged65andabovewasHK$0.1billionin2006oraround70%ofthetotaldiabetes-attributablecostofSOPCforpeopleaged16andaboveinthatyear.
��Trends and Burden of Diabetes in Hong Kong
3.5.5 Current and future economic burden in public sectors
Table3.31showsthesummaryoftheattributablemedicalcostsofdiabetesinthepublicsectorforpeopleaged65andaboveinHongKongin2006.ThisisaroundHK$1.4billionwhichincludesthecostofinpatientcareinpublichospitalandthecostofdoctorconsultations.
Table3.31Summaryoftheattributablemedicalcoststodiabetesamongthepopulationaged65andaboveforthepublicmedicalsectorsinHongKong,2006
Aged 65+ HK$ millionInpatient Care in Public Hospitals 1,218General out-patient clinic (GOPC) 21Accident and Emergency (A&E) 6Special out-patient Clinic (SOPC) 105Total attributable medical costs 1,350
FromTable3.6,itwasestimatedthatin2006,therewereabout0.11millionpeopleaged65andaboveinHongKongwithknowndiabetes.Theattributablemedicalcostsofdiabetespercapitaamongthepopulationaged65andabovewasestimatedbydividingthetotalattributablecostinthepublicsectorforthoseaged65andabovebytheestimatednumberofpeopleaged65andabovein2006withknowndiabetes.Table3.32showsthattheattributablemedicalcostsofdiabetesinthepublicsectorpercapitaamongthoseaged65andaboveinHongKongwasaboutHK$11,915in2006.ThisestimatewasconsistentwiththatestimatedbyChanetal.(2007)eventhoughtheirestimatewasforpeopleofallageswithdiabetes.
Table3.32Summaryoftheattributablemedicalcoststodiabetesinthepublicsectorpercapitaamongthepopulationaged65andaboveinHongKong,2006
Per person aged 65+ HK$Inpatient Care in Public Hospitals 10,750General out-patient clinic (GOPC) 188Accident and Emergency (A&E) 51Special out-patient Clinic (SOPC) 926Total attributable medical cost per capita 11,915
�� Chapter �
Basedontheaboveestimation,thefutureeconomicburdenofdiabetes,intermsoftheattributablemedicalcostsinthepublicsector,amongthepopulationaged65andabovewasprojectedtoyear2036(Table3.33).
Table3.33Estimatedattributablemedicalcosttodiabetesinthepublicsectorforthoseaged65andaboveinHongKongin2036
Aged 65+ 2036Total attributable medical cost per capita HK$11,915Estimated number of known diabetes cases 297,858Estimated attributable medical cost to diabetes in public sectors HK$3.5billion% increase compared with 2006 163%increase
Thisisaconservativeestimatewhichdoesnotincludeprivatesectorcare.Otherdirectcostsnotincludedintheaboveareoverthecountermedicationforwhichwehavenosolidinformation,andotherprescribeddrugcosts,althoughpartofthiscostisincludedinthecostsofmedicalconsultationdiscussedabove.
Althoughthedollarvaluewasnotestimated,therewillbeeconomicimplicationsofdealingwithfunctionalandcognitiveimpairmentresultingfrompoorlycontrolleddiabetesinolderpeople.Theresultingindirectcostwouldbehigherintheolderpopulationthanintheyoungerone.
3.6 Behaviour in Managing Diabetes
InthePopulationHealthSurvey2003/2004,respondentswhohaddiabetesreportedtheirbehaviourinmanagingtheirdisease.Somecommonmanagingbehaviourincludedrugtreatments(suchastakinginsulin,oraldiabetesmedicineandover-the-countermedication)andmodificationoflifestyle(suchasweightcontrol,increasingphysicalactivityorexerciseandhavingahealthierdiet)(DepartmentofHealthofHongKongSpecialAdministrativeRegionandDepartmentofCommunityMedicine,TheUniversityofHongKong,2005).Figures3.9and3.10showtheuptakerateofthesestrategiesamongpeoplewithdiabetesindifferentagegroupsandsex.
��Trends and Burden of Diabetes in Hong Kong
Figure3.9BehaviourinmanagingdiabetesamongthemalepopulationwithdiabetesinHongKong,byagegroup,2003-2004
Datasource:PopulationHealthSurvey,2003/2004.
Figure3.10BehaviourinmanagingdiabetesamongthefemalepopulationwithdiabetesinHongKong,byagegroup,2003-2004
Datasource:PopulationHealthSurvey,2003/2004.
Theaboveresultsshowthattakingoralmedicationswasthemostcommonbehaviourinmanagingdiabetes.Moreolderfemalesusedrugtreatmentthanintheyoungerpopulation,butthereverseistrueforthemalepopulationapartfromtakinginsulin.Olderpeople,meanwhile,bothmenandwomen,werelesslikelythanyoungerpeoplewithdiabetestotrytomodifytheirlifestyle.
FromtheHeartHealthStudy,weknowthatmorethanhalfthepeopleaged65to84whowereknowntohavediabetesstillhadelevatedfastingbloodglucose.Thisimpliesthattherewaspoorcontrolofdiabetesinolderpeopleandthiscouldleadtofurtherseriouscomplications.
8.4
85.3
27.5
57.7 61.2
14.0
79.0
13.4
51.255.4
84.191.5
0102030405060708090
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Taking insulin Taking diabetic pills Taking over thecounter medication
Controlling weightor losing weight
Increasing physicalactivity or exercise
Eating fewer highsugar content, highfat content or highcholesterol foods
Behaviour
Perc
enta
ge(%
)
Aged 15-64 Aged 65+
Figure 3.9 Behaviour in managing diabetes among the male population with diabetes in Hong Kong, by age groups, 2003/2004
Figure 3.10 Behaviour in managing diabetes among the female population with diabetes in Hong Kong, by age groups, 2003/2004
10.4
66.4
13.6
69.273.5
18.3
82.1
19.1
43.3 45.2
76.888.3
0
10
20
30
40
50
60
70
80
90
100
Perc
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ge(%
)
Taking insulin Taking diabetic pills Taking over thecounter medication
Controlling weightor losing weight
Increasing physicalactivity or exercise
Eating fewer highsugar content, highfat content or highcholesterol foods
Behaviour
Aged 15-64 Aged 65+
�� Chapter �
Discussion and ConclusionChapter 4
��
Diabetesexertshighcostsonthehealthcaresystemandthepopulation,especiallyonolderpeoplewhoareatthehighestriskofdevelopingdisease.Apartfromthedirectcostsofcareandtheindirectcostsofmortality,therewillbeaveryhighcostofdisabilityandreducedqualityoflifewhichislikelytobehigheramongtheolderpopulationthanamongthosewhoareyoungerduetofunctionalandcognitiveimpairment.Allofthesecostswillpredictablyincreaseinfutureasthepopulationages.
Theincreasingnumberofolderpeoplewillincreasethenumberofcasesandtheageprofileofpeoplewithdiabeteswillalsoincreaseleadingtoahigherdegreeofdependencyandmoreco-morbidities.Accordingtothedataexamined,alargenumberofexistingolderpeoplewithdiabetesarenotbeingdiagnosedand,evenamongthosediagnosed,alargenumberdonothaveadequatecontroloftheirbloodsugarlevels.
Everyopportunityshouldbetakenbyhealthcareproviderstofindcasesofdiabetesamongolderpeople,toensurethatalldiagnosedcasesarewellcontrolledandmonitoredforthedevelopmentofcomplications.Preventionisbetterthancure.Amongallriskfactorsfordiabetes,obesityandlackofphysicalactivityareexamplesofmodifiablefactors.Adoptionofahealthylifestyleshouldstartatayoungage.
Discussion and ConclusionChapter 4
��Discussion and Conclusion
Apartfromunderscoringtheimportanceofthepreventionofdiabetesanditscomplications,thefindingshavespecificimplicationsforcaringforolderpeoplewithdiabetes,andforadoptinganelder-orientatedapproach:
ο Comprehensivegeriatricassessmentcoveringphysical,functional,psychological,nutritionalandsocialdomainsneedstobecarriedouttoguidethemanagementplan,inviewoftheincreasedpredispositiontofunctionalandcognitiveimpairment,dementia,depressionandpoorqualityoflifeofolderpeoplewithdiabetes,inadditiontothecurrentdiabetescomplicationsscreening.
ο Thereisaneedtoconsidercareinthecontextofasocialunit,recognizingthataproportionoftheolderpopulationislessabletoachievelifestylemodification;lessabletomanagecomplexdrugregimes(andthereforemorepronetoadversedrugeffects);lessabletocopewithmultipleserviceprovidersatmultiplesites;andlessabletohandlegadgetsandinformationtechnology.Carewouldideallybeprovidedinauserfriendlyandconvenientcommunitysettingintegratingmedicalandsocialactivitiesformanagementandmaintenance.
ο Theneedforeyecareandmonitoringforretinopathyisparticularlyimportantsincevisionaffectsindependenceandqualityoflife.
ο Thereisaneedtoconsiderthetrajectoryofthediseaseinthecontextofincreasingfrailtyandtheproximitytoendoflife,inmanagementofthediseaseversustheusual‘static’systembasedapproachgovernedbyguidelines.
70 Chapter �
ReferencesChapter 5
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