MedicalResearch.com Interview with:
Juliana CN Chan MD
Chair Professor of Medicine and Therapeutics
Head, Division of Clinical Pharmacology, Department of Medicine and Therapeutics
Director, Hong Kong Institute of Diabetes and Obesity
Director, Clinical Research Management Office
Faculty of Medicine
The Chinese University of Hong Kong
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: The prevalence of young onset diabetes (YOD) is increasing world-wide with doubling of its prevalence in the last 10 years in many developed nations. Using the Hong Kong Diabetes Register established since 1995, we first reported that 1 in 5 Chinese adults with diabetes were diagnosed before the age of 40 years. These young patients had poor control of multiple risk factors with 1.5 fold higher risk of premature death and cardiovascular-renal complications compared to patients with usual onset of diabetes after the age of 40 (Chan JC et al AJM 2014, Luk A et al Diabetes Care 2014). Due to the multisystem nature of diabetes, we asked the question whether these young patients might have recurrent hospitalizations during their 3-4 decades of complex clinical course.
Using a territory-wide diabetes database involving 0.42 million people followed up between 2002 and 2014, we compared the hospitalization rates accrued till the age of 75 years and found that patients with young onset diabetes had the highest hospitalization rates by attained age. Compared to patients with usual onset of diabetes, patients with YOD had 1.8- 6.7 higher risk of hospitalizations due to all-causes, notably renal disease compared to those with usual onset of disease.
Amongst patients with young onset diabetes, over one-third of the bed-days were due to mental illness before the age of 40 years. We used mathematical modeling and estimated that intensified risk factor control in YOD can reduce the cumulative bed-days by 30% which can be further reduced by delaying the onset of diabetes. These original data is a wakening call to the community regarding the complex nature of YOD involving interactions amongst environment, lifestyles and personal factors (e.g. genetics, education and socioeconomic status) and the biomedical-psychological-behavioral needs of these high risk population, which if undiagnosed, untreated or suboptimally managed, can have huge economic impacts on health care system and loss of societal productivity, leaving personal suffering aside.
MedicalResearch.com: What should readers take away from your report?
Response: There are many paradoxes in diabetes. Due to their long disease duration, young patients pose considerably larger burden on the health care system compared to usual-onset diabetes. While aging is a major healthcare challenge, more emphasis should be put on protecting the young people with or at risk of having diabetes which can lead to major direct and indirect healthcare costs. The earlier we manage diabetes, the easier it is. However, the young age can be deceptive with both patients and providers showing complacency during the newly diagnosed golden period when treatment can be highly effective. Diabetes management is relatively inexpensive compared to the long term costs of hospitalizations and complications but most of the resources are put in hospital care and not preventive care. There are now many innovations such as monitoring devices and insulin pumps which may be most beneficial to these young patients but are often not covered or reimbursed.
Technology aside, young onset diabetes is complex and their multiple needs cannot be managed by one single discipline. These young patients often have insulin insufficiency worsened by obesity and inflammation where clearer classification is needed to guide treatment along with intensive education in order to empower these patients early and help them cope with this life long condition.
MedicalResearch.com: What recommendations do you have for future research as a result of this work?
Response: Management of young onset diabetes is complex. Currently, many of these young patients receive fragmented care in a health care setting with scarce resources or are not covered adequately for these multiple needs. The lack of evidence and treatment guidelines make the care of these subjects often random and subjective based on providers’ experiences and perspectives. Urbanization, obesity, age and family history are the main risk factors of diabetes. Many of these young patients, especially if lean, may simultaneously carry autoimmune, common and uncommon genetic variants, most of which are implicated in beta cell biology, calling for early use of insulin.
On the other hand, some of these patients may carry rare genetic variants of maturity onset diabetes of the young (MODY) who may benefit from sulphonylureas and may not need early insulin. Thus, using biogenetic markers including C peptide and autoimmune antibodies may help providers start a meaningful dialogue to motivate behavioral change and personalize treatment. However, settings, time and efforts are needed to nurture a provider-patient relationship and reduce the psychological burden that comes with a diagnosis of chronic condition in a young person and the multiple demands including long term follow up, changing lifestyle and taking multiple medications. It is also important to note that these young individuals often have competing priorities, e.g. establishing their career, gaining financial independence, child raising.
Due to the lack of symptoms and multiple barriers (e.g. taking time off work, frequent travelling, treatment costs), many of them default or do not change lifestyle or have poor drug adherence leading to poor control. Thus, by combining the expertise of specialists, family doctors, allied healthcare professionals augmented by information technology, biogenetic testing and peer supporters with ongoing social, educational and professional support may increase the accessibility, affordability and cost-effectiveness of these care models, which will need to be adapted, tested and evaluated.
MedicalResearch.com: Is there anything else you would like to add?
Response: Between 1990 and 2000, surveys conducted in USA, UK and Japan have reported 8-10 fold increased prevalence of YOD arbitrarily defined as age of diagnosis <35-45 which coincides with women’s reproductive age highlighting the potential impact of maternal diabetes on the offspring, who are also at high risk of developing YOD, thus, diabetes begetting diabetes. In USA, recent surveys have found that while the overall outcomes, e.g. death rates and event rates of heart disease and leg amputations have improved in the middle-aged and elderly population with diabetes, this is not the case in young people who continue to have poor outcomes including re-appearance of leg ulcers and amputations. Diabetes is now the number 1 cause of dialysis, accounting for 50-60% of all new cases of kidney failure. In Hong Kong, the fastest rate of increase of kidney failure occurs in the 40-50 years highlighting the impact of age of onset. Unlike type 1 diabetes who have severe insulin deficiency and are not likely to be missed or default due to their tendency to develop emergencies with high blood glucose and ketoacidosis, the insidious nature of young onset diabetes often results in delayed diagnosis and treatment.
In the final analysis, we are living in a high risk environment, in part driven by urbanization, and people, young or old, can be affected by diabetes. School education, professional training, government policies and corporate social responsibilities are called for to address this alarming issue affecting our global citizens and to formulate action plans focusing on community education, early intervention and holistic care in order to make our healthcare system sustainable, to reduce complications, premature death or hospitalization rates for enhancing our quality of life.
Professor Juliana Chan is the Director, Hong Kong Institute of Diabetes and Obesity of The Chinese University of Hong Kong, Chief Executive Officer (pro-bono) of the Asia Diabetes Foundation, a non profit research organization that develops and administers the web-based Joint Asia Diabetes Evaluation (JADE) Program and Founding Director of GemVCare, a biotech company established through a incubation scheme of the HKSAR Government, which provides genetic testing service to predict, prevent and personalize diabetes care.
Ke C, Lau E, Shah BR, Stukel TA, Ma RC, So W, et al. Excess Burden of Mental Illness and Hospitalization in Young-Onset Type 2 Diabetes: A Population-Based Cohort Study. Ann Intern Med. [Epub ahead of print ] doi: 10.7326/M18-1900
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