The current state of diabetes management in Taiwan

Diabetes Research and Clinical Practice 54 Suppl. 1 (2001) S55– S65 www.elsevier.com/locate/diabres

The current state of diabetes management in Taiwan L.M. Chuang a, S.T. Tsai b, B.Y. Huang c, T.Y. Tai a,*, The DIABCARE (Taiwan) Study Group 1 a

Department of Internal Medicine, National Taiwan Uni6ersity Hospital, 7 Chung-Shan South Road, Taipei 10018, Taiwan, ROC b Department of Internal Medicine, Veterans General Hospital, Taipei, Taiwan, ROC c Department of Internal Medicine, Chang-Gung Memorial Hospital, Kee-Lung, Taiwan, ROC

Abstract The aim of this study was to provide an overview of diabetes management and complication status in Taiwan. A cohort of 2446 patients (from 25 diabetic centers) with more than 12 months of diabetes management participated and data were collected by interviews and reviewing the medical records. Overall, 97% were diagnosed as type 2 diabetes, with a mean age ( 9 S.D.) of 61.6 911.3 years, duration of diabetes of 10.3 9 7.3 years and age at onset of diabetes of 51.5 911.8 years. Mean BMI was 25.1 9 3.6 kg/m2 and about 50% had BMI \ 25 kg/m2. Majority (75%) were treated with oral hypoglycemic agents (OHAs), 14% with insulin and 10% with combination of insulin and OHA. Mean HbA1c was 8.1 91.6% and 59% had HbA1c \ 7.4% (1% above the upper limit of normal range, 4.7–6.4%). Mean FBG was 9.0 9 3.3 mmol/l and 59% had FBG \ 7.8 mmol/l. Of all the patients who had screening for complications, cataract (38%), neuropathy (30%), proteinuria (17%) and stroke (6%) were the most frequently reported eye, feet, kidney and late complications. We conclude that the majority of patients involved in this study had unsatisfactory glycaemic control which may lead to diabetes complications. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Diabetes mellitus; Glycaemic/metabolic control; Diabetic complications

1. Introduction Diabetes mellitus is a chronic metabolic disease with major implications globally. In 1997, an

estimated 2.1% of the global population had diabetes [1]. Increasing prevalence [2] of diabetes mellitus is a general trend and is a warning of the extent of the impact of this disease on the devel-

* Corresponding author. Tel./fax: + 886-2-232-22169. E-mail address: [email protected] (T.Y. Tai). 1 The participating centers: National Taiwan University Hospital, Veterans General Hospital, Tri-Service Military General Hospital, Mackey Memorial Hospital, Taipei Chang-Gung Memorial Hospital, Cathay General Hospital, Municipal Chung Shin Hospital, Kee-Lung Chang-Gung Memorial Hospital, Fareast Memorial Hospital, Tien Medical Centre Hospital, Shin Kong Wu Ho-Su Memorial Hospital, Lin Ko Chang-Gung Memorial Hospital, Provincial Tao Yuan Hospital, Provincial Hsin Chu Hospital, Taichung Veterans General Hospital, China Medical College Hospital, Changhua Christian Hospital, Chia Yi Christ Hospital, Cheng Kung University Hospital, Chi May Hospital, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung Veterans General Hospital, Kaohsiung Medical college Hospital, Per Ai General Hospital, Saint Mun Hospital. 0168-8227/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 8 - 8 2 2 7 ( 0 1 ) 0 0 3 1 0 - 2

S56

L.M. Chuang et al. / Diabetes Research and Clinical Practice 54 Suppl. 1 (2001) S55– S65

opment of nations economically and sociomedically. In particular, there are more than 50 million people with diabetes in Asia and the numbers of diabetes cases are expected to double in Asia over the next 10 years. In Taiwan, diabetes was the fifth leading cause of death since 1988. In a short span of less than 20 years, the mortality rate from diabetes in Taiwan has seen an increase from 7.91/100 000 [3] in 1980 to 34.67/100 000 [4] in 1997. According to a 1992 survey, the prevalence of diabetes mellitus in the aged over 30 years was 12.4% in Pu-Li, a rural area in central Taiwan [5]. Associated with the disease are the various diabetes complications, such as arteriosclerosis, retinopathy with potential loss of vision, nephropathy leading to renal failure, peripheral neuropathy with risk of foot complications. The results of the Diabetes Control and Complications Trial had shown that with good glycaemic control, the development of diabetic complications could be delayed or prevented [6]. Successful management of diabetes mellitus can only be accomplished when patients receive comprehensive preventive and therapeutic medical care, and glycaemic control is one of the key components. The fundamental to any diabetes management program is the establishment of a reliable baseline status of the disease. In Asia, a ‘DiabcareAsia’ project similar to the DIABCARE project established in Europe several years ago was designed to provide large scale, simple yet standardized information for patients from numerous centers. The Diabcare-Asia project was a collaborative study between Novo Nordisk Asia Pacific Center and participating Asian countries working through national diabetes associations. The objectives were to describe as well as investigate the relationship between the diabetes control, diabetes management and complications status in the diabetes population of each participating country. It was also the aim of this study to provide a means of measuring the quality of diabetes management. This paper presents the outcome of the data collection for the Taiwan diabetes population.

2. Materials and methods

2.1. Study design The study was carried out in 25 diabetes centers between 1 October 1998 and 27 November 1998. Data were recorded in the Diabcare-Asia Data Collection Forms (DCFs) provided for each patient. All data were obtained in each diabetes center by reviewing the patients’ medical records. Data collected included information on patient demography, type of diabetes, frequency and nature of educational interventions received, cardiovascular risk factors (blood pressure, lipids, BMI, smoking history and drinking habits), glycaemic control [HbA1c and fasting blood glucose (FBG)], monitoring of renal function (serum creatinine, microalbuminuria and proteinuria), eye and feet examination in the past 12 months, chronic and severe late complications, diabetes management and self-monitoring (blood and urine glucose).

2.2. Data collection method This was a prospective study and data were recorded in DCFs provided by Novo Nordisk Asia Pacific Center for each patient. Each center in Taiwan contributed all the data that they had available for the patients. Data were obtained by interview and laboratory assessments, as well as clinical examinations as they appeared in patient medical records. Blood samples for centralized HbA1c measurements were obtained by finger prick for all patients recruited and assayed by Bio-Rad referral laboratory (Department of Clinical Pathology in Taipei Municipal Chung-Hsiao Hospital). The VARIANT A1c program was used for the assay, with the 95% confidence limit being 4.7 –6.4%. Data field was left blank if no data were available.

2.3. Study population The study population included all patients registered in that clinic center for the management of diabetes for more than 12 months. The

L.M. Chuang et al. / Diabetes Research and Clinical Practice 54 Suppl. 1 (2001) S55– S65

diabetes clinic was defined as any clinic that had more than 100 diabetic patients per month. Depending on the type of participating diabetes clinics (restructured hospital or primary health care institutes), the recruitment of patients were carried out in such a way that was representative of the diabetic patient population. About 100 patients were recruited from each participating clinic. Data were obtained from patients visiting each center from 1 October to 27 November 1998.

2.4. Data handling and statistical analysis Data were entered into a Statistical Analysis System (SAS, Version 6.12, SAS Institute Inc USA) by electronic scanning and a data entry program was used to validate data quality and generate reports on missing/inconsistent/invalid data. All data were tabulated and presented as appropriate for the type of data. Subgroups were carried out according to type of diabetes and duration of diabetes. Only descriptive statistical analyses were performed.

3. Results

3.1. Patient demographic and characteristics The number of patients participating in 25 centers was 2509, out of which 63 (2.4%) were excluded from statistical analysis due to missing data on basic patient information such as ‘birth date’, ‘visit date’, ‘sex’ and ‘clinic since’. Hence, the final study cohort consisted of 2446 patients. The baseline demographics of patients are shown in Table 1. Majority of patients (97.1%) recruited in this study were diagnosed as type 2 diabetes. The overall mean age of patients was 61.6 911.3 years with majority (51.3%) of patients in the age group 55–70 years. The overall duration of diabetes was 10.397.3 years and mean age at onset of diabetes was 51.59 11.8 years. Overall, mean BMI was 25.193.6 kg/m2 and 53% of patients had BMI525 kg/m2. The proportion of patients with systolic blood pressure \140 mmHg and diastolic blood pressure

S57

\ 90 mmHg was 32 and 10%, respectively. Majority of patients were non-smoker (84%) and nonalcohol drinkers (93%).

Table 1 Clinical characteristics of patients Variable Age (years) N (%)* Mean9 S.D. B15 (%)** 15–30 (%)** 30–40 (%)** 40–45 (%)** 45–55 (%)** 55–70 (%)** ]70 (%)**

2446 (100%) 61.6 911.3 0% 1.1% 2.8% 4.1% 15.6% 51.3% 25.1%

Age at onset (years) N (%)* Mean9S.D.

2437 (99.6%) 51.5 9 11.8

Duration of diabetes (years) N (%)* Mean9S.D.

2437 (99.6%) 10.3 9 7.3

Type of diabetes N (%)* Type 1 (%)** Type 2 (%)** Others (%)**

2440 (99.8%) 1.8% 97.1% 0.2%

Body mass index (kg/m 2) N (%)* Mean9S.D. 525 (%)** \25 (%)**

2425 (99.1%) 25.1 9 3.6 53.1% 46.9%

Smoker N (%)* Yes (%)** No (%)**

2418 (98.9%) 15.7% 84.3%

Alcohol drinker N (%)* Yes (%)** No (%)**

2392 (97.8%) 7.2% 92.8%

Diabetes treatment N (%)* Diet only (%)** Insulin only (%)** Insulin+OHA (%) OHA only (%) Others (%)

2439 (99.7%) 1.5% 13.7% 10.2% 74.7% 0.04%

* % of data available; ** % out of the data available.

S58

L.M. Chuang et al. / Diabetes Research and Clinical Practice 54 Suppl. 1 (2001) S55– S65

Fig. 1. HbA1c profiles— according to different guidelines.

3.2. Treatment The treatment regimen which patients received will be discussed for all patients as well as according to type of diabetes diagnosed. As shown in Table 1, majority (84.9%) of patients were treated with oral hypoglycaemic agents (OHAs) singly or in combination with insulin. In total, 23.9% of patients received insulin therapy and only 1.5% were treated with diet alone. Of all the patients who declared to use OHAs for treatment, majority (66.9%) used either two or more than two types of OHAs, 18.6% used sulphonylureas only and 14.5% used biguanides only. With respect to insulin usage, only 89.4% of type 1 patients were treated with insulin. The remaining 10.6% of type 1 patients were treated with OHAs only. As for type 2 patients, 22% were treated with insulin, 76.5% with OHAs only and 1.5% were on diet control.

3.3. Self-monitoring Based on the data available on glucose selfmonitoring, only 30% of patients practiced any form of self-monitoring. Of these patients, 87.4% had blood glucose monitoring, 6.6% had urine glucose monitoring and 6% had both blood and urine glucose monitoring (data not shown). The

frequency of self-monitoring was 9.6 times per month for blood glucose and 9.2 times per month for urine glucose (data not shown).

3.4. Glycaemic control All data outcome on glycaemic controls (HbA1c and FBG) will be discussed based on an overview and according to types of diabetes, duration of diabetes, BMI and age at onset of diabetes. Based on the central laboratory measurement, overall mean HbA1c value was 8.191.6%. When analyzed according to the upper limits of normal range (ULN), 40.7% of patients had HbA1c 5 7.4% (5 1% above ULN), 24% had HbA1c between 7.4 and 8.4% (1–2% above ULN) and 35.4% had HbA1c ] 8.4% (] 2% above ULN) (Fig. 1). When the HbA1c values were subgrouped according to the American Diabetes Association (ADA) [7], European (EU) [8] and Asia Pacific (AP) [9] diagnostic categories, majority of patients had unsatisfactory glycaemic control (as indicated by HbA1c\7% and \ 6.5%) (Fig. 1). Mean FBG level was 9.09 3.3 mmol/l and regardless of the diagnostic criteria (ADA, EU or AP) used, majority (59%) of patients had poor glycaemic control (FBG \ 7.8 mmol/l) (Fig. 2). Both mean HbA1c and FBG levels were higher in type 1 patients (8.791.8% and 10.29 4.6

L.M. Chuang et al. / Diabetes Research and Clinical Practice 54 Suppl. 1 (2001) S55– S65

mmol/l) when compared with type 2 patients (8.1 91.6% and 9.09 3.2 mmol/l). The ULN profiles for HbA1c levels show that more type 1 patients (67.2%) had HbA1c\7.4% (\1% above ULN) compared with 56.4% of type 2 patients (Table 2). Besides the ULN profiles, the three different diagnostic criteria (ADA, EU and AP) also indicate that the proportion of patients with unsatisfactory HbA1c control was much higher for type 1 patients than type 2 patients (Table 2). Similarly, the proportion of patients with FBG\ 7.8 mmol/l was relatively higher in type 1 patients (66%) than type 2 patients (59%) (Table 2). Table 3 shows the comparison of glycaemic control between different diabetes duration among type 2 diabetic patients. Data from type 1 patients were not presented due to the small number of patients in each diabetes duration subgroups. With increase in duration of diabetes, both mean HbA1c and FBG levels were increased. For the shorter duration of diabetes (1– 3 years), mean HbA1c and FBG values were 7.49 1.5% and 8.49 2.8 mmol/l, respectively, whereas with longer duration of diabetes (] 10 years), mean HbA1c and FBG values were 8.391.6% and 9.39 3.6 mmol/l. In addition, the proportions of patients with unsatisfactory glycaemic control (HbA1c \ 7.4% and FBG\ 7.8 mmol/l) were increased with longer duration of diabetes, from 36.1 to 67.2% (HbA1c) and from 46 to 63% (FBG).

S59

3.5. Lipid control All data outcome on metabolic controls of fasting lipids (triglyceride, total cholesterol and HDL cholesterol) will be discussed based on an overview and according to types of diabetes and duration of diabetes. The fasting lipid profile of diabetes patients are shown in Table 2. Of all patients for whom triglyceride (TG) assessment was available, majority (53%) had TGB 1.7 mmol/l (EU target for good metabolic control) while 29% had TG\ 2.2 mmol/l l (EU target for poor metabolic control). In addition, 56% of patients assessed had total cholesterol level B 5.2 mmol/l and 51% had HDL \ 1.1 mmol/l, all of which indicated that majority of patients had good metabolic control according to the EU diagnostic criteria. The proportions of patients with good metabolic control, as indicated by TGB 1.7 mmol/l, total cholesterol B5.2 mmol/l and HDL \ 1.1 mmol/l) were higher in type 1 patients than type 2 patients. As duration of diabetes increases, the proportions of type 2 patients with TG B1.7 mmol/l (indicative of good metabolic control) were highest in the 1–3 years and 5–7 years subgroups (Table 3). There was however, no observable difference in total cholesterol and HDL-cholesterol profiles between the various duration subgroups (Table 3).

Fig. 2. FBG profiles— according to different guidelines.

S60

L.M. Chuang et al. / Diabetes Research and Clinical Practice 54 Suppl. 1 (2001) S55– S65

Table 2 Metabolic control according to type of diabetes Assessment

HbA1c

Guideline

Upper limit of normal range, ULN

American diabetes association

European NIDDM policy group

Asia pacific NIDDM policy group

FBG

American diabetes association (ADA)

European NIDDM policy group (EU)

Asia pacific NIDDM policy group (AP)

Triglyceride

European NIDDM policy group (EU)

Total Cholesterol

European NIDDM policy group (EU)

HDL Cholesterol

European NIDDM policy group (EU)

3.6. Diabetes complications 3.6.1. Renal function Table 4 shows the renal function of diabetes patients. The total proportion of patients (10%) who had urine microalbuminuria screened was poor compared with serum creatinine (83%) and proteinuria (77%) screening. Overall, 4% had serum creatinine \ 180 mmol/l, 28% had microalbuminuria (20–300 mg/l excreted albumin) and 17% had proteinuria (\ 500 mg/24 h excreted protein). A comparison of the renal function of both type 1 and type 2 diabetes patients showed no considerable difference in the proportion of patients with serum creatinine \180 mmol/l or

Profile

57.4% 7.4–8.4% ]8.4% B7% 7-8% \8% B6.5% 6.5–7.5% \7.5% B7% 7–9% \9% B6.7 mmol/l 6.7–7.8 mmol/l \7.8 mmol/l B6.1 mmol/l 6.1–7.8 mmol/l \7.8 mmol/l B6.0 mmol/l 6.0–7.8 mmol/l \7.8 mmol/l B1.7 mmol/l 1.7–2.2 mmol/l \2.2 mmol/l B5.2 mmol/l 5.2–6.5 mmol/l \6.5 mmol/l B0.9 mmol/l 0.9–1.1 mmol/l \1.1 mmol/l

Proportion of patients (%) All patients

Type 1

Type 2

40.7 23.9 35.4 26.5 29.8 43.6 13.6 30.1 56.3 26.5 49.0 24.4 22.3 18.4 59.3 12.6 28.1 59.3 12.0 28.8 59.3 53.1 17.6 29.3 56.5 32.8 10.7 21.8 27.1 51.1

32.8 21.9 45.3 14.3 25.0 60.7 7.1 23.2 69.6 14.3 50.0 35.7 23.4 10.9 65.6 14.1 20.3 65.6 14.1 20.3 65.6 70.2 10.6 19.2 57.5 34.0 8.5 16.7 25.0 58.3

43.6 22.4 34.0 27.0 30.0 43.0 13.8 30.3 55.9 27.0 49.0 24.0 22.3 18.7 59.0 12.7 28.3 59.0 12.0 29.0 59.0 52.6 17.9 29.5 56.6 32.7 10.8 22.0 27.1 50.8

proteinuria. However, the proportion of patients who were presented with micro- and macro-albuminuria was higher for type 2 patients (32%) than type 1 patients (10%). With longer duration of diabetes, the proportions of patients with serum creatinine level \ 180 mmol/l, microalbuminuria, macroalbuminuria and proteinuria were all increased.

3.6.2. Eye complication Eye complications examination included screening for photocoagulation, cataract, retinopathy and advanced eye disease (Table 4). Overall, cataract (38%) was most commonly reported, followed by retinopathy (31%), photocoagulation

L.M. Chuang et al. / Diabetes Research and Clinical Practice 54 Suppl. 1 (2001) S55– S65

S61

(9%) and advanced eye disease (7%). Among type 1 patients, retinopathy (41%) was the most common whereas in type 2 patients, cataract (39%) was the most common. The frequencies of all eye complications were increased with respect to the increase in duration of diabetes. In particular, the frequencies of cataract and retinopathy showed marked increases, from 29 to 46% and from 13 to 42% (Table 5).

pattern was seen for both type 1 and type 2 patients. The frequencies of late complications (except stroke) were comparable between all duration subgroups whilst the frequency of stroke was raised from 3 to 7% as duration of diabetes increased (Table 5).

3.6.3. Feet complications Feet complications examination included screening for foot pulse, healed ulcer, acute ulcer/ gangrene, neuropathy and leg angioplasty (Table 4). Overall reported frequencies of feet complications were low (ranging from 0 to 30%) and the most common being neuropathy (30%). Similar pattern was seen for both type 1 and type 2 patients. With respect to the increase duration of diabetes, the frequencies of healed ulcer and neuropathy were increased, from 1 to 6% and from 13 to 42%, respectively (Table 5).

During the past few years, there has been a growing awareness of the increasing prevalence of diabetes as well as the direct and indirect health care cost for diabetes to the society. Considerable efforts have also been undertaken by the scientists and healthcare professionals in conducting clinical and epidemiological studies, health education and patient management and intervention programs. Here, we presented our recent findings on the diabetes control, management and complication status in a wider scope of Taiwanese patient population. This multicenter study inevitably suffers from the drawback that not all centers could comply with the recruitment strategy outlined in the protocol, leading to a potential bias in selecting patients with better diabetes management— better blood glucose control, more comprehensive screening and treatment of complications, in some centers. In addition, only major diabetes centers within Taiwan were involved in this study. Thus,

3.6.4. Se6ere late complications Severe late complications examined were legal blindness, myocardial infarction/coronary artery bypass graft/angioplasty (MI/CABG/angioplasty), cerebral stroke, renal failure and leg amputation (Table 4). The most frequently reported late complication was stroke (6%) and similar

4. Discussion

Table 3 Glycemic control according to duration of diabetes ]10 years

1–3 years

3–5 years

5–7 years

7–10 years

HbA1c assessment N Mean 9 S.D. 57.4% (%) 7.4–8.4% (%) ]8.4% (%)

130 7.49 1.5 64% 17% 19%

334 7.7 9 1.7 54% 19% 27%

296 7.9 91.5 23% 31% 37%

362 8.1 9 1.6 37% 28% 35%

895 8.3 9 1.6 33% 26% 41%

FBG assessment N Mean9 S.D. B6.1 mmol/l (%) 6.1–7.8 mmol/l (%) \7.8 mmol/l (%)

153 8.49 2.8 10% 43% 46%

392 8.4 9 2.7 15% 35% 50%

332 8.8 9 2.8 13% 27% 60%

413 9.1 9 3.2 12% 26% 62%

1019 9.3 9 3.6 13% 24% 63%

N, number of patient data analysed.

S62

L.M. Chuang et al. / Diabetes Research and Clinical Practice 54 Suppl. 1 (2001) S55– S65

Table 4 Diabetic complications Complications

Renal function

Eye complications

Feet complications

Late complications

Proportion of patients (%)

Serum creatinine \180 mmol/l Microalbuminuria Macroalbuminuria Proteinuria Photocoagulation Cataract Retinopathy Advanced eye disease Absence of foot pulse Healed ulcer Acute ulcer Neuropathy Angioplasty Legal Blindness Myocardial infarction Stroke Renal Failure Leg amputation

All Patients (%)

Type 1 patients (%)

Type 2 patients (%)

4 38 2 17 9 38 31 7 0 5 1 30 0 1 4 6 1 1

4 10 0 18 11 22 41 5 0 8 3 20 0 3 2 3 1 1

4 29 3 175 9 39 31 7 0 4 1 30 0 1 4 6 1 1

data obtained from sampling in various diabetes centers could not be representative of the entire diabetes population in Taiwan and should be handled with care and reservations. Of the 2446 diabetic patients studied, majority (97.1%) were diagnosed with type 2 diabetes mellitus. The overall mean age was 61.69 11.3 years and the mean duration of diabetes was 10.39 7.3 years. As slightly more than half (53%) of the patients had BMI525 kg/m2, control of body weight appears to be satisfactory and majority were not overweight or obese, as judged by European standards. Using various diagnostic criteria, we showed that the majority of patients surveyed had unsatisfactory glycaemic control, as assessed by both centralized HbA1c and FBG measurements. Mean values of HbA1c and FBG were 8.19 1.6% and 9.09 3.3 mmol/l. In addition, selfmonitoring data was only available from 30% of patients, suggesting that majority (70%) might not have performed any blood glucose or urine glucose home monitoring. The lack of awareness of self-monitoring could be due to only a small proportion of patients being educated on self-

monitoring. Since increasing evidence has suggested an association between poor glycaemic control and an increased risk of development of both micro- and macro vascular complications in type 2 diabetes [10–15]. There is therefore a need to educate diabetes patients on the importance of self-monitoring in managing the disease. Screening for appearance of abnormal levels of albumin in urine was rarely performed in Taiwan, as indicated by the availability of data in only 10% of patients. Hence the data on proportion of patients presented with microalbuminuria should be interpreted with care. Data on frequency of complications showed that cataract (38%), neuropathy (30%) and stroke (6%) were the most common eye, feet and severe late complications. Since diabetic neuropathy has been reported to increase the risk for other complications including amputations and foot ulcers [16], screening programs for earliest stage of diabetic nephropathy (microalbuminuria) should be performed on a regular basis.

L.M. Chuang et al. / Diabetes Research and Clinical Practice 54 Suppl. 1 (2001) S55– S65

With a longer duration of diabetes, a deterioration in glycemic control as indicated by the increase in mean HbA1c and FBG levels was observed. Similarly, higher frequencies of diabetic complications (eyes, feet and severe late complications) were also characterized by longer diabetic duration. These results appear to suggest that

S63

duration of diabetes is a risk factor for diabetes complications, a finding similar to other reported literatures [17–20]. Given that onset of complications (e.g. retinopathy, neuropathy) is to occur much later prior to the diagnosis of type 2 diabetes, it is essential to maximize the effectiveness of the screening programs.

Table 5 Diabetic complications according to duration of diabetes Complications Eye

Feet

Severe late

Photocoagulation N Frequency (%) Cataract N Frequency (%) Retinopathy N Frequency (%) Advanced eye disease N Frequency (%) Absence of foot pulse N Frequency (%) Healed ulcer N Frequency (%) Acute ulcer/Gangrene N Frequency (%) Neuropathy N Frequency (%) Angioplasty N Frequency (%) Legal blindness N Frequency (%) MI/CABG/Angioplasty N Frequency (%) Cerebral stroke N Frequency (%) Renal failure N Frequency (%) Leg amputation N Frequency (%)

]10 years

1–3 years

3–5 years

5–7 years

7–10 years

135 1

340 4

286 4

381 6

943 15

107 29

283 29

252 32

348 37

897 46

104 13

286 16

254 21

342 25

878 42

107 4

288 4

256 3

348 4

892 11

142 0

356 0

291 0

377 0

910 0

147 1

371 3

306 3

403 5

984 6

147 1

371 1

306 0

403 1

983 2

147 13

375 18

307 20

400 27

974 42

147 1

371 0

306 0

402 0

983 1

154 0

394 0

335 2

420 2

1040 1

154 1

393 4

333 4

418 3

1037 4

154 3

393 4

333 4

420 6

1040 7

154 0

395 0

335 0

421 0

1040 1

154 0

394 1

335 0

420 1

1041 2

S64

L.M. Chuang et al. / Diabetes Research and Clinical Practice 54 Suppl. 1 (2001) S55– S65

5. Conclusions In conclusion, the current data present the status of diabetic control, management and complications in Taiwan. Results of the U.K. Prospective Diabetes Study Group [21,22] Steno Group [23] and Kumamoto trial [24,25] have reiterated that poor diabetic control over a long period of time contributes to chronic diabetic complications in type 2 diabetes. The Diabetes Control and Complications Trial (DCCT) [26] also clearly indicated that intensive glycaemic control in type 1 diabetes prevents and reduces diabetic complications. The Diabcare-Asia (Taiwan) data presented here indicates that most of the patients involved in this study had unsatisfactory glycemic control. This reinforces the needs for establishment and maintenance of quality diabetes management standards in Taiwan, improving the awareness among health professionals of the potential to retard the progression of major diabetic complications and providing intensive diabetes education programs.

Acknowledgements The authors would like to thank Denise H.C. Hung for the assistance and J.P. Yeo for her help in preparation of the manuscript. This study was made possible by a research grant provided generously by Novo Nordisk Asia Pacific Center, Singapore.

References [1] A.F. Amos, D.J. McCarty, P. Zimmet, The rising global burden of diabetes and its complications: estimates and projections to the year 2010, Diabetic Med. 14 (1997) S7 – S85. [2] The WHO national diabetes program initiative. Diab. Res. Clin. Pract. 34 (1996) (Suppl) S1-S6. [3] Department of Health, Health Statistics I. General health statistics, Taipei, Republic of China, Department of Health, Executive Yuan, 1980. [4] Department of Health, Health Statistics I. General health statistics, Taipei, Republic of China, Department of Health, Executive Yuan, 1997.

[5] P. Chou, C.L. Li, H.S. Kuo, K.J. Hsiao, S.T. Tsai, Comparison of the prevalence in two diabetes surveys in Pu-Li, Taiwan, 1987 – 1988 and 1991 – 1992, Diab. Res. Clin. Pract. 38 (1997) 61 – 67. [6] American Diabetes Association, Implications of the diabetes control and complications trial, Diabetes Care 21 (Suppl 1) (1998) S88 – S90. [7] American Diabetes Association, Standards of medical care for patients with diabetes mellitus, Diabetes Care 20 (Suppl 1) (1997) S5 – S13. [8] A desktop guide for the management of non-insulin-dependent diabetes mellitus (NIDDM). A contribution to the implementation of the St. Vincent Declaration. 1993. [9] Non-insulin dependent diabetes mellitus (NIDDM) practical targets and treatments. Asia-Pacific NIDDM Policy Group. 1995. [10] R. Klein, Hyperglycemia and microvascular and macrovascular disease in diabetes, Diabetes Care 18 (1995) 258 – 268. [11] M.I.J. Uusitupa, L.K. Niskanan, O. Siitonen, E. Voutilainen, K. Pyo¨ ra¨ la¨ , Ten-year cardiovascular mortality in relation to risk factors and abnormalities in lipoprotein composition in type 2 (non-insulin-dependent) diabetic and non-diabetic subjects, Diabetologia 36 (1993) 1175 – 1184. [12] D.K.G. Andersson, K. Sva¨ rdskudd, Long-term glycaemic control relates to mortality in type 2 diabetes, Diabetes Care 18 (1995) 1534 – 1543. [13] J. Kuusito, L. Mykka¨ nen, K. Pyo¨ ra¨ la¨ , M. Laakso, NIDDM and its metabolic control predict coronary heart disease in elderly subjects, Diabetes 43 (1994) 960 – 967. [14] M-A Gall, K. Borch-Johnsen, P. Hougaard, F.S. Nielsen, H.H. Parving, Albuminuria and poor glycaemic control predict mortality in NIDDM, Diabetes 44 (1995) 1303 – 1309. [15] S. Lehto, T. Ro¨ nnemaa, K. Pyo¨ ra¨ la¨ , M. Laakso, Predictors of stroke in middle-aged patients with non-insulin-dependent diabetes, Stroke 27 (1996) 63 – 68. [16] G.E. Reiber, R.E. Pecoraro, T.D. Koepsell, Risk factors for amputation in patients with diabetes mellitus: a case control study, Ann. Intern. Med. 117 (1992) 97 – 105. [17] M. Harris, R. Eastman, C. Cowie, Symptoms of sensory neuropathy in adults with NIDDM in the US population, Diabetes Care 16 (1993) 1446 – 1452. [18] M. Flynn, D. O’Brien, I.A. Corrall, The prevalence of autonomic and peipheral neuropathy in insulin-treated diabetic subjects, Diabet. Med. 12 (1995) 310 – 313. [19] H.U. Janka, J.H. Warram, L.I. Rand, A.S. Krolweski, Risk factors for progression of background retinopathy in long-standing IDDM, Diabetes 38 (1989) 460 – 464. [20] D.A. Infeld, J.G.O. Shea, Diabetic retinopathy, Postgrad. Med. J. 74 (1998) 129 – 133. [21] R.G. Bretzel, K. Voigt, H. Schatz, The United Kingdom Prospective Diabetes Study (UKPDS). Implications for the pharmacotherapy of type 2 diabetes mellitus, Exp. Clin. Endocrin. Diab. 106 (1998) 369 – 372. [22] UK Prospective Diabetes Study Group, Intensive blood-

L.M. Chuang et al. / Diabetes Research and Clinical Practice 54 Suppl. 1 (2001) S55– S65 glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33), Lancet 352 (1998) 837 – 853. [23] P. Gaede, P. Vedel, H.H. Parving, O. Pedersen, Intensified multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria; the Steno type 2 randomized study, Lancet 353 (1999) 617 –622. [24] Y. Ohkubo, H. Kishikawa, E. Araki, et al., Intensive insulin therapy prevents the progression of diabetic microvascular

S65

complications in Japanese patients with non-insulin-dependent diabetes mellitus: A randomized prospective 6-year study, Diab. Res. Clin. Pract. 28 (1995) 103 – 117. [25] M. Schichiri, Strict glycemic control and diabetic microvascular complications, Internal. Med. 36 (1997) 144 – 147. [26] The Diabetes Control and Complications Trial Research Group, The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus, New Engl. J. Med. 329 (1993) 977 – 986.