India, Indonesia and Papua New Guinea, all Asia-Pacific nations, all share the motto “Unity in Diversity”. Further afield, South Africa and the European Union subscribe to the same philosophy. Does Asian diabetes merit the same label? 

The syndrome of diabetes mellitus covers a broad-spectrum of clinical conditions.¹ Though united by their degree of dysglycemia, they represent a wide variety of causative factors, clinical presentations, comorbid conditions, confounding issues, complications and consequences. Add to this, the diversity and dynamism of a continent as huge as Asia, and we have a situation tailor-made to create confusion and chaos.

Asian Phenotypes of Diabetes

Diligent researchers and astute clinicians, however, have been able to connect the dots, to describe what are termed the “Asian phenotypes” of diabetes. These descriptions create a framework, which allows easier suspicion, screening and substantiation of the disease, as well as more efficient selection of interventions and supervision of therapy.

The clinical features that characterize the Asian diabetes phenotype include a low body mass index with increased visceral fat, associated metabolic and inflammatory dysfunction, along with insufficient beta cell response.² These have been reported from Eastern Asian as well as South Asian cohorts.^3,4 The relatively higher rate of childhood obesity, young-onset type 2 diabetes and gestational diabetes mellitus, along with greater risk of progression to renal disease and cancer has been noted.² Recent advances in technology have facilitated identification of clusters of diabetes, based upon age, insulin deficiency and insulin resistance.⁵

All these developments are welcome, as they contribute to the streamlining of diabetes care in our continent. Chan et al highlight the various challenges posed by the Asian diabetes epidemic, including biomedical and psychosocial realities. They also go on to explore multiple opportunities that this opens up, to ensure better health.²

Forgotten Phenotypes

Much more, however, needs to be done to characterize the myriad forms of diabetes and its complications that are endemic to Asia. The World Health Organization (WHO) now lists “hybrid diabetes” in its classification of syndrome.⁶ Such types of diabetes, variously known as type 1.5 diabetes, Flatbush diabetes and double diabetes are common in Asia. Pancreatic diabetes, earlier known as fibrocalculous pancreatic diabetes, also occurs in certain geographical areas.⁷ Malnutrition-related diabetes mellitus, which was recognized as a distinct entity till a few decades ago, has not disappeared entirely.⁸ 

Complications of diabetes, that owe their occurrence to suboptimal healthcare, are also reported from Asia. Examples include Mauriac syndrome and syndrome of limited joint mobility in type 1 diabetes,⁹ as well as premature vascular complications in type 2 diabetes. Various challenges of diabetes are also unique to certain parts of Asia. Examples include the challenge in managing persons living with diabetes who wish to fast during religious occasions such as Ramadan, Buddhist Lent and Hindu or Jain festivals. Endemic forms of hypoglycemic encephalopathy such as litchi-associated encephalopathy, also exist in the continent.¹⁰

United We Stand

Modern diagnostics and therapeutics have enhanced our ability to manage diabetes.¹¹ These must be coupled, however, with an emphasis on public awareness and social marketing of the importance of diabetes care. These activities along with advocacy, will fuel a demand for diabetes care services. Policymakers, politicians, payers, pharmaceuticals and the physician fraternity will automatically step in to fill the gap and offer quality care.¹²

We aim to make Asia the Diabetes Care Capital of the world.

References

1. Draznin B, Aroda VR, Bakris G, Benson G, Brown FM, Freeman R, et al. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2022. Diabetes Care. 2022;45(Suppl 1):S17-38.
2. Chan JCN, Yeung R, Luk A. The Asian diabetes phenotypes: challenges and opportunities. Diabetes Res Clin Pract. 2014;105(1):135-9.
3. Chan JCY, Chee ML, Tan NYQ, Cheng CY, Wong TY, Sabanayagam C. Differential effect of body mass index on the incidence of diabetes and diabetic retinopathy in two Asian populations. Nutr Diabetes. 2018;8(1):16.
4. Anjana RM, Baskar V, Nair ATN, Jebarani S, Siddiqui MK, Pradeepa R, et al. Novel subgroups of type 2 diabetes and their association with microvascular outcomes in an Asian Indian population: a data-driven cluster analysis: the INSPIRED study. BMJ Open Diab Res Care. 2020;8(1):e001506.
5. Anjana RM, Pradeepa R, Unnikrishnan R, Tiwaskar M, Aravind SR, Saboo B, et al. New and unique clusters of type 2 diabetes identified in Indians. J Assoc Physicians India. 2021;69(2):58-61.
6. HEARTS D: diagnosis and management of type 2 diabetes. Available at: https://www.who.int/publications/i/item/who-ucn-ncd-20.1. Last accessed February 12, 2022.
7. Kumaran S, Unnikrishnan AG. Fibrocalculous pancreatic diabetes. J Diabetes Complications. 2021;35(1):107627.
8. Balcha SA, Phillips DIW, Trimble ER. Type 1 diabetes in a resource-poor setting: malnutrition related, malnutrition modified, or just diabetes? Curr Diab Rep. 2018;18(7):47.
9. Nagesh VS, Kalra S. Type 1 diabetes: syndromes in resource-challenged settings. J Pak Med Assoc. 2015;65(6):681-5.
10. Kalra S, Arora V, Kapoor N. Endemic syndromes associated with diabetes - A call for awareness, recognition and management in India and beyond. J Pak Med Assoc. 2021;71(8):2093-6.
11. Kalra S, Baruah MP, Kalra B. Diabetes care: evolution of philosophy. Indian J Endocrinol Metab. 2017;21(4):495-7.
12. Wangnoo SK, Maji D, Das AK, Rao PV, Moses A, Sethi B,et al. Barriers and solutions to diabetes management: an Indian perspective. Indian J Endocrinol Metab. 2013;17(4):594-601.