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

20

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).


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).


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.


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.


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.


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.


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

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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


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

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15-24 25-44 45-64 65-84

Age group

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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).


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

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Figure 3.5 Crude and age-adjusted* death rate for diabetes in Hong Kong, 1981-2007


0

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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



Figure3.6Age-adjusted*deathratesfordiabetes(per100,000),byagegroup,HongKong,1981-2007



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

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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

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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


Figure3.8Proportionofdeathswithdiabetesasprincipalcauseamongthepopulationaged65andabove,1981-2007


Whilethedeathratesfromdiabetesincreasedwithage,femaleshadhigherdeathratesthanmalesamongtheoldergroup(DepartmentofHealthofHongKongSpecialAdministrativeRegion,2005,2008a).In2007,mortalityratesfromdiabeteswere43.2per100,000formalesand56.5forfemalesaged65andabove(Table3.14).


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


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


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.


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.


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)


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).


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.


�� 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.


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.


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.


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.


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

100

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

enta

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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