中文译文漏掉了后半部分，英文的原文在此

The Lancet, Volume 379, Issue 9833, Pages 2227 - 2228, 16 June 2012

<Previous Article|Next Article>

doi:10.1016/S0140-6736(12)60963-5Cite or Link Using DOI

Diabetes saps health and wealth from China's rise

Ted Alcorn , Yadan Ouyang

Rapid economic change in China is propelling a wave of diabetes that health professionals and the public and are only beginning to wake up to. Ted Alcorn and Yadan Ouyang report.

Treatment for diabetes has changed dramatically over the past 40 years in China, and no one knows this better than Wang Wenying. Now retired from her government job but as active and gregarious as ever, the 76-year-old remembers the onset of her type 2 diabetes back in 1974, before she had been diagnosed. At that time she weighed 15 kg more than she does today, and she had begun suffering from fainting spells and often felt thirsty. “There's nothing wrong with you: it's a blessing that you eat a lot and are gaining weight”, she recalls the doctor saying. “Now I've realised that it's a suffering, not a blessing”, she says.

This is the paradox of diabetes in China: the epidemic is a direct byproduct of the country's rapid increase in prosperity, and many of the factors contributing to it are luxuries the Chinese have worked a lifetime to achieve. Rising household incomes have allowed Chinese citizens to eat more and to shift to foods that are higher in fats and sugars. As rural residents relocate to cities, many adopt more sedentary lifestyles. And in embracing a market-based economy, they have also taken on many daily stressors that come with it. Frank Hu, a professor of nutrition and epidemiology at Harvard University, MA, USA, says that all of these factors are at work in China. “It's a perfect storm”, he says.

At the time of Wang's diagnosis in 1974, fewer than one in 150 of China's citizens had developed the disease. But during the intervening decades the number of diabetics in the country has multiplied more than tenfold. Recent national surveys suggest that one in ten Chinese now have diabetes, and among those aged 60 years and older, the prevalence is closer to one in five. When Wang joins a dozen friends for dinner in the evening, four of them bring their insulin-injection pens. Hu is especially alarmed to observe that the increasing prevalence of childhood obesity in China has outpaced the growth in western countries. “It's possible that the prevalence of diabetes will be even greater for the next generation.”

The ramifications for China's health system are enormous. Non-communicable diseases account for two-thirds of China's disease burden and the World Bank describes them as “China's number one health threat”. Among them, diabetes is the most prevalent.

Chronic conditions like diabetes are also disproportionately costly because they require daily treatment in perpetuity. The International Diabetes Federation estimated that in 2010, 13% of China's health expenditures—US$25 billion—was attributable to diabetes. And if the country's total health expenditures grow an additional 50% over the next 5 years as expected, the World Bank says it will “significantly undermine” China's efforts to expand health insurance coverage, while increasing the odds of a future slowdown in economic growth.

Of course, Chinese diabetics are getting something in return for all of those additional outlays. Back in the 1970s, even after her diabetes diagnosis, Wang could obtain little information about her condition and resorted to fasting to control her symptoms. Each day after work, she mixed a few drops of urine with testing solution and boiled it over a kerosene lamp to check her blood-sugar levels. Today she has a detailed understanding of the importance of maintaining a stable blood glucose level, and technology is available to help her do so. She tests her blood daily with a glucose strip, purchases sugar-free foods, and takes oral drugs to keep her blood glucose in a healthy equilibrium.

Where Wang and the Chinese Government see an expense, the private sector sees a business opportunity. In fact, Wang and her peers are now one of the most aggressively courted groups of diabetics in the world. Global Business Intelligence valued the Chinese market for diabetes treatment at $1·5 billion in 2011, and although this still represents a small fraction of global sales, with one in four diabetics on earth now in China, it won't remain that way for long. Barclays Equity Research estimates that over the next 10 years, 29% of global growth in diabetes treatment will take place in China.

Full-size image (87K) Ted Alcorn

Rising household incomes have led Chinese citizens to buy fatty and sugary foods

Drug companies are expanding their facilities to meet the anticipated demand. In January, China's Zhuhai Labs announced that it would build a new $151 million production facility, and in May, the French pharmaceutical giant Sanofi inaugurated a $90 million assembly plant in Beijing for the manufacture of pre-filled insulin-injection pens. Both are dwarfed by the latest investment of the market-leader, Danish firm Novo Nordisk, which sells 63% of the insulin consumed in China. The company is building a formulation and filling plant in Tianjin for $400 million. When completed, it will be the largest in the world, but Ron Christie, who heads commercial business in China for Novo Nordisk, cautions that even this facility may not satisfy Chinese demand. “If every diabetic patient was treated and treated properly, we'd need a couple of these factories. It's a question of how fast the market evolves.”

Aided by public policy and also by their own rising incomes, Chinese consumers are increasingly able to afford the products manufactured by these companies. Major reforms to the Chinese health-care system over the past 3 years have extended insurance coverage to nearly every citizen and increased the availability of basic drugs, including insulin, in rural areas. Because the reimbursement rates for diabetes treatment vary by province and by insurance scheme, coverage is still highly unequal across the population. But observers generally agree that affordability isn't as big an obstacle to obtaining care as is unfamiliarity with the disease, amongst both practitioners and patients.

Wang has become quite knowledgeable about diabetes in the 38 years she has managed her own condition, but most people lack her experience, even urbane residents of Beijing. She recalls how when a neighbour complained of a recurrent foot infection, she recognised it might be a symptom of diabetes and instructed the neighbour to get tested immediately. The neighbour was sceptical but a doctor later confirmed the diagnosis, before amputating two of her toes.

60% of Chinese diabetics are like Wang's neighbour: they have developed the disease but don't yet know it. By contrast, 20% of diabetics in the USA are undiagnosed. This is part of the reason why China's rate of hospital admissions for acute complications of diabetes is three times higher than that of the USA. Delayed treatment invariably requires more invasive care, at greater cost, and with worse outcomes.

Drug companies and the government thus share an interest in educating the public about diabetes, since it will expand the market for therapies while lowering overall health-care costs. In large and medium cities across China, they are collaborating to provide educational programmes for physicians and patients. But national objectives are thus far modest: the latest National Plan for Non-Communicable Disease Prevention and Control calls for providing 40% of the country's diabetics with standard treatment by 2015 and achieving good blood glucose control in 60% of that group. Even if those goals are met, only one in four Chinese diabetics will be effectively controlling their disease.

In addition to expanding care, China may have to reshape the way physicians and patients relate to one another if the epidemic is to be brought under control. Jason Mann, a physician who grew up in China and now heads China Healthcare at Barclays Equity Research, says that doctors in China typically examine and diagnose patients based on their chief complaints but rarely take a proactive approach to managing other observed risk factors. “In an environment where the patient has very limited experience with or awareness of diabetes, this sets you up for a silent epidemic.” In the next 5 years, he hopes that China's health-care system will begin to shift away from its current hospital-centric form towards a primary health care model in which patients develop a relationship with a single physician who helps them manage their health in the longer-term. A family-doctor programme launched in Jiangsu province in February indicates that the government may be exploring this direction.

Better diagnosis and treatment will improve outcomes for the tens of millions of Chinese that have already developed diabetes, but staunching the torrent of new cases demands changes outside of the health sector, in areas that pit the government and commerce against one another. Taxes deterring the consumption of unhealthy foods or campaigns encouraging the population to get additional exercise would not be unprecedented in China, where the state often wields a heavy hand in the lives of the population. But the government has shown little appetite for experimenting with such tactics in the case of diabetes, perhaps because the factors contributing to the epidemic are so intertwined with economic growth, its most cherished objective.

For now, prevention efforts are few and fragmentary. Last year, the government deepened its national healthy lifestyle campaign and pilot projects are underway in areas across the country to improve non-communicable disease prevention by strengthening disease surveillance, educating the population about chronic disease, and standardising care. Chen Wei, newly elected Director-General of the Beijing Diabetes Prevention and Treatment Association, says that the efforts demonstrate vision but not action. “In my opinion, it hasn't been carried out satisfactorily—that is to say, they have ideas but haven't turned them into practice.”