What is Diabetes?

28 December 2006 Diabetes is a chronic disease that has no cure. Diabetes is a disease in which the body does not produce or properly use insulin, a hormone that is needed to convert sugar, starches, and other food into energy needed for daily life. The cause of diabetes is a mystery, although both genetics and environment appear to play roles. There are two major types of diabetes: Insulin-Dependent (type 1). An autoimmune disease in which the body does not produce any insulin, most often occurring in children and young adults. People with type 1 diabetes must take daily insulin injections to stay alive. Non-Insulin-Dependent (type 2). A metabolic disorder resulting from the body's inability to make enough or properly use insulin, it is the most common form of the disease. Who Is At Greater Risk For Type 1 Diabetes? y Siblings of people with type 1 diabetes. y Children of parents with type 1 diabetes. Who Is At Greater Risk For Type 2 Diabetes? y People with a family history of diabetes. y People who are overweight. y People who do not exercise regularly. y Women who have had a baby that weighed more than 9 pounds at birth. Warning Signs Of Diabetes Type 1 Diabetes: y Frequent urination. y Unusual thirst. y Extreme hunger. y Unusual weight loss. y Extreme fatigue. y Irritability. Type 2 Diabetes: Any of the type 1 symptoms, plus... y Frequent infections. y Blurred vision. y Cuts/bruises that are slow to heal. y Tingling/numbness in the hands or feet. y Recurring skin, gum, or bladder infections. Profile Of The Diagnosed There are nearly 1.2 million people in Malaysia who have diabetes. Diabetes is actually a general term for a number of separate but related disorders. These disorders fall into two main categories:

y type 1, which usually occurs during childhood or adolescence, and y type 2, the most common form of the disease, usually occurring after age 30. What is type 1 (insulin-dependent) diabetes? Type 1 (insulin-dependent) diabetes is a disease which results from the body's failure to produce insulin -- the hormone that "unlocks" the cells of the body, allowing glucose to enter and fuel them. This is most often the result of an autoimmune process in which the body's immune system attacks and destroys the insulin-producing cells of the pancreas. Since glucose cannot enter the cells, it builds up in the blood and the body's cells literally starve to death. People with type 1 diabetes must take daily insulin injections and regularly monitor blood sugar levels. There are an estimated 24,000 people with type 1 diabetes in Malaysia today. The risk of developing type 1 diabetes is higher than virtually all other severe chronic diseases of childhood. Peak incidence occurs during puberty, around 10 to 12 years old in girls and 12 to 14 years old in boys. The symptoms for type 1 diabetes can mimic the flu in children. Type 1 diabetes tends to run in families. Brothers and sisters of children with insulin-dependent diabetes have about a 10% chance, or a 20-fold increased risk, of developing the disease. The identical twin of a person with insulin-dependent (type 1) diabetes has at least 50 times the risk of developing type 1 diabetes than a child in an unaffected family. In type 1 diabetes, incidence is highest among whites. Scandinavian countries have the highest incidence in the world, approximately 30 cases per 100,000 children. What is type 2 (non-insulin-dependent) diabetes? Type 2 (non-insulin-dependent) diabetes results from the body's inability to make enough or properly use insulin. Often type 2 diabetes can be controlled through diet and exercise alone, but sometimes these are not enough and either oral medications or insulin must be used. The fact that few people with type 2 diabetes require insulin has led to the myth that this is a "mild" form of the disease. Of the nearly 1.2 million Malaysians with diabetes, more than 98% have type 2 diabetes. People with type 2 diabetes often develop the disease after age 30, but are not aware they have diabetes until treated for one of its serious complications. The risk for type 2 diabetes increases with age. Studies indicate that diabetes is generally under reported on death certificates, particularly in the cases of older persons with multiple chronic conditions such as heart disease and hypertension. Because of this, the toll of diabetes is believed to be much higher than officially reported. Diabetes In Youth How Are Young People Affected? The risk of developing type 1 diabetes is higher than virtually all other severe chronic diseases of childhood.

Peak incidence occurs during puberty, around 10 to 12 years old in girls and 12 to 14 years old in boys. Type 1 diabetes tends to run in families. Brothers and sisters of children with type 1 diabetes have about a 10 percent chance, or a 20-fold increased risk, of developing the disease. The identical twin of a person with type 1 diabetes has at least 50 times the risk of developing type 1 diabetes than a child in an unaffected family. In type 1 diabetes, incidence is highest among whites. Scandinavian countries have the highest incidence in the world, approximately 30 cases per 100,000 children. The symptoms for type 1 diabetes can mimic the flu in children. Diabetes And Seniors How Are Seniors Affected? Diabetes prevalence increases with increasing age. Approximately half of all diabetes cases occur in people older than 55. People with diabetes are more likely to be institutionalized in nursing homes than are people without diabetes.

Never too young

28 November 2008 By Prof Dr Mustaffa Eembong Obesity and physical inactivity are raising the risk of Type 2 diabetes in children today. Prof Dr Mustaffa Eembong tells us about the importance of early detection and the warning signs parents need to watch out for. Funilly enough, many people think that diabetes affects only fat or overweight adults, which is true to a certain extent. But it's no longer a laughing matter when they discover that this "mother of all diseases" is also one of the most common chronic diseases of childhood. Diabetes, in fact, can occur in children of any age, including toddlers and infants. And today, the number of children afflicted with this global epidemic is on the rise. The International Diabetes Federation (IDF) estimates each year, 65,000 children under the age of 15 develop Type 1 diabetes worldwide, with studies showing that Type 1 diabetes is growing by three per cent among children and adolescents and by five per cent among pre-school children. Of the estimated total of 430,000 prevalent cases of Type 1 diabetes at childhood, more than a quarter come from Southeast Asia. Type 2 diabetes, once regarded as an adult disease, is today increasing at a disturbing rate among children and adolescents. In Japan, according to the IDF, the number of children with Type 2 diabetes has doubled over a period of 20 years, making Type 2 diabetes among Japanese children more common than Type 1. This trend is not only limited to Japan, however, as childhood Type 2 diabetes has become the main kind in many parts of the world. Until recently, the only kind of diabetes frequent in children was Type 1 diabetes. Type 1, previously known as insulin-dependent or childhood-onset diabetes, occurs when the pancreas, as a result of immune destruction, produces very little or no insulin (the hormone that regulates the absorption of glucose into cells). Without daily insulin shots, Type 1 diabetes is usually rapidly fatal. Type 2 diabetes, where the pancreas is unable to produce enough insulin to overcome the body's resistance to insulin (insulin resistance), is the more common form of the disease. In Malaysia, this

usually occurs after the age of 30. But today, owing to the global rise of childhood obesity and physical inactivity, Type 2 diabetes (formerly called non-insulin-dependent or adult-onset) has become much more widespread among children in developed and developing countries. Most children with Type 2 diabetes have a family history of the disease. Research shows hat at least 75 per cent of children with Type 2 diabetes have a parent, brother or sister with the disease. However, it's not all to do with genes. Other factors that come into play include obesity or being overweight, insufficient exercise and unhealthy eating habits. Obesity is one of the major risk factors for Type 2 diabetes, especially when excess body fat is concentrated around the abdomen. Children who have reached puberty are also more likely to develop Type 2 diabetes compared with younger children, as insulin resistance normally increases about 30 per cent at puberty -- this possibly because of the effects of growth hormones. Gender plays a role as well, with girls being more prone to Type 2 diabetes than boys. Type 2 diabetes in young children is made more severe as a result of complications that may arise because of the longer duration of the disease and poor management. The earlier a child develops diabetes, the more likely he or she will have long-term health problems, such as diseases related to the eyes, heart, blood vessels, nerves and kidneys. Studies show that children with Type 2 diabetes will also develop the above-mentioned diabetes-related micro- and macro-vascular complications, just as in the case of adults. Diabetes also affects children mentally and physically more than adults. Their daily activities are disrupted by the need for medication and a close watch on their diet and physical activity. They also need to monitor their blood glucose level, leaving them often unable to indulge in the many childhood activities enjoyed by their friends. Children with Type 1 diabetes may not have the energy to fully concentrate in school. This lack of energy, coupled with increased fatigue and irritability, the need to have insulin shots and the frequent desire to go to the bathroom (when diabetes is not well-controlled), can affect their ability to study and mingle with friends. It can also make them feel lonely and different from other children. While children with Type 1 diabetes usually have obvious (and abrupt) symptoms, those with Type 2 may not notice many of the usual symptoms and the disease may develop slowly over a period of time. In fact, some children with Type 2 diabetes may not exhibit any symptoms or signs. While others may experience: * increased thirst * frequent urination * extreme hunger * weight loss * fatigue * blurred vision * slow-healing wounds/sores or frequent infections Some children (especially girls) with Type 2 diabetes may also have a dark patches of skin around the neck or in the armpits. This condition, called acanthosis nigricans, could be a sign of insulin resistance. It's important to keep in mind that not everyone with Type 2 diabetes develops these symptoms, and that not everyone with these signs necessarily has Type 2 diabetes. But if your child does exhibit any of these symptoms, it's best to consult a doctor immediately as early detection is crucial. It is also prudent to bring your child for a check up if he/she is at high risk of developing diabetes as a result of being overweight or obese, especially when there is a history of diabetes in the family. There's a reason why diabetes is called the "mother of all diseases". If left undetected or untreated at childhood, it can lead to many life-threatening complications, including heart attacks and stroke. And the risk of falling victim to these diseases is even higher when your child develops diabetes at a young age.

Though there are no effective ways to prevent Type 1 diabetes at present, the good news is that studies have shown that Type 2 diabetes can be prevented or delayed. All that needs to be done is to help your children lead a healthy lifestyle: encourage them to watch their weight and diet and make sure that they are physically active and get sufficient exercise. If you have diabetes yourself, be extra vigilant as your children's chances of developing the disease are higher. Once you realise that diabetes doesn't favour any age group, you'll know that what's important is cultivating a healthy lifestyle in your loved ones from the earliest age possible. In our next article, we'll take a look at how you can prevent your young ones from developing diabetes through healthy lifestyle tips for the whole family.

Emeritus Professor Datuk Dr Mustaffa Embong is consultant diabetologist and endocrinologist at the National Diabetes Institute.

This article was first published in www.nst.com.my on 15. November 2008 Diabetes Epidemic in Malaysia 07 January 2007 Second National Health and Morbidity Survey - Diabetes DIABETES MELLITUS Among Adults Aged 30 Years And Above (Volume 9) Written by Dr. Rugayah Bakri Public Health Institute 1. 2. 3. 4. 5. Introduction Objectives Methodology Findings and Discussion Conclusion

1. INTRODUCTION Diabetes mellitus is now a major global public health problem. The incidence and prevalence of diabetes are escalating especially developing and newly industrialized nations. The estimated number of 80 million sufferers in 1990 is expected to double by the year 2000. In Asia alone, it is estimated that the total number of diabetes could reach more than 138 million. World Health Organization (WHO) recognizes 2 major clinical forms, namely Insulin-Dependent Diabetes Mellitus (IDDM) and Non-Insulin-Dependent Diabetes Mellitus (NIDDM). About 90% of all cases of diabetes in developed and developing countries are NIDDM, primarily found in adults more than 30 years of age. The category of Impaired Glucose Tolerance (IGT) includes those whose glucose tolerance test is beyond the boundaries of normality as defined by 1985 WHO Study Group. When tested 5 to 10 years after diagnosis of IGT, about one-third progresses to diabetes. The prevalence of diabetes in adults ranges from less than 2% in Tanzania and Mainland China to 40-50% in urban Papua New Guinea. Exceptionally high prevalence is seen in population who have changed from traditional to modern lifestyle. This difference in rates reflects the underlying behavioral environmental and social factors such as diet, level of obesity and physical activity. The lowest rates are often found in rural areas within the country of origin where people live closer to their traditional lifestyles Migrant populations, however, for example the Asian Indians who migrated to various part of the world recorded high prevalence of diabetes. The prevalence of diabetes is noted to vary with ethnicity. However, the developing and newly industrialized nations, and the disadvantaged community groups in the developed countries are said to be at highest risk of having diabetes. It has also been demonstrated that as age increases, the risk of having diabetes and hence the prevalence of diabetes increases. About half of the diabetes is unaware of their diabetic condition. This leads to the question of the potential benefits of screening asymptomatic individuals. Symptoms of NIDDM include frequent

micturition, unusual thirst, extreme hunger, unusual weight loss, fatigue and irritability. Additional symptoms include frequent infections, blurred visions, wounds that are slow to heal, tingling/numbness in hands or feet and recurrent gum, skin or bladder infections. The complications associated with diabetes are appalling. It is estimated that about 15,000 to 39,000 people lose their sight because of diabetes and about 14.6% of NIDDM aged 40 years and above, developed diabetic retinopathy after 5 years duration of diabetic condition. It is also estimated that 10% of diabetes develop kidney disease and 50% develop evidence of nerve damage after over 25 years of having diabetes. People with diabetes are 2 to 4 times more likely to have heart disease and 5 times likely to suffer a stroke. The risk of leg amputation is 27.7 times greater and the occurrence of impotence due to diabetes neuropathy, among men is one third of male diabetics. It should be stressed that early detection in asymptomatic individuals provides an opportunity in attempting to prevent or delay the complication of diabetes through dieting and pharmacological measures to achieve euglycaemia. Hence, it is important that prompt and effective treatment is made available to diabetics. There are 4 major components in the management of diabetes mellitus namely, diet, exercise, medication and education. Nonpharmacologic treatment (diet and exercise) must be attempted for at least 3 months before drug treatment is introduced in ambulant uncomplicated and especially obese diabetics. In addition, monitoring for diabetic control and management of complications should be emphasised. In Malaysia, diabetes is a growing concern. Through the Ministry of Health's six year thematic Healthy Lifestyle Campaign which began in 1991, diabetes mellitus was the theme for the year 1995. Here, the promotion of adopting healthy lifestyle practices relating to the prevention of diabetes namely creating awareness and balance diet, maintain ideal body weight and physical activities were encouraged. The campaign also emphasised on creating, awareness of the disease and its complications to the public. Guidelines on management of diabetes and patient education to the diabetes were also developed. In addition, many small studies about diabetes had been conducted either on hospital base or selected communities The first National Health and Morbidity survey included diabetes as a major component in the survey This second National Health and Morbidity Survey, attempted to provide a comparative picture of the epidemiology of diabetes in Malaysia within the last 10 years on a wide population based. 2. OBJECTIVES 2.1 General objective: To determine the prevalence of diabetes in Malaysia and the health seeking behaviour amongst, the diabetes 2.2. Specific objectives: 2.2.1 To determine, the prevalence of self-reported diabetes by socio-demographic subgroups 2.2.2 To determine the prevalence of undiagnosed diabetes by the socio -demographic subgroups 2.2.3 To describe the health seeking behaviour among the known diabetes in relation to their treatment status, place of treatment, reasons for seeking treatment and presence of complications due to the diabetic condition 2.2.4 To determine the association of other risk factors with the diabetes disease among the known and the undiagnosed diabetes 2.2.5 To formulate recommendations to the Health Programme Managers to strengthen the Diabetic Programme in Malaysia 3. METHODOLOGY The details of the sampling design were described in Volume 1. Data on diabetes was obtained from adult respondents 30 years and above through interviews by trained nurses using precoded questionnaires. A 2-hour-post - glucose load test was conducted by the nurses to the respondents who self-professed that they were non-diabetics and have not been diagnosed by any, medical personnel. These non-diabetes were measured for their blood glucose level using glucophotometer in a dry non-wipe technique. Those who refused to be examined were classified as refused to be examined and those who could not tolerate glucose due to old age were classified as unable to be examined.

For the purpose of analysis in this survey, the respondents were categorised into 3 categories. The known diabetes were the adult respondents who self-professed they were diabetics and diagnosed by medical personnel. Those non-diabetics who had undergone the 2 hour - post glucose load test and whose blood glucose measurement level of 11.1 mmol/1 or more were categorised as undiagnosed diabetes. Those with blood glucose measurement of 7.8 - < 11.1 mmol/1 were classified as impaired glucose tolerance (IGT) The known diabetes were enquired about their treatment status, utilisation pattern of health facilities and perceived complications associated with their diabetic condition. 4. FINDINGS AND DISCUSSION From the survey, the national prevalence of known diabetes in Malaysia was found to be 5.7% (5.4% - 6.1%). However, through the 2 hour- post- glucose load test, the national prevalence of undiagnosed diabetes was 2.5% (2.3-2. 7%). Taking into account these 2 categories of diabetes, hence the prevalence of diabetes in Malaysia would be 8.3% (7.8% - 8.7%). From other studies conducted in Malaysia, the prevalence seemed to be on the rise. In 1986, the prevalence of diabetes in Peninsular Malaysia as reported in the first National Health and Morbidity Survey was 6.3% and in 1995 as reported by the Cardiovascular Unit in the Department of Public Health, Ministry of Malaysia was 7.7%. If estimating the population of Malaysia in 1996 to be approximately 21 million, the total number of diabetic sufferers would approximately be 1.7 million. With further industrialisation plus modernisation, the number of people affected by diabetes may double by 2010. By far, Asia was recognised as having the potential increase with 2.5 to 3 times more common diabetes then it is today. Hence, by 2010, Asia was projected to have 138 million diabetic sufferers. Recently there has been consideration to use the IGT to diabetes ratio as prognostic index of the epidemicity of diabetes in a given population. From this study, it was found that the prevalence of IGT was 4.3% (4.0 - 4,7%). Therefore, the prognostic index here is about 1 ~ 2, possibly implying either the diabetes was on the wane or more likely reflecting a situation in which most genetically susceptible persons already manifested the disease. Whatever the situation is, the economic implication of diabetes is enormous. In US, it was estimated that with the 7% prevalence of diabetes, it had incurred about US S20.4 billion in 1987 due to direct and indirect costs of diabetes. The social disease burden and subsequently the economic implication as a result of the diabetic complications is also considerable. Hence, the survey showed that perceived complications associated with their diabetic condition among known diabetes was mainly vision problem (50.6%, 42.2% - 53.9%) and numbness (38.5%, 34.8% - 42.1 %). Similar findings were found in a study conducted by Gafel C. et al that the most common complication was eye disease namely 27% of the diabetic patients. In this survey, another about 10% of the known diabetes perceived that they suffered slow wound healing, stroke and cardiovascular diseases associated with their diabetic condition. Almost similar findings were found by the a hospitalbased study conducted locally in Kuala Lumpur Hospital by the National University Malaysia in 1988. Diabetic is a costly, disorder. Defining the distribution of specific characteristics among di abetics can assist in the planning, implementing and evaluating diabetic programmes for primary, secondary and tertiary prevention and control of diabetes. In planning of services for diabetes control, equity policies have to be considered. The survey revealed geographical variations in the observed prevalence of diabetes by states. The highest observed prevalence of known diabetes occurred in the more developed states like Selangor (7.3%, 6.1 - 8.4%) and Penang (7.3%, 5.3 - 9.4%). Similarly, the prevalence of undiagnosed diabetes was highest in the more developed states like Negeri Sembilan (4. 1%, 2.8 - 5.401o), Penang (3, 5%, 2.4 - 4.5%) and Melaka ( 1%, 1.9% - 4.2%). The same findings were found among IGT. States like Melaka (6.6%, 4.6 - 8.6%), Wilayah Persekutuan Kuala Lumpur (5.3%, 3.8-6.9%) and Johor (5.4%, 4.1%-6.7%) recorded highest prevalence of IGT. Similar accounts were observed elsewhere in many literature where urbanisation and modernisation changed the lifestyles of some population which was associated with the increase risk of having, diabetics. For the 3 categories of diabetes, the urban areas recorded significantly higher prevalence from the rural areas. As many literature documented, the prevalence increased with age for all the 3 categories of diabetes. By ethnicity, the prevalence of known diabetes in Indians (11.5%, 9.7% - 13.2%) was significantly

higher than other races. The Other Bumiputeras recorded significantly low prevalence of the known and undiagnosed diabetes, indicating a true observation of low prevalence among populations whose lifestyles remained close to their traditional lifestyle. Elsewhere, many studies have shown that the migrant Asian Indians had been observed to have a high prevalence of diabetes. Among the IGT, however, the Chinese recorded high prevalence namely 6.5% (5.1% - 7.9%). Since it is said that about one-third of IGT progressed to diabetes, the prevalence in the Chinese would increase in 5 to 10 years time. From the survey, it was found that the prevalence of all 3 categories of diabetes decreased with education level. The unemployed seemed to have high prevalence of known (12.8%, 11.2% 14.5%) and undiagnosed (3.6%, 2.8% - 4.5%) diabetes. The pensioners had also high prevalence of known and undiagnosed diabetes varying from 12% in known diabetes to 4% in undiagnosed diabetes. This was probably due to increased prevalence among the older age groups. Although the service sector recorded high prevalence among known diabetes (5.1%, 3.8% - 6.3%) while the sales sectors recorded high prevalence of the undiagnosed (3,30/6, 2.3% - 4.3%), it seemed that there was no significant difference between the working sectors. Similarly, no significant differences were found in gender and income for known and undiagnosed diabetes, Although many prevalence studies showed high prevalence of NIDDM in females than males, analysis on many incidence studies in US by Nelson R.G. and Everhart J. E. showed no evidence of gender influence on risks for NIDDM. This survey also revealed that 10.7% (10% - 11.9%) of known diabetes had hypertension. In a hospital-based study conducted by Dr. Khalid Kadir in 1988, it was found that 37% of the diabetic patients had hypertension. In another population based study, about 14% of diabetes had hypertension. This survey also showed 21.8% (12.4% - 33.3%) of diabetes had high cholesterolaemia and 7.5% (6.6 - 8.5%) and 11.3% (9.0% - 13.5%) was overweight and obese respectively. These associations seemed to be significant. In organising services for the diabetes, effective and prompt treatment and education must be given to curb, delay or even prevent complications. These will directly increase the quality of life for the diabetics and hence, their productivity. The current treatment regime especially for obese uncomplicated patients is diet control and exercise which should be attempted for at least 3) months before pharmacologic treatment is started. From the survey, it was found that among the known diabetics on diet control alone comprises 8.5% (6.6% - 10.3%), while those on diet control and currently on medication comprises 71% (68.0 - 74.0%) and those on current medication alone was 6.8% (5.2% - 8.4%). In France, a study in a sample of diabetics from medical analysis laboratories found that 11, 5% of their patients were on diet alone. It was estimated from this survey, that those who were not currently on medication neither were they on diet was 3.5% (2.4% - 4.7%). However, approximately 2% of known diabetes was never on medication while the remainder did not respond or refuse to respond. Conversely, in the first National Health and Morbidity Survey, it was observed that 90.4% were on medication and diet while only 3.8% were on diet alone and only 2.2% was never on medication. Here, the proportion of those on medication alone would have included among those who were on medication and diet together. The survey revealed that in the less developed states, the proportion of known diabetes on diet alone was high. However, these proportions were not significantly different. The highest proportion was in Kelantan (19.7%, 5.5% - 33.9%) followed by Pahang (18.9%, 8.8% -19.1%) and Terengganu (17%, 6.7% - 29.0%). In Melaka, it seemed none of the known diabetes was on diet control alone. However, Melaka showed a high proportion of known diabetes on diet control and current medication namely 84.6% (75.9 - 93.3%). Similarly, Johor (80.0%, 71.7% - 88.2%), Wilayah Persekutuan Kuala Lumpur (81.1%, 70.2% -92.0%) and Pulau Pinang (79.2%, 67.6% 90.3%) showed high proportions of known diabetes on current medication and diet. The survey also showed that Negeri Sembilan (13.7%, 4.4% - 22.9%), P. Pinang (12.3%, 1.6 23.1%), Kelantan (11.7%, 1.1% - 22.3%) and Terengganu (11.3%, 0.9% - 21.6%) had high proportions of known diabetes on current medication alone. However, Terengganu (11.5%, 1.9% 21.2%) showed highest proportions of known diabetes not on current medication and diet. By strata, the survey showed that urbanites had higher proportions of known diabetes on current medication and diet control (74.0%, 70.2% - 77.8%). Similarly, diet control alone (8.5%, 6.2% 10.9%) was higher in urbanites. However, higher proportion of diabetics either on current medication alone or neither on current medication or diet were found in the rural areas, (6.5%, 4.87.8% and 5.2%, 3.0% - 7.4 respectively). By ethnicity, more Malays claimed that they were on diet alone (10.3%, 7.2% - 13.3%) while more Indians (80.6%, 74.4% - 86.1%) claimed they were on diet control and medication. A high

proportion of Other Bumiputeras claimed that they were not on current medication or diet control (8.7%, 2.4% - 14.9%). By gender, there was no significant difference in the proportions in all the categories of treatment status. However, more females claimed they were on medication and diet control (74.0%, 50.1% 77.9%) while more males claimed they were on diet control alone (9. 1%, 6.3% - 11.9%) and on medication alone (8.2%, 5.7% - 10.3%) By household income, the proportion of known diabetes on diet control alone decreased with increase in income level while the reverse was observed among those who were on current medication only. Those who were not on diet control or current medication was more on the lower income group. The proportion of those on current medication and diet control increased with the increase in Income level. The survey showed that the proportion of known diabetes on diet control alone increased with educational level. There was no marked trend observed among those with current medication and diet control. By age group, there seemed to be a decreasing trend as age increased in the proportions of known diabetes on diet control alone which meant that the younger age group were more on diet control alone. However, the proportions of those on diet and current medication had the reverse trend namely the proportions were higher among the older age groups. This finding corresponded to the findings that those on current medication and diet control were higher among the pensioners while those on diet control alone was higher among the government and private employee (the younger age groups). Among those who were not on diet control or current medication, the lower income group, the younger age group, the sales sector and employees in the government and private sectors seemed to record higher proportions. This survey also looked into the pattern of utilisation of health facilities by known diabetes. Statistics collected from government hospitals showed that only 30,000 diabetes patients were hospitalised in government hospitals in 1994 while only about 150,000 were under treatment in government facilities. In this survey it was found that majority of the known diabetes on current medication sought treatment in government facilities namely 56% (52.1% - 59.8%) while only 31.6% (28.0 35. 1 %) sought treatment from private facilities. A higher proportion of these diabetes in Melaka (76.1%, 64.3% - 87.9%), Pahang (66.0%, 50.6 - 81.4%) Perak (65.6%, 56.2% - 175. 1 %) and Sarawak (63.8%, 53. 1 % - 74.6%) utilises government facilities. The survey also showed that more of the urbanites (35.6%, 30.9% - 40.3%) used private facilities while more of the rural population (62.2%, 56.1% - 58.2%) used government facilities. Comparatively, more Chinese (45.9%, 39.1% - 52.8%) used private facilities while more Other Bumiputeras used government facilities (70.7%, 53.2% - 88.3%). From this survey, it was found that a high proportion of the low-income group utilised more government facilities. On the contrary, a higher proportion of the higher income group utilised private facilities. The survey also showed that more government employees (57.9%, 55.5% - 80.2%) and housewives (64.3%, 57.7 - 70.9%) used government facilities as compared to private employees. Hence, more private employees used private facilities (51.0%, 42.3% - 63.8%). However, it was observed that the pensioners, government (71.2%, 60.0% - 86.5%) or private (84.2%, 50%, - 118.3%) made up the higher proportions that utilised government facilities Diabetes is one disease where full co-operation of the patient is necessary to ensure good control. Good adherence by the patients is only when the disease is understood and the objectives of the control is clearly explained. It was found from this survey that only 7.7% (5.6% - 9.7%) of the known diabetes on current medication ever stopped medication. It was found that the urbanites (7.7%, 5,2% - 10.3%), the males (8.5%, 5.1% - 11.8%), the Malays (10.6%, 6.7% - 14.4%) and the other Bumiputeras (10.9%, 0 - 22.8%), the younger age groups, the higher income groups and the higher educational levels seemed to have higher proportions of medication non-adherence. When these known diabetes who stopped medication were enquired about their reasons, majority (40.3%) said they felt they had recovered from the illness. About 13.2% said they were advised to stop by their doctor. Here, it probably demonstrated, as suggested elsewhere, that self-perceived

health status played an important role in the adherence to diabetic management and metabolic control. Hence, education to patients and family or relatives is pertinent in this context in the control of diabetes. 5. CONCLUSION 5.1 Prevalence of diabetes in Malaysia was found to be 8.2%. There was an increase in prevalence as compared to the NHMS in 1986, which only reported 6.3% in Peninsular Malaysia. This indicated that diabetes is a growing concern in Malaysia, which warrants strengthening of the prevention and control programme. It should be noted that the undiagnosed diabetes, which represented the unfelt needs among diabetes, was 2.5%. In addition, the variability of the estimated observed prevalence by states, the urban population having higher prevalence, the increasing prevalence by age and higher prevalence in lower educational level groups requires various emphasis on the allocation of resources provided by, the health care delivery systems. The survey also revealed that the lower income group, the older age groups, and those in the rural areas who utilised more of the government facilities than private facilities. This should be of great concern for health service planners in Malaysia. 5.2. Diabetes is a debilitating disease. Once diagnosed, a diabetic patient must be given prompt and adequate treatment to prevent or delay complications. About 86.3% of the known diabetes was somewhat on medication alone or diet control alone or both medication and diet. It could be seen here that proportion of diabetes on diet alone had increased as compared from the NHMS 1986 which reported 3.8% only. The treatment by diet alone is the treatment being promoted for uncomplicated diabetes especially in obese patients. Hence the health care professionals should realise that education in an effort to gain satisfactory compliance must be emphasised. In the care of diabetes, the health care professionals must spend sufficient time with their patients. Education about diabetes should be extended to relatives and public in order to get full cooperation from patients for their treatment compliance or adherence. 5.3. The survey also revealed significant risks factors were associated with known diabetes, namely 10.9% had hypertension, 22.8% had high hypercholesterolaemia and 18.8% were overweight and obese. Hence it is proposed that as a risk strategy approach be applied in the prevention and control of diabetes in Malaysia where there are resources deficit in the care of diabetes. The findings of this survey showed that the perceived complications namely vision problems and numbness were the commonest among known diabetes. This should be highlighted to consider secondary and tertiary prevention strategies. The timely consensus guidelines recently developed by the Ministry of Health in the management of diabetes retinopathy should be issued to all health facilities either private or government in the attempt to control the most common complication of diabetes. In the care of diabetes, the socioeconomic implications are alarming. Prevention of diabetes and its consequences would be a major challenge not only in the future, as WHO quoted, but essential in attaining health for all. Reproduced from The Second National Health and Morbidity Survey II - Diabetes Epidemic in Malaysia was published in 1997 by the Public Health Institute, Ministry of Health, Malaysia