The diabetes epidemic and its impact on thailand 2013

1
the diabetes
epidemic and its
impact on Thailand
Researched and written by:

2
Diabetes is a chronic disease that requires life-long treatment and
greatly increases the risk of serious, costly complications including
heart attack, stroke, kidney failure, blindness and limb amputa-
tion1,2
.
Today, 382 million people in the world have diabetes3
.
The number of people with diabetes is increasing in every country in
the world3
.
DIABETES, A GLOBAL EPIDEMIC

3
“No country is immune to the threat and no country is fully equipped to re-
pel this common enemy alone. The coming fight will require a united stand
with the full support of the international community, for this is a battle the
world cannot afford to lose.”
Prof Jean Claude Mbanya, President of the International Diabetes Federation, 2009-2012
IDF press release, 18 October 2009
“If we fail to give people with diabetes the long and healthy lives we are
capable of giving them, we will not be forgiven.”
Bill Clinton, US President, 1993-2001
Keynote lecture at the ‘Global Changing Diabetes Leadership Forum’, New York, 2007
“Without tackling the diabetes epidemic which is now gripping our world,
we will, I fear, find many of our ambitions for the future simply impossible to
achieve.”
Kofi Annan, Secretary-General of the United Nations, 1997-2006
Keynote lecture at the ‘Unite to Change Diabetes Forum’, Moscow, 2008
“We believe addressing the prevention and control of chronic noncommu-
nicable diseases offers a window of opportunity to create healthy develop-
ment. Unless this opportunity is seized by donors, governments and other
partners, the current progress on the internationally agreed development
goals will be undermined and countries will face unbearable costs to their
economies and health systems. The world is thus at a unique tipping point
in the history of public health; an opportunity that will rapidly fade if no
timely action is taken.”.
Prof Pierre Lefebvre, Chairman of the World Diabetes Foundation, 2003-present
Annual Review of the World Diabetes Foundation, 2010
“Cancer, diabetes, and heart diseases are no longer the diseases of the
wealthy. Today, they hamper the people and the economies of the poor-
est populations even more than infectious diseases. This represents a public
health emergency in slow motion.”
Ban Ki-Moon, Secretary-General of the United Nations, 2007-present
United Nations global summit on non-communicable disease, New York, 2011
“In the absence of urgent action, the rising financial and economic costs of
these diseases will reach levels that are beyond the coping capacity of even
the wealthiest countries in our world.”
Margaret Chan, Director-General of the World Health Organisation, 2007-present
The First Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Disease Control, Moscow, 2011

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Today, 3.2 million people have diabetes in Thailand3
.
By 2035 an additional 1.1 million Thai adults will live with diabetes3
.
An estimated 183 people die of the consequences of diabetes in
Thailand... every day3
.
DIABETES IN THAILAND

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PREFACE
Changing lifestyles lead to overweight and obesity, which has now become one of the leading causes
of chronic non-communicable diseases (NCDs), also known as lifestyle diseases. These diseases are
currently spreading globally and becoming increasingly more severe. If they are not adequately ad-
dressed, the NCDs will likely cause more morbidity, disability, mortality, and substantial healthcare
burden and economic loss.
Thailand is also facing the problem and is attempting to address the threats of five major preventable
lifestyle diseases including diabetes mellitus, hypertension, heart diseases, cerebrovascular disease and
cancers. The attempt to tackle these diseases is included as one of the major development goals in the
10th and 11th National Economic and Social Development Plan. We realise the need for multisectoral
engagement in order to adequately address the problems, the Ministry of Public Health (MoPH), the
National Economic and Social Development Board (NESDB) and Mahidol University have collaborated
to develop the ‘Thailand Healthy Lifestyle Strategic Plan 2011-2020’ in response. The cabinet has, in
principle, approved this national strategic plan and its implementation mechanism, which will be used
as a framework to advance coordinated and united efforts of program implementation at all levels,
with the aim to campaign for a new, healthy way of life which reduces risk factors, morbidity, compli-
cations, disability, mortality and financial burden at individual, family, community, society and national
levels.
H.E. Mr. Pradit Sintavanarong
Minister of Public Health, Thailand, 2013

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Diabetes is a threat to Thai society, to avert the worst, clear priorities should be set for the future management
of diabetes. First, screening should be increased; screening for diabetes in high risk populations as well as sys-
tematic annual screening for diabetes complications in patients already diagnosed. Second, the factors affect-
ing poor treatment outcomes in the majority of patients not well controlled today have to be identified and
addressed. These priorities address the need for early diagnosis and successful intervention to help prevent and
delay the onset and progression of the serious and costly complications of diabetes.
Third, policy should specify clear targets. Fourth, a monitoring framework should be provided and used to track
progress towards these targets, requiring further improvement in data availability. Up-to-date data on the medi-
cal and economic burden of diabetes at the national level and at least a regional level is essential to identify
needs and monitor progress. Priority areas for data collection include the incidence of diabetes in children and
adults, the prevalence of GDM, the cost of diabetes and its complications and finally treatment compliance and
outcomes at an individual level. Some data is available from individual studies, however systematic and longi-
tudinal data collection is essential. The NHES survey is conducted regularly and includes good data on diabetes
prevalence, however these surveys are only conducted every 5 to 7 years.
Fifth, promotion of a healthy lifestyle for the prevention of diabetes has to be stepped up through education
and quality health information delivered to the public. Efforts to address these issues have already started in
some areas of the country but not nationwide. In order to achieve this, a multisectoral effort including concert-
ed policy actions from a variety of policy makers (beyond the Ministry of Public Health) and of public opinion
leaders as well as interventions involving public and private delivery channels is required.
Professor Chaicharn Deerochanawong
Diabetes and Endocrinology Unit, Department of Medicine
Rajavithi Hospital, Rangsit Medical School, Bangkok, Thailand
Diabetes mellitus was the first chronic noncommunicable disease that was brought up to the attention of the
National Epidemiology Board of Thailand. In 1987, a Task Force for Control of Diabetes Mellitus was estab-
lished. One year after gathering all existing data, a technical report was released with the title ‘Diabetes Mel-
litus in Thailand 1987: Review and Prospective’. The report called for the need of standardised data collection
in all aspects of diabetes including epidemiology, care process, management outcome, risk factors and com-
plications. Updating diabetes knowledge for practising physicians, care teams and education for patients and
caregivers was required among many priorities of care delivery. For almost two decades of accumulated works,
an improvement in many areas was recorded in the ‘Diabetes Situation in Thailand 2007’. The progress was
recently summarised by Prof. Chaicharn Deerochanawang and published in Globalisation and Health in 2013.
The National Health Security Office (NHSO) also paid attention to the importance of holistic management of
diabetes mellitus and foresaw the necessity of improving the quality of care and outcomes. A working group
of NHSO and diabetes experts launched a ‘Clinical Practice Guideline for Diabetes Mellitus’ in 2008. The NHSO
and the Ministry of Public Health guided and supported the implementation of the clinical practice guidelines
countrywide. A chronic care model has been initiated to facilitate efficient and effective care of diabetes in
Thailand.
This booklet represents another version illustrating the burden and impact of diabetes mellitus in Thailand.
Bringing diabetes care and outcomes to a higher quality level is a big challenge to all care providers with high
expectations of success.
Wannee Nitiyanant, M.D.
President, Diabetes Association of Thailand
Under the Patronage of Her Royal Highness Princess Maha Chakri Sirindhorn
FOREWORD

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1. Executive summary
Much progress has been made in recent years, but there is still room for
improvement in tackling the growing diabetes challenge in Thailand.
Successfully controlling type 2 diabetes will help millions with the disease
lead a longer, healthier life but will also significantly contribute in the
prevention of other chronic diseases, due to their shared risk factors,
underlying determinants and opportunities for intervention.
The burden of chronic diseases
Until recently, communicable diseases have been the
primary cause of mortality and morbidity across the globe.
The balance is however tipping towards non-communicable
diseases (NCDs). Chronic diseases are one of the great-
est challenges for Thailand. The most common of these
diseases are cardiovascular disease (heart disease and
stroke), cancer, respiratory disease and diabetes4
, together
they account for a substantial proportion of total mortality
and disability5
. Within the scope of a decade, the share of
all deaths in Thailand by NCDs has increased from 59% in
2002 to 71% in 20086
.
An integrated approach
Most healthcare systems today are organised to treat the
acute symptoms of disease and manage conditions sepa-
rately. We are less advanced when it comes to integrated
prevention efforts, early detection and care and treatment
for chronic non-communicable diseases. An integrated
patient-centred approach will capitalise on common treat-
ment needs and thus have a greater impact.
In the case of type 2 diabetes treatment, research has
shown the benefits of an integrated approach. Intensify-
ing treatment to include tight control of multiple diabetes
risk factors such as high blood glucose, blood pressure and
cholesterol have been found to significantly reduce the risk
of death from cardiovascular causes and the development
of end-stage renal disease7
.
What you can find in this book
‘The diabetes epidemic and its impact on Thailand’ begins
with an introduction to diabetes and describes the seri-
ous complications that may occur when the disease is not
adequately controlled. Following this, the burden of dia-
betes in Thailand is discussed, reviewing available data on
the prevalence of diabetes and discussing the human and
financial burden of the disease in Thailand.
‘The Rule of Halves’ is then introduced as a simple concept
to reveal the real challenges of managing diabetes success-
fully. The book continues with a review of the quality of
diabetes care and the current diabetes health in Thailand,
stressing the importance of women’s and children’s health
in the following section.
The book then asks the important question “What needs
to change?”, outlining the benefits of early detection and
the need for education and data collection. Finally, this
book shares experiences from across the globe, showcas-
ing successful national health strategies and local diabetes
projects.
The objectives we have in mind
As effective interventions exist for the prevention and
control of chronic diseases such as diabetes, the evidence
investigated and summarised in this book aims to pro-
vide payers, policymakers, patient associations, the expert
community and other stakeholders in Thailand at a local,
regional and national level with a clear demonstration of
the challenges presented by diabetes and offers possible
solutions.
It is hoped this book will contribute to the development
of sustainable improvements in diabetes prevention and
detection, and the provision of affordable, effective care
throughout Thailand.
Acknowledgement
We thank Prof. Chaicharn Deerochanawong; this booklet
draws inspiration and important insight and knowledge
from his recently published review article ‘Diabetes man-
agement in Thailand: a literature review of the burden,
costs, and outcomes’. His paper can be downloaded from:
http://www.globalizationandhealth.com/content/9/1/11.

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Table of contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1. Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2. About diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3. Diabetes in Thailand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
4. The human burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
5. The financial burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
6. The rule of halves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
7. Current diabetes health in Thailand . . . . . . . . . . . . . . . . . . . . . . . . 26
8. Women, diabetes and the next generation . . . . . . . . . . . . . . . . . . . 30
9. What needs to change? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
10. Prevention provides the greatest potential for gain . . . . . . . . . . . . . 33
11. Improving outcomes by early detection . . . . . . . . . . . . . . . . . . . . . . 35
12. Patient self-management, education and support . . . . . . . . . . . . . . 37
13. Treatment towards target . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
14. Measure, share, improve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
15. Conclusion: diabetes affects Thailand, at every level . . . . . . . . . . . . 41
16. Sharing experiences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
17. About Novo Nordisk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
18. Diabetes glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
19. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

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2. ABOUT DIABETES
Diabetes is defined by a failure of the pancreas to produce insulin or to
produce and utilise sufficient insulin to keep blood glucose under control8
.
Diabetes and Insulin
Diabetes is a chronic disease that occurs when the pancreas
is no longer able to make insulin, or when the body cannot
make good use of the insulin that it does produce8
.
Insulin is a hormone made by the pancreas whose main ac-
tion is to enable glucose to be transported from the blood
into the cells of the body so it can be used for energy. It
acts like a key that opens the door for the food (glucose) to
leave the bloodstream and get into the body’s cells9
.
When not enough insulin is produced, or when it is not
used effectively, glucose builds up in the blood (known as
hyperglycaemia). Over the long-term high glucose levels are
associated with damage to the body and failure of various
organs and tissues8
.
Types of diabetes
Type 1 diabetes is usually caused by an autoimmune reac-
tion where the body’s defence system attacks and destroys
the insulin-producing cells. The disease may affect people
of any age, but usually develops in children or young adults.
People with type 1 diabetes are dependent on insulin injec-
tions for survival8
.
Type 2 diabetes accounts for at least 90% of all cases of di-
abetes. It is characterised by insulin resistance and a relative
insulin deficiency, either or both of which may be present
at the time of diagnosis. It most commonly occurs after the
age of 40 and is strongly associated with overweight and
obesity which contributes to insulin resistance10
. Increasing-
ly, type 2 diabetes also affects overweight children, adoles-
cents and young adults11
.
Both type 1 and type 2 diabetes are serious. There is no
such thing as mild diabetes8
.
GDM (Gestational Diabetes Mellitus) is a form of diabetes
occuring during pregnancy. Estimates of its prevalence
differ across the world depending on diagnostic criteria,
however it may develop in as many as one in 6 pregnancies
worldwide12
. GDM is associated with complications to both
mother and baby such as larger than normal babies and
higher rates of foetal abnormalities. Although the diabetes
typically disappears after delivery, both women with GDM
and their offspring are at increased risk of developing type
2 diabetes later in life8
.
Other types of diabetes exist, including latent autoimmune
diabetes in adults (LADA). This is sometimes referred to as
type 1.5 diabetes, as people present signs of both type 1
and type 2 diabetes. At least 10% of all cases of type 2
diabetes have some symptoms of type 1 diabetes13
.
Pre-diabetes occurs when blood glucose levels are higher
than normal but not high enough for a diagnosis of ‘full-
blown’ diabetes. People with pre-diabetes are at high risk
of developing type 2 diabetes and have an increased risk of
cardiovascular disease9
.
Symptoms and diagnosis
The onset of type 1 diabetes is usually sudden and dramatic
while the symptoms of type 2 diabetes can often be mild
or absent, making it hard to detect8
. All too often type 2
diabetes is only diagnosed when presenting to the doctor
with the first signs of complications or during a random
test. As early detection and treatment can decrease the risk
of developing the complications of diabetes, it is important
to recognise its symptoms, which include14
:
• Tiredness
• Feeling of thirst
• Frequent urination
• Feeling hungry
• Blurry vision
• Slow healing cuts
• Tingling or numbness in
hands or feet
Living with diabetes
It is not easy to hear a diagnosis of diabetes. There is no
cure and people will often have seen headlines of what can
go wrong or frequently will have witnessed first-hand the
negative effects of uncontrolled diabetes9
.
It entails a number of physical problems which affect both
private and working life and may require additional sup-
port from friends or family. These may include discomfort
caused by high blood sugar, such as tiredness and frequent
infections, or discomfort caused by low blood sugar such as
palpitations and mood swings.
The stress involved can often lead to depression, especially
for young people with diabetes, so support form healthcare
professionals and family members is vital. If people with
diabetes have access to adequate support, they are more
confident and more able to manage their own treatment
effectively.

14
Diabetic retinopathy is the leading cause of
blindness among working-aged adults around
the world17
. As many as 1 in 2 people with
long-standing diabetes in Thailand will devel-
op mild to moderate eye complications such
as blurred vision37
whereas 1 in 10 will experi-
ence vision threatening eye complications15
.
higher risk of
stroke
3-4
Strokes occur when the flow of oxygen to
the brain is interrupted, most often caused by
a blood clot that blocks blood vessels in the
brain. Diabetes accelerates atherosclerosis, the
hardening of arteries, which leads to accu-
mulation of plaque and when this ruptures a
stroke may occur. Stroke occurs 3 to 4 times
as often in people with diabetes compared to
those without diabetes20,47,48
. For people below
65 years of age the risk is 15 times higher20
.
Diabetes complications
Diabetes can lead to many serious health problems, usually after a number of years and particularly if diabetes is not de-
tected early or well treated. Consistently high blood glucose levels can damage the small blood vessels in the eyes (retinopa-
thy), kidneys (nephropathy) and the nerves (neuropathy); these are called micro-vascular complications. High blood glucose
also affects larger blood vessels by accelerating the build-up and inflammation of plaque (atherosclerosis) which contributes
to stroke, coronary heart disease and peripheral artery disease; these are called macro-vascular complications. People with
diabetes have a 2-fold excess risk of a wide range of vascular diseases18
and are also more likely to die from these142
. Other,
non-vascular, complications of diabetes include teeth and gum problems and infections and people with diabetes also have
a higher risk of cancer and are more likely to develop depression18
.
Kidney disease is caused by dam-
age to small blood vessels in the
kidneys leading to the kidneys
becoming less efficient or to fail al-
together. People with kidney failure
require dialysis or kidney transplan-
tation for survival. Diabetes is the
leading cause of kidney failure in
Thailand, 6 to 7 people start renal
replacement therapy every day42
. have nerve
damage
Diabetes can cause damage to the nerves
throughout the body when blood glucose
and blood pressure are too high17
. The major-
ity of people with diabetes will develop some
form of nervous system damage16
leading to
impaired sensation or pain in extremities of
the body, including the feet or hands, slowed
digestion of food and erectile dysfunction.
70%
experience foot
ulcers
10%
Loss of feeling in the feet from nerve damage
can allow injuries to go unnoticed, leading
to infections. As diabetes slows healing of
wounds, serious ulcers may develop affecting
ten percent of people with diabetes. In Thai-
land, 3 to 4% of people with long-standing
diabetes undergo a lower limb amputation as
a consequence of progressing ulcers37
.
times
Coronary heart disease is caused by
plaque building up along the inner walls
of the arteries (atherosclerosis) of the
heart which narrows the arteries and
restricts the blood flow. This may cause a
heart attack. For both men and women
with diabetes the risk of fatal coronary
heart disease is elevated, the risk for
women with diabetes is higher (3.5 times)
than in men (2.1 times)85
higher risk of fatal
heart disease
3
times
of kidney failure
in Thailand
#1
cause
vision threatening
eye complications
10%
people
people
early death
Diabetes is associated with a 2-fold higher risk of death48,142
and, diagnosed at age 50,
diabetes reduces a person’s life expectancy by 6 to 8 years 18,136
.
6-8years
people
+

15
Diabetes is a chronic, progressive disease that requires life-long treatment
and greatly increases the risk of serious, costly complications including heart
attack, stroke, kidney failure, blindness and limb amputations.
How is diabetes managed?
People with type 1 diabetes have lost the ability to pro-
duce insulin themselves and insulin therapy is required
to stay alive9
. Most people with type 2 diabetes begin
treatment with dietary changes and increased exercise but
unfortunately most patients are unsuccessful in control-
ling blood sugar without pharmacotherapy. Tablets that
stimulate insulin release or enhance insulin sensitivity are
typically the first medications used in treatment19
.
As the number of insulin producing cells (Beta-cells) inevi-
tably decline over time, blood sugar rises and further phar-
macotherapy is required to maintain control10
. Treatment
guidelines from the American Diabetes Association (ADA)
and the European Association for the Study of Diabetes
(EASD) propose a step-wise intensification. Ultimately,
insulin therapy will be required in many people with type 2
diabetes to maintain good glycaemic control21
.
Challenges in diabetes management
The challenges of treating diabetes are many. People with
diabetes require extensive education and motivation to
comply with pharmacotherapy, monitor glucose levels and
participate in self-care to control their disease. Medication
requires titration and monitoring and a careful balance
has to be maintained between strict glycaemic control
required to avoid complications and side-effects such as
weight gain and hypoglycaemia (low blood glucose).
Hypoglycaemia is often considered the limiting factor
in the successful treatment of diabetes22
. Whereas mild
hypoglycaemia is definitely unpleasant, if left untreated it
can lead to severe hypoglycaemia (very low blood glucose)
possibly resulting in unconsciousness and in some cases
can even be fatal. Evidence further shows that severe but
also moderate hypoglycaemia is associated with an overall
increased rate of long-term mortality in type 2 diabetes23
.
Delaying the onset of complications
It is well established that the risk of micro- and macrovas-
cular complications is related to glycaemia as measured by
HbA1c. Reducing glucose therefore remains a major focus
of therapy. Prospective randomised clinical trials have doc-
umented reduced rates of complications in people with
diabetes treated to lower glycaemic targets21
. Findings
from a long-term, landmark study in the UK show that
intensive blood-glucose control substantially decreases
the risk of microvascular complications24
. After 10 years of
follow-up these benefits are maintained and demonstrate
lower mortality in the intensively controlled group25
.
Data from the same study was used to demonstrate that
each 1%-point reduction in HbA1c reduces the risk of
complications, without an apparent lower threshold26
.
Diet and exercise
Tablets
GLP-1
Insulin
Time
Betacellfunction
Progression of type 2 diabetes and
treatment intensification19

17
3. DIABETES IN THAILAND
An estimated 3.2 million Thai adults have diabetes today; 6.4% of the adult
population. This number will increase by more than 1.1 million by 20353
.
Diabetes is a serious problem
The growth of diabetes is serious. Increasing obesity
in children and adults is to diabetes (and other chronic
diseases) what melting glaciers are to climate change: a
warning signal of times to come.
The prevalence of diabetes in Thailand - diagnosed and
undiagnosed - has grown dramatically in the last decade
and if nothing changes its growth will continue. A good
indication of the challenge to come is the 4.1 million Thai
adults with pre-diabetes today3
. This group has impaired
glucose metabolism but has not - yet - developed overt
diabetes. They are at high risk of developing diabetes in
the future unless a significant change in lifestyle is made,
often aimed at reducing weight.
Obesity
Obesity is an important risk factor for chronic diseases,
including diabetes. Obesity, defined as a body mass index
(BMI) in excess of 30 kg/m2
but also overweight (BMI >25
kg/m2
), greatly increases the risk of developing type 2
diabetes.
Being obese leads to more than a seven-fold increase in
the risk of developing type 2 diabetes, while being over-
weight increases the risk nearly three-fold. Furthermore,
people who are severely obese (BMI >35 kg/m2
) have a
risk of developing type 2 diabetes up to 60 times greater
than those with a normal bodyweight27
.
In 2009 more than 30% of Thai men and more than 40%
of Thai women were estimated to be overweight, a rate
that has doubled over the last 2 decades28,29
. Data from
the National Health Examination Survey (NHES) shows the
prevalence of diabetes to be as high as 1 in 7 in adults
with a BMI over 30 kg/m2
, more than 3 times as high as in
those with a normal BMI30
.
Although the typical time of onset of type 2 diabetes is
after the age of 50, childhood and adolescent obesity is
causing the emergence of type 2 diabetes in the young as
a serious health problem. Whereas virtually all (19 out of
20) diagnosed cases of diabetes in the young were identi-
fied as type 1 diabetes until 1995, a near-tripling of the
obesity prevalence in the same period31
has caused a rapid
increase of type 2 diabetes in the young to 1 in 5 cases of
diabetes diagnosed.

18
Ageing
With the typical onset of type 2 diabetes in Thailand
after the age of 50 and with prevalence peaking at 1 in
6 between the ages of 55 and 74, the ageing of the Thai
population points towards a rise in the disease burden32
.
Population data suggests the number of Thai people over
the age of 60 to be close to 20% of the total population
by 2030, a doubling since 200033
.
Urbanisation
Sedentary lifestyles and unhealthy diets are more common
in urban areas. Not suprisingly, the prevalence of diabetes
is higher in urban areas than in rural areas of Thailand. In
particular people moving from rural areas to urban areas
are at a higher risk of developing diabetes34
.
The growth in the number of people with diabetes in Thailand is being
fuelled by an ageing population and by increasingly unhealthy lifestyles with
poor diets and falling levels of exercise causing a rapid increase in the rate of
obesity.

19
The number of people with diabetes will grow by 1.1 million over
the coming 2 decades, affecting 1 in 12 adults by 20353
.
This growth is being fuelled by an ageing population and a rapid
rise in the prevalence of obesity.
Overweight doubles the risk of diabetes, obesity triples the risk of
diabetes30
.
RAPID GROWTH OF DIABETES IN THAILAND

20
4. the human burden
Diabetes often affects people in their productive years when they carry a
substantial responsibility for their families. The complications of diabetes are
not only a personal tragedy, families and close ones are impacted and the
burden of poorly treated diabetes can push families into poverty.
Diabetes is a leading cause of death
As the number of people with diabetes continues to
grow, diabetes is establishing itself as a leading cause of
death. Diabetes already is the third leading cause of death
in women of all ages and the leading cause of death in
women over the age of 50. In men, diabetes ranks lower
due to the higher mortality levels related to road traffic
accidents and HIV/AIDS35
.
Leading causes of death in women35
15-49 years 50-74 years >74 years
1 HIV/AIDS Diabetes Stroke
2 Traffic acc. Stroke Isch. heart disease
3 Cancer cervix Isch. heart disease Diabetes
4 Stroke Nephritits Respiratory
5 Diabetes Cancer cervix Nephritis
According to estimates of the International Diabetes
Federation, 180 Thai people die of the consequences of
diabetes every day, nearly 8 every hour3
.
Complications
The long-term complications of diabetes are a serious and
major burden of the disease. In a 2003 cross-sectional
study with participation of 11 hospitals and more than
9.400 patients it was identified that diabetic nephropathy
was the most common complication affecting 43.9% of
the people with diabetes. This was followed by diabetic
retinopathy (30.7%) and ischaemic heart disease (8.1%)36
.
A 4-year study conducted from 2006 to 2010 in 1,120
patients reported very similar numbers and also found
24% of patients to have lost protective sensation in the
feet due to neuropathy143
.
It is important to realise the impact of disease duration on
the prevalence of complications. Prolonged uncontrolled
blood glucose is a major predictor of diabetes complica-
tions24,25,26
and it is expected to see the prevalence of
complications increase with diabetes duration. After 15
years of diabetes the prevalence of diabetic retinopathy
was found to be 4 times as high as in Thai people with
less than 5 years of diabetes37
.
Similarly, whereas less than 1% of the people with dia-
betes with a disease duration less than 15 years will have
had a lower-limb amputation, this is 3.5% in the group
with long-standing diabetes37
.
Kidney disease (nephropathy)
The job of the kidneys is to remove waste products from
the blood. Sustained high levels of blood glucose can
damage the blood-filtering capillaries in the kidneys and
cause them to leak useful proteins into the urine. Small
amounts of protein in the urine is called micro-albuminu-
ria38
which occurs in up to 40% of Thai people with type
2 diabetes39,40
and increasies to more than 60% with long-
standing diabetes37
.
Unless diagnosed and treated early, kidney disease will
get worse. When larger amounts of protein appear in the
urine this is called macro-albuminuria which may result in
end-stage renal disease when the kidneys fail and waste
products start to build up in the blood. This is very seri-
ous and a person with end-stage renal disease requires a
kidney transplant or machinal blood filtering (dialysis)38
.
Macro-albuminuria occurs in approximately 8% of Thai
people with diabetes with 0.5% to 1% requiring dialy-
sis or kidney transplantation39,40,41
. Diabetes is the most
common cause of end-stage renal disease accounting for
nearly half of all new cases in Thailand. In 2009, dialysis
was initiated in 2,425 Thai people with diabetes or 6 to 7

21
people every day42
. In the same year, the total number of
people with diabetes on dialysis was 9,487, an increase of
90% compared to 200742
.
Eye disease (retinopathy)
Tiny blood vessels (capillaries) in and behind the eyes’
retina - responsible for recording images - provide the
required energy for the eye to function. When due to
sustained high blood glucose the capillaries in the back of
the eye balloon and pouches are formed, blurred vision
may appear. This most common form of diabetic retinopa-
thy is called non-proliferative retinopathy, developing in
stages as more and more blood vessels become blocked38
.
One-in-five Thai people with diabetes has non-proliferative
retinopathy41,43,44,45
and with duration of diabetes a major
risk factor the prevalence in people with 20 years of diabe-
tes was found to be 43%46
.
Blood vessels can become so damaged they close off and
cause new blood vessels to grow in the retina. This can
lead to blood leaking onto the retina or scar tissue form-
ing leading to blocked vision. This is called proliferative
retinopathy and may ultimately lead to blindness38
. Dura-
tion of diabetes is again a major risk factor and prevalence
of proliferative retinopathy increases from 2% in those
with diabetes duration less than 5 years to 10% in those
with diabetes for more than 15 years46
. Blindness may oc-
cur in 1.5% of people with diabetes43
making diabetes a
leading cause of blindness.
Regular screening for diabetic retinopathy and aggressive
management of associated risk factors (glucose, blood
pressure) can help to prevent and delay the prevalence
of diabetic retinopathy. Laser therapy can help delay its
progression and prevent severe visual impairment and
blindness.
Cardiovascular disease (CVD)
People with diabetes have a higher than average risk of
having a heart attack or stroke, striking three to four times
as often than in people without diabetes20,47,48
. More than
half of all people with diabetes globally18
and in Thailand49
will die of cardiovascular disease. People with diabetes of
50 years and older with CVD live on average 7.5 (men)
and 8.2 (women) years less than people without diabe-
tes50
.
Macrovascular complications are reported by 1 in 3 Thai
people with long-standing diabetes37
. Coronary arterial
disease, sometimes called hardening of the arteries, is
reported by 1 in 6 and may lead to a heart attack or myo-
cardial infarction. Stroke, the no.1 leading cause of death
in Thailand35
, strikes 4.4% of all people with diabetes36,41
.
Strokes are caused by a sudden interruption of the blood
supply to the brain most often as a result of a blood clot
blocking a blood vessel in the brain or neck38
.
Peripheral arterial disease (PAD) occurs when the blood
vessels in the legs are narrowed or blocked by fatty depos-
its and blood flow to feet and legs decrease, it increases
the risk of heart attack and stroke. PAD is not easily
diagnosed as it is often symptomless or symptoms are
not recognised. In the Thailand Diabetes Registry Project
prevalence of PAD was found to be 7.4% in long-standing
diabetes37
, however a study with specialised diagnostic
equipment in a high risk diabetic population in Thailand
has demonstrated a prevalence of 60%51
.
Foot complications
People with diabetes can develop many different foot
problems, most often caused by nerve damage (peripheral
neuropathy) when loss of feeling results in injuries going
unnoticed. Poor circulation (PAD) in the lower limbs may
also contribute to foot problems as feet may be less able
to fight infection and heal38
.
Nerve damage and PAD make it easier to get ulcers and
infections leading to amputations. Twenty-four percent of
Thai people with diabetes have loss of protective sensation
in the feet143
and 5 to 6% have a history of foot ulcers36,41
.
Amputations occur in 2% of all people with diabetes41
and in long-standing diabetes 1 in 10 people will have had
a foot ulcer and 3.5% will have undergone amputation37
.
Diabetes is the leading cause of non-traumatic lower limb
amputation.
Depression
Having diabetes is associated with a significantly higher
risk of developing depression and other psychological
problems compared with the general population38
. This
may be because of the stress of daily diabetes manage-
ment or when facing diabetic complications. According
to a 2008 study amongst people with diabetes visiting a
Bangkok tertiary university hospital out-patient clinic 28%
suffered from depression, with a higher prevalence identi-
fied in those with poor glycaemic control52
.
Depression not only causes suffering to the individual but
can also adversely affect treatment adherence and is as-
sociated with poor medical outcomes and high healthcare
costs53
.
Families
A diagnosis of diabetes imposes a lifelong burden, not
only on the individual but also on their family, due to the
constant need for practical and emotional management of
the disease. The social and emotional impact on a family
dealing with diabetes may be greater than the direct costs
of treatment and lost income.

22
5. the FINANCIAL burden
Dying young or living with long-term illness or disability has economic
implications. The rapid growth in the number of people with diabetes has
a dramatic impact on the direct and indirect cost for the individual with
diabetes, the family, the national economy and the government.
The size of the problem
As the number of people with diabetes grows, the disease
takes an ever-increasing proportion of national health care
budgets. Because of its chronic nature, the severity of its
complications and the means required to control them,
diabetes is a costly disease, not only for the affected indi-
vidual and his/her family, but also for health authorities54
.
It is estimated that diabetes accounts for 12% of the
total healthcare expenditure globally, although individual
country estimates differ widely55
. Whereas the estimated
average spend on diabetes per person is USD 53 in South
East Asia, this is USD 7,900 in the United States56
.
The costs of diabetes in Thailand
Little information is available on the actual cost of dia-
betes in Thailand. A 2009 micro-costing study of people
receiving treatment in a 30-bed public district hospital in
North-East Thailand estimated a mean cost of illness of
THB 28,200 (1 USD = 31 THB)57
and the Minister of Public
Health recently estimated the total cost of diabetes to ap-
proach 50 billion THB144
.
Although the cost of diabetes is most visible in direct med-
ical costs such as dispensing and drug bills; these however
make up less than a quarter of the yearly total cost. It is
the in-hospital care of complications that contributes most
with nearly half of the total cost57
.
Economic costs of diabetes
Direct non-medical cost contribute 40% to the total cost
of illness with cost of informal care alone contributing
28%. The biggest contributor to indirect cost was found
to be the cost of permanent disability, contributing 19%
to the total cost of illness. The study is likely to have un-
derestimated the real cost of illness by as much as 60% as
it used minimum wages only to calculate cost of informal
care and disability and not GDP per capita57
.
The morbitiy and premature mortality rates attributable to
chronic diseases highlight the need for effective interven-
tions. Dying young or living with long-term illness or dis-
ability has economic implications for families and society
and the cost to employers and economies is increasing.
Complications drive cost
Data from the Ministry of Public Health on diabetes-
related hospitalisations shows a dramatic increase over the
past decades, a strong indication of the increasing finan-
cial burden of diabetes33
. This is supported by actual cost
data showing hospitalisation to contribute nearly 50% to
the total cost of diabetes illness57
.
A patient requiring hospitalisation sees a nearly 10-fold
cost increase compared to a patient managed in the
out-patient-department. Similarly, a patient with diabetic
nephropathy or diabetic foot has a greatly increased cost
of illness compared to one without58
.

23
With the prevalance of complications of diabetes increas-
ing with diabetes duration, it is unsurprising to see that
the cost of illness increases with diabetes duration. During
the first 5 years of the disease, the median yearly cost is
THB 3,400 and is multiplied by more than 6-fold for those
with a disease duration over 20-years57
. It is the future
burden of diabetes that is thus of greatest concern and an
investment in prevention, early diagnosis and treatment
may save cost later.
The cost of hypoglycaemia
It is well understood that reducing blood glucose levels
helps prevent or delay complications24
and may thus save
costs. A key barrier to reducing blood glucose however is
hypoglycaemia23
. It has been demonstrated that patients
are just as worried about hypoglycaemia as they are about
complications such as blindness59
. Many patients decrease
their insulin dose after a hypoglycaemic event resulting in
sub-optimal glucose control60
. Beyond the indirect impact
of hypoglycaemia on treatment compliance there is also
a direct medical cost of hypoglycaemia. Severe hypogly-
caemic events frequently require medical intervention and
hospital admission61
.
Data from Thailand on hypoglycaemia is scarce, one study
however investigated the clinical risk factors associated
with severe hypoglycaemia and recorded the length of
stay after being admitted to hospital62
. The study showed
that at least 2 people with diabetes and severe hypogly-
caemia were admitted to the hospital monthly, half of
them unconsciousness. The average hospital stay was
6 days resulting in a direct cost per event of nearly THB
22,00058
.

24
6. THE RULE OF HALVES
According to the concept of the Rule of Halves63
, only around 6% of people
with diabetes live a life free from diabetes-related complications.
The silent pandemic
While diabetes care has improved greatly in recent dec-
ades, the International Diabetes Federation estimates
4.8 million people died of diabetes in 20123
. This makes
diabetes a bigger killer than HIV/AIDS, malaria and tuber-
culosis combined64
.
The Rule of Halves shows the gravity of diabetes and ex-
plores which factors play a role - displaying the inequality
of access to the right treatment and support63
.
The Rule of Halves
Of all the people with diabetes in the world, only about
50% are thought to have been diagnosed3
, meaning a
huge part of the population is at risk of developing com-
plications that will significantly impair their quality of life.
Due to late diagnosis up to half of all people with diabetes
have some evidence of complications at the time of detec-
tion65,66
. For others the treatment they receive is inad-
equate or they do not have access to medicine or doctors
who can tell them how to use it. Yet others maintain too
high blood sugar because they fear the consequences of
low blood sugar (hypoglycaemia), a common side effect of
(insulin) treatment.
Ultimately, the Rule of Halves suggests that only around
6% of people with diabetes live a life free from diabetes-
related complications.
UN resolution
In 2006, the IDF and the global diabetes community
brought the “UNite for Diabetes” campaign to the highest
political forum – the United Nations - to raise awareness.
The UN passed Resolution 61/225 in December 2006, af-
firming diabetes as a major global health threat.
The UN High-Level Summit on Non-Communicable
Diseases (NCDs) held in 2011 in New York was a major
milestone. The Summit was only the second time the UN
General Assembly devoted exclusive attention to a health-
related issue and world leaders made unprecedented
commitments to accelerate global progress on diabetes
and NCDs66
.
ACHIEVE
TREATMENT
TARGETS
ACHIEVE
DESIRED
OUTCOMES
DIABETES
DIAGNOSED
RECEIVE
CARE

26
7. CURRENT DIABETES HEALTH in
thailand
Poor glycaemic control increases the risk of long-term complications24
.
With around half of patients diagnosed and only a third of them reaching
treatment targets, many people with diabetes in Thailand are at risk and will
develop complications.
Data sources
An extensive literature search was conducted for a 2013
review of diabetes management in Thailand, finding 46
peer-reviewed papers68
. These provide an accurate and up-
to-date insight in the current diabetes health in Thailand
and this booklet builds on this. The key sources of diabe-
tes data used include:
• National Health Examination Survey (NHES); dis-
ease data from a national representative sample of
>20,000, conducted in 1991, 1997, 2004 and 2009
• Diabetes Registry Project; including 9,419 people with
type 1 and type 2 diabetes, conducted in 2003 with
follow-up until 2006 on mortality
• DiabCare Asia; data collection from over 2,300 pa-
tients, conducted in 1998, 2001, 2003 and 2008 in
Thailand and throughout South East Asia
• InterASIA; survey of nationally representative sample
of more than 5,100 people conducted in 2000
• DM/HT study (NHSO research project); large national
cross-sectional survey of quality of care in 28,649
people with diabetes from >600 hospitals throughout
Thailand, data collected from 2010 to 2012
• A substantial number of other - mostly local - studies
contribute to insights in specific sub-groups of people
with diabetes or specific diabetes related topics
Diabetes diagnosis in Thailand
The IDF estimates that half of all people with diabetes in
Thailand are not aware they have diabetes69
. Findings from
the NHES suggest that diagnosis rates have improved in
recent years to reach 65%, however the NHES uses single
Fasting Plasma Glucose measures for diagnostic purposes
which may underestimate the prevalence of diabetes, as
also acknowledged in the paper70
. Late diagnosis allows
unchecked high blood glucose levels and thus contributes
to the risk of the long-term complications of diabetes.
Access to care is not the same for all
Access to doctors and medicines to treat diabetes in
Thailand should be adequate since the introduction of
the Universal Coverage Scheme (UCS) in 2002. Today the
scheme provides access to 75% of the population with
the remaining 25% of the population covered by the Civil
Servant Medical Benefit Scheme (CSMBS) and the Social
Security Scheme (SSS) for formal employees.
Although coverage is universal, access to healthcare staff
and medication does differ between the schemes. A
comparative study showed a higher proportion of patients
from the CSMBS than the UCS accessing secondary and
tertiary care71
, this is important as more patients were
found to successfully reach their HbA1c target when treat-
ed in specialised secondary and tertiary care hospitals139
.

27
The national DM/HT study conducted by the NHSO
(responsible for administering the Universal Coverage
Scheme) found its members least successful in achieving
an HbA1c level <7.0%139
. The more generous health pack-
age available and better access to specialised care for civil
servants under the CSMBS scheme resulted in 30% more
of its members achieving an HbA1c target of less than
7.0% compared to those insured under the UCS139
.
With substantially more patients covered by the CSMBS
reaching treatment targets, they will experience fewer
complications and live a longer life24,25
. It has been shown
that mortality rates are almost twice as high for people
with diabetes covered under the UCS compared to the
CSMBS72
. The social economic status of participants in the
UCS scheme may explain part of the difference, however
inequalities in care - such as access to drugs and special-
ised health services - are a likely contributer as well68
.
Quality of care
To control diabetes with the aim to reduce complications,
it is essential to optimise physiological values such as
glycaemic levels and blood pressure24
and perform regular
examinations for complications116
.
HbA1c has become the gold standard to assess glucose
control. Evidence suggests the use of this and other tests
is suboptimal in Thailand. In a 2008 review of the quality
of diabetes care provided at 300 provincial Primary Care
Units (PCU), HbA1c testing was found to be conducted
annually in 19% of PCUs73
. Another study in 48 provincial
PCUs conducted in 2009 found 30% of medical files of
people with diabetes contained the result of an HbA1c
test conducted in the last 12 months74
. Without accurate
and recent knowledge of how good or how bad glucose
control actually is, it must be near impossible to make the
right clinical decisions in an effort to reach the targets so
important for reducing complications.
With the rapid growth of the number of people with
diabetes, primary care has to take on a bigger role in the
prevention and management of diabetes. Evidence sug-
gests that PCUs may be underfunded and understaffed73
.
Annual examinations for complications are recommended
as early intervention can prevent worsening of compli-
cations116
. A review of medical records of people with
diabetes visiting the out-patient department of a major
Bangkok University hospital found foot examinations
conducted in less than 1 in 5 patients, approximately 4
out of 10 received eye examination and a similar number
were screened for diabetic nephropathy75
. Examinations
in tertiary clinics however are conducted more frequently
with up to 8 out of 10 people reported to have received
eye examinations43
.

28
Regional variation
The NHSO’s DM/HT study was conducted from 2010 to
2012 in 602 hospitals in 76 provinces. The data available
makes it possible to compare treatment outcomes on a
regional level and this reveals considerable variation in
average glucose control as measured by HbA1c; the risk
of complications in some areas will thus be considerably
higher than in others.
Whereas in Bangkok 45% of patients reached target
HbA1c of less than 7.0%, in the North-East of Thailand
only 23% of patients reached target, approximately
half the patients compared to Bangkok139
. Some of the
individual provinces in the North-East of Thailand show
less than 1 in 5 patients reaching target; in Nong Bua Lum
Phu the success rate is 11% and in Maha Sarakham and
Amnart-Charoen it is just below 17%.
Several factors may contribute to this variation, first is the
easy access to tertiary care in Bangkok, specialised dia-
betes services may be less widespread outside of urban
centres. A second factor may be differences in socio-
economic situation; the majority of people in the prov-
inces are employed in agriculture whereas a much larger
proportion of the Bangkok population is higher educated
and employed in the service sector.
Further analysis of the wealth of data in the NHSO’s DM/
HT study - which is unpublished at the time of writing of
this book - will provide further important insight in the
differences of the quality of diabetes care offered across
Thailand. Such analyses should provide important input to
the formulation of national, regional and local healthcare
resourcing plans with the ultimate objective to improve
outcomes.
Know your ABC
Strong evidence exists that controlling blood glucose helps
delay and prevent complications25
and with more than half
of people with diabetes also suffering from high cholester-
ol and high blood pressure it is important to aim for good
control of all these three risk-factors7
.
A = A1c = Blood Glucose
A1c (or HbA1c) is a measure of average blood glucose
levels over the last 2 to 3 months. It shows whether blood
glucose stayed close to the target range most of the time
or was too high or too low. The American (ADA) and
European (EASD) diabetes associations recommend an
HbA1c <7.0% for most people with diabetes although for
some an HbA1c <6.5% is recommended21
.
Thailand has its own guidelines for diabetes treatment
endorsed by the Thai Diabetes Association, the Endocrine
Society of Thailand and the Ministry of Public Health. The
guidelines are updated every three to four years and the
latest version was published in 2011140
.
Many people in Thailand still rely on a Fasting Plasma Glu-
cose (FPG) test to monitor glucose levels as HbA1c is not
standard of care. Although valuable, FPG does not give in-
sight how good or bad long-term glucose has been, it can
only tell how good or bad glucose is at the moment of the
test and may provide a too optimistic picture of glucose
control. Whereas HbA1c and FPG testing is typically done
during regular check-up visits in the hospital, it is essential
that patients assume an active role in their care. Struc-
tured education of patients is considered to play a critical
role alongside self-monitoring of blood glucose (SMBG)116
.
SMBG has been recommended for people with diabetes
and their health care professionals in order to achieve a
Success rates of patients reaching HbA1c
<7.0%139
by NHSO’s BranchPercentageofThaiadults
reachingHbA1c<7.0%
50%
40%
30%
20%
10%
0%
Bangkok
Branch
(Region
13)SaraburiBranch
(Region
4)SuratthaniBranch
(Region
11)RatchaburiBranch
(Region
5)
Phitsanulok
Branch
(Region
2)
Rayong
Branch
(Region
6)Songkhla
Branch
(Region
12)
N
akornsaw
an
Branch
(Region
3)
Chiang
M
aiBranch
(Region
1)
N
ational
N
.Ratchasim
a
Branch
(Region
9)
UdonthaniBranch
(Region
8)
U.RatchathaniBranch
(Region
10)
Khon
Kaen
Branch
(Region
7)

29
specific level of glycemic control and to prevent hypo-
glycemia141
. In Thailand, the glucose strips required for
SMBG are not reimbursed and the proportion of patients
using SMBG as part of their treatment plan is low at 36%
despite most physicians advocating its use80
.
All studies reviewed show that unfortunately only a minor-
ity of people with diabetes in Thailand manages to achieve
their glucose target of HbA1c <7.0%76-82,139
. Four out of
ten people with a relatively short duration of diabetes
reaches target, however those with a longer duration of
diabetes generally have a higher level of HbA1c and as
few as 1 in 4 will achieve their glucose target139
.
On average, one-third of patients achieve an HbA1c
<7.0% and a similar proportion has very poor glucose
control with HbA1c levels higher than 9.0%139
. These
patients have a considerable excess risk of developing
complications and early death24,25
.
B = Blood Pressure
Elevated blood pressure (hypertension) and blood glucose
are - together - responsible for much of the risk increase
of cardiovascular complications. Hypertension as a co-
morbidity is very common with prevalence ranging from
approximately 40% in studies with recently diagnosed
patients77
to up to 80% in studies with patients with dia-
betes duration of more than 10 years82
.
Despite more than 8 out of 10 people with diabetes re-
ceiving anti-hypertensive medication in the Diabetes Reg-
istry Project, as few as 14% achieved treatment targets83
.
Since 2003, the time of data collection for the Diabetes
Registry Project, access to anti-hypertensive medications
has improved dramatically and in the recent DM/HT study
52% of people with diabetes had blood pressure below
target of 130/80 mmHg139
, similar to the results from the
4-year Thai DMS Diabetes Complications project com-
pleted in 2010143
.
C = Cholesterol
The third risk factor for many of the long-term complica-
tions is elevated levels of bad cholesterol (dyslipidaemia).
Dyslipidaemia is present in as many as 80% of people with
diabetes. Before the introduction of the Universal Care
Scheme 55% of all patients were prescribed lipid-lowering
agents with a further 30% requiring but not receiving this
type of medication84
. Cheap generic statins have made
access to medicine much easier and as many as 8 out of
10 people with diabetes today take lipid lowering medica-
tion80
with 44% reaching recommended LDL levels <100
mg/dl139
.
Current diabetes health; conclusion
All studies in people with diabetes report that glucose
control is sub-optimal in Thailand. Approximately one-
third of all patients achieve the target HbA1c of <7.0%
however fewer do so as diabetes duration increases. It is
also important to identify that control tends to be better
for people managed in tertiary care and by implication is
better for those with better access to tertiary care and bet-
ter medicines.
To delay or even prevent complications and to prolong
a healthy life, glucose control has to improve. From the
evidence presented in this chapter, access to specialised
healthcare staff, medicine, education and self-man-
agement tools may all provide good starting points for
improving quality of care and improving outcomes for
people with diabetes. Action plans should be developed
taking regional needs in account as marked differences
can be observed in treatment outcomes across provinces.
Measuring progress is important and the NHSO’s DM/HT
project is a good example of how powerful insights can
be obtained to direct healthcare strategies and develop
actionable plans to improve care.

30
8. WOMEN, DIABETES AND THE
NEXT GENERATION
Gender influences the development of risk factors and diseases and affects
health risks, access to and utilisation of healthcare.
Women are at greater risk than men
In women with diabetes, the risk of death from coronary
heart disease is about 50% greater than in men85
. It also
appears that the effects of hyperglycaemia in combination
with other risk factors such as smoking, hypertension, hy-
percholesterolaemia and overweight are more harmful to
women than men86
. In type 1 diabetes, women are twice
as likely as men to suffer neural and retinal problems87
.
These gender differences in mortality and risk of complica-
tions may be explained by more frequently occurring high
levels of bad cholesterol and high blood pressure in wom-
en85
. Another potential reason is that pre-menopausal
women with diabetes lose the natural protection against
heart disease that non-diabetic women have86
.
Diabetes kills more Thai women
than men
In Thailand, more than twice as many women die of
diabetes than men. At ages 50-74, diabetes is ranked as
7th
cause of death in men whereas it is ranked as the 1st
leading cause of death in women, responsible for 1 in 8
deaths36
. Although independent factors such as road-traf-
fic and HIV / Aids mortality play a role in explaning these
differences, it is also true that in Thailand more women
than men have diabetes; 8.3% vs. 6.6%70
. This may be
explained by a 50% higher prevalence of overweight and
obesity in women compared to men29
.
The foundations of life are laid in
early life
In addition to the genes they pass on to their offspring
and the direct biological influene imparted during preg-
nancy (through the uterine environment), women can also
influence the next generation by feeding and caring for
their children and encouraging them to adopt a healthy
lifestyle88
. Healthy habits, such as eating a balanced diet,
exercising and not smoking, are learnt early in life, and are
associated with parental examples89
.
Interventions that account for a life-course approach
to chronic diseases highlight that chronic disease risks
increase with age and that interventions made early in life
produce a substantial risk reduction later in life.
Gestational diabetes
The value of a healthy pregnancy cannot be underesti-
mated, directly, Gestational Diabetes Mellitus (GDM) is as-
sociated with an elevated risk of birth complications. From
a diabetes perspective, women diagnosed with GDM are
seven times more likely to develop type 2 diabetes later in
Impact of intervention to chronic diseases

31
life compared with women without GDM90
. Furthermore,
children of mothers with GDM or pre-existing diabetes are
more likely to develop diabetes themselves in later life91,92
.
According to WHO criteria, GDM affects 1 in 7 preg-
nancies in Thailand93
and with the stricter criteria of the
International Association of the Diabetes and Pregnancy
Study Groups as many as 23% of pregnancies in Thailand
was found impacted by GDM12
. Reason for the preva-
lence estimates to vary significantly are the differences in
screening methodology, testing procedures and diagnos-
tic criteria applied in various studies and the controversy
around these. It is evident though that if and when close
follow-up and testing is applied, prevalence of GDM is
high. This was recently confirmed by a prospective study
in Chulalongkorn hospital which identified up to 1 in 5
women with GDM142
.
Fact is, as young Thai women approach the age of first
birth their level of physical activity is going down and at
age 18 is less than a third it was at age 1394
. Prevalence of
overweight and obesity in women increases rapidly after
age 18 and nearly a third of women is overweight26
at the
time when their first child is born95
. With a rising aver-
age age of marriage in Thailand96
, together with weight a
key risk factor for GDM, the prevalence of GDM is set to
increase.
Children with type 1 diabetes
The incidence of type 1 diabetes in Asia and Thailand is
low in comparison to Europe. Whereas 30 to 40 children
per 100,000 are diagnosed with type 1 diabetes annu-
ally in Northern Europe97
, this number is as low as 1.6 per
100,000 children in Bangkok98
and possibly even lower at
0.6 per 100,000 children in Northern99
and Southern100
Thailand. Genetic susceptibility may play a role101
and it
has been suggested that a lower exposure to sunlight and
vitamin D contributes to the higher incidence in Europe102
.
It is also worthwhile to note that in Thailand, the inci-
dence rate of type 1 diabetes appears to be much higher
in girls than in boys, for reasons not explained.
Tomorrow’s challenge: children with
type 2 diabetes
Although the incidence of type 1 diabetes in Thai children
is suspected to increase98-100
, there is more concern for the
increase in the number of children with type 2 diabetes
coinciding with the rapidly increasing prevalence of obe-
sity in children31
.
The paediatric department of Ramathibodi hospital has
seen the proportion of children with type 2 diabetes in-
crease from virtually none in the 1990s to 40% of all cases
by 2005103
. Similar data is reported from Siriraj hospital
where 30% of all children with newly diagnosed diabetes
in 2004 were diagnosed with type 2104
. The incidence
rate of type 2 diabetes in children can be expected to have
increased further in the last years but no recent data was
discovered to provide further insight. Better data availabil-
ity should help contribute to an appropriate health policy
response.

32
The social and financial burden of diabetes is large and growing fast. Most
of the cases of type 2 diabetes are preventable and most of the long-term
complications can be delayed or prevented.
If we fail to act now, the future costs will be even higher.
Long-term rather than short-term thinking is essential. Investment in
measures to prevent diabetes, to diagnose the disease early and treat it well
is critical and urgent. Strong systems are also needed to track progress and
drive improvement.
• Measure: collect information on as local a level as possible
• Share: publish this information and identify the best practices
• Improve: learn from the differences, exchange best practices and
implement them to improve outcomes for people with diabetes
9. WHAT nEEDS TO CHANGE?

33
Primary prevention of chronic
diseases
Prevention programmes must be recognised as a corner-
stone in a global response to the chronic disease bur-
den105
. By encouraging and facilitating a healthier lifestyle
with a balanced diet, moderate exercise, and an avoidance
of tobacco and alcohol, primary prevention aims to pre-
vent people from developing chronic diseases.
Large clinical trials as well as ‘real-world’ prevention
programmes have provided evidence that lifestyle inter-
ventions can prevent or delay the onset of type 2 diabetes
in people at high risk107
. Specifically, the risk of develop-
ing type 2 diabetes can be reduced by 58% over a 3 to 5
year period for people with impaired glucose tolerance by
intensive lifestyle modification programmes108,109
. A risk
reduction of 31% can be achieved through pharmacologi-
cal intervention109
.
The key to successful prevention is lifestyle changes, such
as weight reduction, increased physical activity, and dietary
modifications to increase dietary fibre and reduce total
and saturated fat intake. The more of these lifestyle goals
or healthy behaviours that are achieved, the lower the
incidence of type 2 diabetes107,110
.
This has clear benefits for the individual and society, as
preventing or delaying the onset of diabetes will reduce
the occurrence of costly and irreversible diabetes-related
complications.
The complex nature of chronic diseases, including diabe-
tes, requires a sustainable and comprehensive approach
to prevention. Ideally, prevention programmes should
combine broad population-based primary prevention while
simultaneously targeting disadvantaged groups and peo-
ple at high risk of developing a chronic disease105
.
10. PREVENTION PROVIDES THE
GREATEST POTENTIAL FOR GAIN
Diabetes and other chronic diseases, especially for people at high risk, can
be delayed or even avoided by prevention programmes.
Common risk factors
The chronic disease burden is largely caused by shared
modifiable risk factors, including diet, physical activity,
alcohol and tobacco105
. Based on these common risk fac-
tors, a common approach could reap significant rewards.
A community-based prevention programme – for example,
one that encourages a healthy diet – could have the ben-
efit of reducing the rise in diabetes, but also of reducing
the risk of other chronic diseases. Furthermore, multiple
risk factors are often present within the same individual.

34
As a ‘health in all policies’ approach is needed111
, it is
necessary to collaborate to ensure the success of health
promotion and disease prevention interventions; health-
care professionals, payers, education providers, the food
industry, the media, urban planners, politicians and non-
governmental organisations must join forces to utilise pre-
vention efforts112
. Furthermore, alignment of all national
policies including agriculture, trade, industry and transport
is needed to promote improved diets and increased physi-
cal activity4
.
Primary prevention is often cost-
effective
Prevention programmes improve health in the long term
but can involve costs in the short term. Furthermore, in
the case of chronic diseases, the health benefits – and cost
savings – are only realised many years after having imple-
mented such prevention programmes. Health budgets are
often allocated to activities that provide tangible benefits
in the short term – even if the benefit to society in the
medium to long term is smaller, compared with investing
in prevention programmes112
.
However, ‘best buys’ in terms of prevention exist. These
interventions have a significant public health impact,
and are highly cost-effective, inexpensive and feasible to
implement. Such interventions in terms of lifestyle include
promotion of public awareness about diet and physical
activity through mass media, reduced salt in food and
replacement of trans-fats105
.
By encouraging reduced consumption of tobacco,
alcohol and unhealthy food, improving awareness
of healthy lifestyles and using financial incentives,
prevention programmes can effectively tackle the leading
causes of NCDs and their underlying risk factors112
.
Thailand Healthy Lifestyle Strategy
Recognising the need for multi-sectoral collaboration to
tackle the emerging burden of chronic non-communicable
diseases, the National Economic and Social Development
Board (NESDB), the Ministry of Public Health (MoPH) and
the Institute of Nutrition of Mahidol University (MU), have
collaborated to prepare the Thailand Healthy Lifestyle
Strategic Plan for 2011 to 2020113
.
In this strategic document the ultimate long-term goal
outlined is to increase life expectancy free of lifestyle dis-
eases, decrease mortality from and expenses for treatment
of lifestyle diseases.
Key medium term targets are aimed at reducing obesity
and increasing physical activity. It also recognises that
successful intervention requires leaders of all sectors to
collaboratively push the identified policies.
The strategic plan was approved in principle by the cabinet
in 2011 although no detailed action plan has been pub-
lished covering its implementation towards target.

35
11. IMPROVING OUTCOMES BY
EARLY DETECTION
Early detection and appropriate intervention presents an opportunity to
improve outcomes for people with diabetes and other chronic diseases.
Is early detection warranted?
In 2013, the International Diabetes Federation3
estimated
4.1 million Thai adults had impaired glucose tolerance and
are at increased risk of developing diabetes in the future.
This represents 8.4% of the Thai adult population and is
expected to affect more than 1 in 10 Thai adults by 2035.
Why detect early?
The purpose of early detection is to detect a disease with
no apparent symptoms and improve the patient’s outlook
by timely treatment. Health checks can identify people
who are undiagnosed or at high risk of developing a dis-
ease and allow for treatment and prevention. Criteria for
identifying when health checks are effective measures to
improve public health have been developed:
1. The disease should constitute a public health issue of
sufficient severity
2. The disease should be well understood and have early
detectable phases when symptoms are not apparent
3. Interventions in the early phase should be effective
in preventing or delaying onset of the disease and its
complications
4. A safe, reliable and accepted testing procedure exists
Targeted, opportunistic case finding – based on national
risk factors for type 2 diabetes and heart disease – where
the population to be screened is selected by simple ques-
tionnaires, can meet these criteria111,114
.
Why detect diabetes early?
Diabetes-related complications can be potentially post-
poned or avoided through early detection111
, assuming
appropriate treatment and management and appropri-
ate preventive measures. Furthermore, it has been found
that people who have a high cardiovascular risk should be
treated with a multi-drug regimen and counselling, which
reduces the risk of developing heart attacks, strokes and
kidney disease105
.
Early intervention can be effective and, even if the inter-
vention is stopped after some years, the patient may ben-
efit from fewer complications in the long term because of
the early lifestyle changes and early intensive treatments25
.
Cost-effectiveness of early detection
Ideally, policy decisions should be made on the basis of
strong, long-term clinical evidence115
. However, for early
detection and health-check programmes, this is unlikely
to occur116
due to time, cost and ethical considerations.
In the absence of this information, modelling future
outcomes becomes relevant115
. Recent modelled results of
type 2 diabetes health-check programmes have indicated
cost-effectiveness in given settings117
. Other early
detection interventions, including providing aspirin to peo-
ple with a heart attack and controlling blood glucose
levels in people with diabetes, have also been identified
as cost-effective, often being inexpensive and feasible to
implement105
.

37
12. Patient self-management,
education and support
Multi-disciplinary strategies that help motivate, educate and support
people to manage their condition are an essential part of chronic care.
Effective self-management cannot
be assumed
A large proportion of people with diabetes and other
chronic conditions have difficulties following their pre-
scribed treatment and as a result do not achieve optimal
treatment outcomes118,119
; less than 50% of people with
diabetes have satisfactory blood glucose, cholesterol and
blood pressure control81,83,84
. Many factors play a role in
influencing self-management in chronic illness and multi-
disciplinary strategies are needed at national and local
levels118
.
In diabetes, and other self-managed chronic conditions,
it is the person with the condition and their family mem-
bers, rather than the healthcare team, who are ultimately
responsible for managing daily treatment. Lack of confi-
dence in managing the disease and the effectiveness of
treatment are some of the factors playing a key role in
diabetes self-management120
.
Other factors include the complexity and lack of under-
standing of treatments and dosing, especially for patients
receiving multiple medications for different conditions118
.
In type 2 diabetes, psychological barriers to initiation or in-
tensification of treatment among patients and healthcare
professionals also contribute to delays in initiating required
medical therapy121
.
Without the patient involved, treat-
ment will be less effective
Diabetes treatment guidelines also highlight the central
role of education and self-management issues for the
management of diabetes122
. National policies and pro-
grammes for the prevention and management of chronic
illnesses, such as diabetes, depend on an in-depth under-
standing of the social, psychological and behavioural as-
pects of the condition and its treatment. Multi-disciplinary
strategies that help motivate, educate and support people
to manage their condition are an essential part of chronic
care.
The World Health Organisation’s (WHO’s) innovative
framework for care of chronic conditions123
calls for chron-
ic care policies to focus efforts on the activated patient
and enable effective roles for the family and the com-
munity in healthcare systems. The International Alliance
of Patient Organisations’ (IAPO’s) declaration on patient-
centred healthcare124
highlights the need for involvement
of patients in all phases of healthcare change.
Better adherence to diabetes treatment is associated with
better management and lower healthcare utilisation125
and the evidence on the effectiveness of self-management
support is growing126-127
.
A model for patient-centred care
Little research on the status of provision of quality assured
and evidence-based diabetes self-management education
is available from Thailand, an area for special focus and
attention in the future.
The figure below summarises the key areas that have
been shown in large studies to influence a patient’s ability
to self-manage and achieve a good quality of life with
diabetes. Future health policy frameworks should encour-
age better practices and evidence-based strategies for
addressing all of these dimensions in an evidence-based
and cost-effective way.
With less than 50% of people with diabetes achieving sat-
isfactory control of blood glucose, cholesterol and blood
pressure, there is a need to strengthen healthcare systems
and to ensure patient-centred care across various levels of
healthcare4
.

38
13. TREATMENT TOWARDS TARGET
Effective treatment after diagnosis can help to extend and improve the lives
of millions - and produce long-term cost-savings at the same time.
Scenarios
In recent years much evidence has shown that enhanced
treatment improves the long-term prospects of the person
with diabetes7,25
. Computer simulation models can help to
clarify the impact of enhanced treatment on benefits and
costs. The CORE Diabetes Model is well validated128
and
allows a calculation of long-term outcomes, based on the
best data available from published trials. Diabetes man-
agement strategies can thus be compared in different pa-
tient populations in a variety of realistic clinical settings129
.
Baseline
According to the data collected in the UKPDS25
the aver-
age person with diabetes - diagnosed at age 52 - can ex-
pext to develop minor complications after 8-10 years and
after 14-16 years the first major complications. Amongst
these complications, 1 in 5 people will develop severe vi-
sion loss and 15% will suffer from endstage renal disease.
Enhanced treatment
With enhanced treatment aimed at HbA1c <7.0%21
both
minor and major complications can be delayed by 2-4
years compared to baseline and life expectancy is ex-
tended by 2 years with strong effects on life quality. The
number of people with endstage renal disease will be
60% lower compared to baseline130
.
Early diagnosis
Early diagnosis and effective intervention will further delay
the onset of minor and major complications with fewer
than half the people suffering from severe vision loss com-
pared to the baseline scenario. Life expectancy is extended
by 1 more year130
.
Economic cost of diabetes
The CORE Diabetes Model can also be used to calculate
the direct economic costs of diabetes, including the cost
of medication, management and complications. Analysis
in a UK setting shows that more effective treatment at an
earlier stage will increase the early costs, in particular that
of medication, but costs will be reduced in the longer term
by delaying or preventing the expensive hospital treatment
needed for a wide range of complications such as end-
stage renal disease and diabetic retinopathy130
.

39
14. MEASURE, SHARE, IMPROVE
By effectively measuring and sharing data – utilising the potential of health
informatics – the lives of people with diabetes can be improved.
The power of measuring and shar-
ing data
Care for chronic diseases, including diabetes, cannot
be improved until there is a solid understanding of the
level of care today. Only when outcomes are consistently
and continually measured and compared can strategies,
treatment methods and healthcare systems be improved.
Collection of indicators of healthcare and outcomes and
analysis based on income level, age, sex and ethnicity is
necessary to allow policymakers to adequately assess the
effects of interventions and allocation of healthcare budg-
ets and ensure progress towards equality89,111
. By measur-
ing and sharing data – utilising the potential of health
informatics – the lives of people with diabetes, and other
chronic diseases can be improved.
Measuring and sharing quality–of-care data increase
knowledge which can lead to improved care for people
with chronic diseases such as diabetes. It can also contrib-
ute to better awareness and understanding of a disease
and relevant treatment practices. There are many ways to
measure quality of care of people with chronic diseases;
for example, monitoring potentially preventable hospital
admissions is a good indicator of the quality of diabetes
primary care131
.
Several countries in Europe collect data on diabetes in
a national diabetes registry132,133
. A diabetes registry
that captures information on quality of care offers great
potential for continuous monitoring and improvement134
.
However, collecting information on risk factors such as
tobacco use, unhealthy diet, lack of physical activity and
alcohol consumption is also necessary89
.
In Thailand, there is no national diabetes registry continu-
ously monitoring diabetes control and quality of care. Two
separate initiatives with a relatively large sample size give
some insight in the development over time, the National
Healthy Examination Surveys (conducted in 1991, 1997,
2004 and 2005) and the DiabCare Study series (conducted
in 1998, 2001, 2003 and 2008). More than 10 stud-
ies have been identified providing insight in control and
quality of care at one time-point for a single hospital or
province. There is no systematic way in which these data
are collected and shared to discuss good practices.
Changing Diabetes®
Barometer135
A constructive model to share solutions and raise aware-
ness of problems in the control of diabetes and quality of
care is provided by the Changing Diabetes Barometer. Its
three cornerstones are Measure, Share and Improve. The
Barometer aims to illustrate the link between the quality
of diabetes care provided, reduction in complications and
socio-economic costs, thus providing all stakeholders with
the opportunity to make informed choices.
The Barometer’s doctrine is that ‘only when outcomes
are measured and shared can improvements be made’,
inspiring stakeholders to adopt and follow good practice
examples.

40
15. CONCLUSION: DIABETES
AFFECTS THAILAND... AT EVERY
LEVEL...
...the person with
diabetes
It is the person with diabetes that feels the impact of a
diagnosis most directly. The realisation that life expectancy
is shortened by 6-8 years18,134
, that lifelong medication is
required and that lifestyle adjustments have to be made
often hits hard.
People with diabetes worry about the possibility of long-
term complications but also about hypoglycaemia and
how their diabetes may impact work and family income59
.
Having diabetes is associated with a significantly higher risk
of developing depression and other psychological problems
compared with the general population52,53
.
Although Thailand has nationally organised healthcare that
includes coverage for essential medicine and hospitalisation,
these direct costs are only part of the total cost of illness
with the patient and familes having to shoulder the cost of
informal care, travel, work absence and disability58
.
...family and
carers
Treatment for all aspects of chronic diseases such as diabe-
tes may not be accessible, available or affordable, and the
life-long burden of treatment and management costs can
push families into poverty89
. The social and emotional im-
pact on a family dealing with diabetes is often greater than
the direct costs of treatment and lost income alone.
Furthermore, as older and socially disadvantaged groups of-
ten have multiple chronic diseases and risk factors, effective
treatment often demands numerous medications89,118
and
the elderly are the greatest consumers of prescription
drugs89
. For this reason, adherence to long-term therapy
can be a challenge118
. Stigma and discrimination also play
a role, and certain chronic diseases such as diabetes can
diminish employment opportunities111
. This compounds
the interrelationship between poverty and ill health89
.
Diabetes has been shown to have a substantial negative
impact on family relationships and social life, leading to a
reduction in health-related quality of life137
. The availability
of social support plays a crucial role in people with diabetes
being able to adhere to treatment and manage their condi-
tion successfully118
.
...employers and
the national econ-
omy
Dying young or living with long-term illness or disability
has economic implications for families and society and the
cost to employers and national economies is increasing.
Poor health of employees causes productivity losses due
to lost working time through absenteeism, sub-optimal
performance due to physical and psychological problems,
sickness, early retirement and premature death.
Research on the economic impact of diabetes and other
chronic diseases is still in its early stages globally and
information from Thailand is scarce. The morbidity and
premature mortality rates attributable to chronic diseases
highlight effective interventions for chronic disease that
could bring significant health and economic gain to many
countries including Thailand.

42
16. SHARING EXPERIENCES
There are already many successful programmes in and around Asia that are
tackling diabetes in innovative and effective ways. Sharing information and
ideas about ‘what works’ is one of the most positive options for the future.
Thailand: retinopathy screening
Retinopathy is one of the most common long-term com-
plications of diabetes and early detection and treatment
can help to slow progression and prevent blindness.
Two mobile eye units equipped with
digital camera and laser therapy machine
were built supported by a donation from
the World Diabetes Foundation and a
charity donation from the Royal Danish
Embassy in Thailand in 2009. The mobile
clinics work under grant support from
the National Health Security Office and
the Ministry of Public Health in coopera-
tion with the Royal College of Ophthal-
mologists and Diabetes Association of
Thailand.
Two years of Service in 43 provinces, fundoscopic pictures
were taken in 822,573 patients and diabetic retinopathy
was detected in 101,783 cases (12.4%). Laser therapy
was performed in 14,493 eyes138
.
Italy: measuring and sharing quality
of care data
The Italian Association of Diabetologists (AMD) realised
the importance of measuring and sharing quality-of-care
data to reduce the burden of diabetes. For this reason it
began collecting diabetes quality indicators from all diabe-
tes outpatient clinics in 2004.
The initiative now involves 250
diabetes clinics throughout Italy,
covering a total of over 400,000
people with type 1 or type 2
diabetes. The quality-of-care data
collected are compared with re-
alistic gold standards established
by identifying the best centres
operating in the same healthcare
system under similar conditions. This approach represents
a key feature of the continuous quality-improvement ef-
fort implemented in Italy.
Results are then publicised through a specific publication
(AMD Annals) and on a dedicated page of the AMD
website, and discussed with investigators at an annual
meeting. The project is conducted without allocation
of extra resources or financial incentives, but through a
physician-led effort made possible by the commitment of
the specialists involved.
The participation of clinicians in the AMD Annals
initiative has already proven effective in improving
process and intermediate outcomes indicators.
Israel: continuous improvement of
a chronic care model
Since 1997, a diabetes programme has been in place
in Israel run by one of the major health insurers, Clalit
Health Services. It includes adaptation of clinical guide-
lines, continuous medical education, improved national
electronic health records and software to support health-
care professionals making clinical decisions. The scheme
provides a way of ensuring that patient information can
be consistently accessed and tracked, and is incorporated
in the electronic medical file of each patient, thus requir-
ing minimal training to use.
The system helps to facilitate preventive care,
and faster and more accurate detection. It
has also been found to increase the time
that healthcare professionals can spend with
patients, and reduces costs by reducing du-
plicate testing and unnecessary procedures.
Currently, it covers 100% of the population
of Clalit Health Services. In recent years, all of
the other health maintenance organisations
in Israel have adopted a similar solution to
combat diabetes, and they all work together
under the auspices of the Israeli Diabetes Barometer.
Building primarily on the quality indicators in this diabetes
programme, a National Programme for Quality Indicators
for Health was established in 2004. To date, the pro-
gramme has had positive results, with the proportion of
people with diabetes receiving the necessary blood tests
increasing four-fold. Furthermore, improvements in the
proportion of people with diabetes adequately control-
ling their cholesterol and blood glucose levels have been
observed: the proportion of people with diabetes in good
control rose from 28% in 1999 to 53% in 2007.

43
Clalit is Israel’s largest health maintenance organisation,
covering about 70% of all people with diabetes in Israel.
With government support, it initiated the registry in 1996,
and now has an extensive collection of diabetes quality
indicators. The registry has been accompaniedby a range
of workshops and activities with the aim of improving
diabetes care.
UK: structured diabetes self-man-
agement education (DESMOND)
A recent study involving 824 adult patients from 207 gen-
eral practices in the UK found that people who received a
group-based, patient-centred structured diabetes self-
management education course had greater improvements
in weight loss and smoking cessation compared with
people who did not. The education programme, Diabe-
tes Education and Self-Management for On-going and
Newly Diagnosed (DESMOND), was carried out by the UK
National Health Service.
DESMOND is a structured patient
education and management pro-
gramme designed for newly diagnosed
people with type 2 diabetes. It aims to
support people in identifying health
risks and developing personalised
goals while also providing emotional
and social support. This study also
evaluated the cost-effectiveness of the
DESMOND programme, and conclud-
ed that it is likely to be cost-effective
compared with usual care for people with type 2 diabetes.
The programme fulfils the National Institute for Health and
Clinical Excellence national guidelines and quality criteria
for education, and is available through a quality assured
process on a national basis. The education model has been
adapted in the Netherlands and, more recently, in Austral-
ia, and provides inspiration for potential wider use.
Saudi Arabia: better diabetes care
through specialised diabetes centers
In response to the high prevalence rates of diabetes in the
region, the Ministry of Health in Saudi Arabia developed
and supported a plan to establish more specialised diabe-
tes centres in the different parts of the Kingdom. These
centres provide education, training, and treatment and
management plans for people with diabetes.
As diabetic foot complications
are a leading cause of lower-limb
amputation, some of these centres
were given specific responsibility
for increasing awareness among
healthcare providers and people with diabetes of dia-
betic foot care and the prevention of complications. The
preliminary results from these centres suggest that the
programme has been successful in increasing awareness
and decreasing the rate of amputation. Furthermore, the
success of these programmes have been effective in all lo-
cations, with satisfactory results being achieved in tertiary
care facilities as well as remote hospitals affiliated to the
Ministry of Health.
Thailand: holistic diabetes care
Most healthcare systems today are organised to treat the
acute symptoms of disease and manage conditions sepa-
rately. Diabetes is a complicated chronic disease and ef-
fective management requires a multi-disciplinary approach
addressing glucose management, lifestyle modification,
management of complications and not in the least patient
education. An integrated patient-centred approach will
capitalise on common treatment needs and is thus set to
have a greater impact.
Trained in the United States, Professor
Thep Himathongkam returned to Thai-
land to find the implementation of a ho-
listic team-based model of diabetes care
such as he had observed in the world-
famous Joslin Diabetes Center in Boston,
USA, very challenging. In 1985 Dr Thep
established the Theptarin Diabetes and
Thyroid Center with the goal to create a
model for holistic treatment of diabetes
in Thailand. The model emphasised the
empowerment of people with diabetes
to care for themselves and the integrat-
ed diabetes care team comprised of an endocrinologist, a
diabetes nurse educator and a dietitian.
The facility was modest at first, with only eight beds, and
struggled to attract medical professionals and patients,
but as awareness of diabetes increased, patient demand
grew and the center gained increasing recognition and
started to expand its size and services. The hospital be-
came the first in Thailand to offer a specialised diabetic
foot clinic for wound care and prevention and opened a
‘Lifestyle Building’ to promote the prevention of diabetes
and related chronic diseases.
Although a private hospital, it is unusual in its commit-
ment to public education and professional capacity build-
ing and has successfully sought partnerships with donors
and corporations to fund these activities. The World
Diabetes Foundation has funded several of its programmes
and it partners with multinational companies to help its
employees keep healthy.

44
17. ABOUT NOVO NORDISK
Novo Nordisk is a global healthcare company with 90 years of innovation
and leadership in diabetes care.
Novo Nordisk in short
Novo Nordisk is a global healthcare company with 90
years of innovation and leadership in diabetes care. In
1923, our Danish founders began a journey to change
diabetes. Today, we are thousands of employees across the
world with the passion, the skills and the commitment to
continue this journey to prevent, treat and ultimately cure
diabetes. The company also has leading positions within
haemophilia care, growth hormone therapy and hormone
replacement therapy. Headquartered in Denmark, Novo
Nordisk employs approximately 35,000 employees in 75
countries, and markets its products in more than 180
countries.
Building on the past - looking to the
future
Two small Danish companies, Nordisk (1923) and Novo
(1925), started production of the revolutionary new drug
insulin that had just been discovered by Canadian scien-
tists. Competing intensely with one another, the compa-
nies developed into two of the best in their field responsi-
ble for many innovations, such as the breakthrough insulin
NPH (Neutral Protamine Hagedorn) introduced in 1950
and the world’s first insulin injection device launched in
1985.
Still in the early days of their existence, both Novo and
Nordisk established their own hospitals to offer better
treatment and provide outlook on a normal life for people
with diabetes. The hospitals were combined in 1992 to
form the Steno Diabetes Centre, an internationally recog-
nised centre of excellence in diabetes treatment, educa-
tion and translational research.
The companies merged in 1989, creating Novo Nordisk,
one of the world’s largest biotechnology groups and a
group that has been expanding rapidly ever since. Today,
the Novo Nordisk Way shows responsibility to patients,
employees, communities and investors. We will in the
future continue to build on the legacy left by the found-
ers of Novo Nordisk and do whatever it takes to change
diabetes. Our history tells us it can be done.
Changing diabetes®
Changing diabetes® is a commitment to answer the
needs of people with diabetes in every decision and
action. This means delivering targeted treatments based
on a deep understanding of individual needs, and doing
so with financial, social and environmental responsibility.
But treatment is only part of the solution to the diabetes
challenge. This is why we advocate for concerted action
to address the pandemic, challenging systems, political
priorities and health expectations worldwide. In addition,
we collaborate with global organisations and governments
in driving diabetes awareness, prevention and equal access
to care.
Through our actions we will break the curve of the dia-
betes pandemic, and we will measure and report on our
progress. Until we defeat diabetes, we will continue to
support people in living fuller, healthier and more produc-
tive lives.
World Diabetes Foundation
The World Diabetes Foundation (WDF) is dedicated to cre-
ate awareness, care and relief to people with diabetes in
the developing world. At its heart lies the promise of equal
access to diabetes care.
The WDF was launched as an independent, non-profit
organisation through a grant from Novo Nordisk, and
tries to help where it will count the most - in developing
countries where 80% of the world’s explosion in diabetes
is expected to occur.
Since 2001, the WDF has supported several projects in
Thailand with 2 examples described in chapter 16 of this
booklet, for more information on the WDF please visit
www.worlddiabetesfoundation.org.

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