What are the guidelines for managing diabetes in South-East Asia?

Diabetes Management Guidelines for South-East Asia

The management of diabetes in South-East Asia requires a multidisciplinary collaborative approach tailored to the unique characteristics of the South Asian population, who develop diabetes at younger ages, with higher glycemia, and increased risk of complications compared to other ethnic groups. 1

Diagnosis and Risk Assessment

BMI and Waist Circumference Thresholds

• Lower BMI thresholds for South Asians:
  • Overweight: BMI ≥23 kg/m²
  • Obesity: BMI ≥25 kg/m² with complications
  • Waist circumference cut-points: ≥90 cm for men, ≥80 cm for women 2

Screening Recommendations

• High-risk populations should be screened early:
  • Adults >40 years
  • History of prediabetes
  • Overweight/obese individuals (BMI ≥24 kg/m²)
  • Screen at least once every 3 years if initial results are normal 2
• For children/adolescents in high-risk groups:
  • Begin screening at age 10 or at puberty (whichever comes first) 2

Treatment Approach

Lifestyle Interventions

1. Dietary Modifications:

   • Replace refined carbohydrates (white rice) with whole grains (brown rice) 3
   • Reduce intake of saturated fats, partially hydrogenated oils, and sugar
   • Increase fiber, protein, fruits, and vegetables intake 2
   • Daily energy intake goals:
     • Women: 1200-1500 kcal/day
     • Men: 1500-1800 kcal/day 2

2. Physical Activity:

   • Minimum 20 minutes of moderately intense activity daily 2
   • Tailor physical activity recommendations to individual capabilities

3. Weight Management:

   • Target 5-15% weight loss over 6 months 2
   • Greater weight loss (>10%) may be needed to prevent progression to T2DM 2

Pharmacological Management

1. First-line Therapy:

   • Metformin remains the cornerstone of initial pharmacological therapy 4
   • Start at low dose and titrate based on glycemic response
   • Monitor renal function regularly

2. Second-line Options:

   • GLP-1 Receptor Agonists:

     • Consider for patients with BMI >27 kg/m² without complications or BMI >25 kg/m² with complications 5
     • Contraindicated in patients with history of medullary thyroid carcinoma or MEN2
     • Require gradual dose titration to minimize GI side effects

   • SGLT2 Inhibitors (e.g., Empagliflozin):

     • Beneficial for patients with established cardiovascular disease or high CV risk 6
     • Monitor for ketoacidosis, genital mycotic infections, and urinary tract infections

   • Thiazolidinediones (e.g., Pioglitazone):

     • Can be initiated at 15 or 30 mg once daily
     • Monitor for fluid retention and heart failure risk
     • Do not initiate if active liver disease or elevated transaminases 4

3. Insulin Therapy:

   • When initiating insulin with oral agents like pioglitazone, the insulin dose can be decreased by 10-25% if hypoglycemia occurs 4
   • Individualize insulin regimens based on glycemic patterns

Monitoring and Follow-up

1. Blood Glucose Monitoring:

   • Self-monitoring frequency based on individual needs and treatment regimen
   • More frequent monitoring (4-7 times daily) for hospitalized patients or those with poor glycemic control 2

2. HbA1c Monitoring:

   • Better indicator of long-term glycemic control than FPG alone
   • Evaluate response to therapy after 3 months of treatment 4

3. Complication Screening:

   • Regular assessment for microvascular and macrovascular complications
   • Early and aggressive management of risk factors (hypertension, dyslipidemia)

Special Considerations for South-East Asian Populations

1. Cultural Factors:

   • Address cultural beliefs about weight and health
   • Consider dietary preferences and traditional food patterns
   • Recognize family-centered meal practices 2

2. Socioeconomic Factors:

   • Adopt a stratified approach based on healthcare resources
   • In countries with limited specialist resources, primary care physicians can effectively support patients 2

3. Cardiovascular Risk Assessment:

   • Consider using the QRISK2 calculator for South Asians
   • Standard risk calculators may underestimate risk in this population 2

Pitfalls and Challenges

1. Common Pitfalls:

   • Delayed diagnosis leading to early complications
   • Inadequate treatment and follow-up
   • Use of ineffective alternative medicines
   • Non-compliance with lifestyle recommendations 1

2. Strategies to Overcome Challenges:

   • Strengthen primary care models
   • Improve referral linkages
   • Implement rehabilitation services for patients with chronic complications
   • Provide training to non-physician healthcare workers 1

The management of diabetes in South-East Asia requires recognition of the unique characteristics of this population, including earlier disease onset, higher complication rates, and specific dietary and cultural factors. A comprehensive approach focusing on early intervention, aggressive risk factor management, and culturally appropriate lifestyle modifications is essential to reduce the burden of diabetes in this region.