Department of Medicine, Faculty of Medicine, University of Indonesia, Salemba 6 Jakarta, Indonesia

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Tohoku J. exp. Med., 1983, 141, Suppi., 219-228 Diabetes Mellitus in an Urban Population in Jakarta, Indonesia S. WASPADJI, A.B, RANAKUSUMA, S. SUYONO, S. SUPARTONDO and U.

1 Tohoku J. exp. Med., 1983, 141, Suppi., Diabetes Mellitus in an Urban Population in Jakarta, Indonesia S. WASPADJI, A.B, RANAKUSUMA, S. SUYONO, S. SUPARTONDO and U. SUKATON Department of Medicine, Faculty of Medicine, University of Indonesia, Salemba 6 Jakarta, Indonesia Data are not available of the prevalence of diabetes mellitus in several parts of the world vary greatly, not only because of geographic and ethnic differences but also because of a lack of standardized diagnostic criteria and methods of investigations1,2,3,4) The use of the WHO diagnostic criteria published in 1980 presents an opportunity to compare the prevalence and evaluate factors which are incrimina ted as possible contributing factors in the development of diabetes mellitus. Standardized methods of investigation and reporting are expected to further facilitate this comparison and evaluation of the disease 2,3,4). We conducted a study on diabetes mellitus in order to make a contribution to the task of carrying out a comparative study of data concerning diabetes mellitus among world populations. MATERIALS AND METHODS The survey was conducted in Koja Utara subdistrict, Tanjungpriok, Northern Jakarta, from December 1981 until June The total population was 41,961 (8,895 families) with a male to female ratio of 102: 100 and a population density of 7,018 persons/km2. The adult population (15 years and over) comprises 60% of the total populations 6>. The majority of the population are laborers. Socio-economic levels range widely from very low in the labor group to high ranking government officers and rich merchants in the high socioeconomic level. These different levels were determined by using a demographic scoring system based on housing conditions, environmental sanitation, family property, family income and family expenditure on several items. Obesity is defined by a body mass index (BMI) (weight (kg)/height ~2 (m)) 27 in males and 25 in females. Overweight was defined as percent desirable weight (PDW), normoweight as PDW, and underweight as <90 PDW. (BMI 27=120% PDW in males and BMI 25=120% PDW in females1,3,4). Several days before the test, the initial approaches to the leader of the village and the sample families (drawn by the simple random sample method) were made by house to house visits, to collect data on age, sex, religion, occupation of the head of the family and socioeconomic conditions. All members of each family aged 15 years and over were requested to take the test. Glucose (75g) was given early in the morning following overnight fast without any preparatory diet before. Venous blood samples were collected 2 hours after the glucose load. Plasma glucose was measured within 4 hours of the sample collection, using the 219

2 220 S. Waspadji et al. Technicon autoanalizer, ferricyanide method. Those found to be diabetic according to the WHO criteria set in 1980, and also the control group drawn from the normal sample matched with the diabetic group on sex, age, BMI, and socioeconomic level, were reexamined for signs, symptoms, and complications of diabetes mellitus. Chest X-ray and ECG examina tion were carried out in the nearest municipal hospital. Ophthalmoscopic examination was performed with fully dilated eyes. Blood examination was performed as well as urine examination for proteinuria (sulfosalicylic method). Subjects were questioned about their diets and these were analyzed by a competent dietician. Part of the data were analyzed using the ADDS M 6210 compurer at the data analysis laboratory of the Department of Public Health and Preventive Medicine, Faculty of Medicine, University of Indonesia. The diagram below shows the sequence of activities during the study. RESULTS The details of the study population are presented together with the sex, age, BMI, socio-economic specific prevalence in Tables 1, 2, and 3. The response rate was 75%. Non-responders were mostly from the low and high socio-economic level groups. The distribution of 2-hr plasma glucose in the study population showed a unimodal distribution with skewness to the right. In each of the age groups we found a similar distribution, except in the age group, which had the highest Fig. 1. Frequency distribution of 2 hr plasma glucose after 75g glucose load - all ages.

3 Diabetes mellitus in Indonesia 221 Fig. 2. Frequency distribution of 2 hr plasma glucose after 75 g glucose load age group. prevalence (10%), and which tended toward bimodality. (Figs. 1, 2, 3). The prevalence of diabetes mellitus defined as 2-hr plasma glucose 200mg/ 100ml was 44/2,704=1.63%, while that of impaired glucose tolerance defined as 2-hr plasma glucose 140mg/100ml and <200mg/100ml was 3.07%. Among these 44 diabetics, 18 (40%) were known diabetics and only 50% of them were receiving regular treatment. The highest prevalence of diabetes mellitus was found in the age group as shown in Table 1. Prevalence increased with age (Fig. 4). Findings in the 65 age group did not back up this conclusion due to the small number of people studied and because much of the group had succumbed to other diseases. There was no significant difference in prevalence between males and females, figures being 1.8% and 1.5% respectively (Table 1). The male to female ratio in TABLE 1. Age and sex specific prevalence

4 222 S. Waspadji et al. Fig. 3. Frequency distribution of 2 hr plasma glucose after 75 g glucose load age group. this study was 1.2:1. As for socio-economic conditions, we found that diabetes mellitus was signifi cantly more prevalent in the high level group than in the medium and the low level groups (the prevalence being 4.5%, 1.75% and 0.9% respectively, p <0.01), but there was no significant difference between the medium and the low level groups (Table 2). In agreement with other studies, we found the prevalence of diabetes mellitus to be significantly higher among the obese compared to the normoweight and underweight groups (obese 6.69%, normoweight 0.95% and underweight 0.4%, p<0.01) but there was no significant difference between the obese and the overweight group (6.7% and 3.7% respectively, p > 0.05). Among diabetics, we found 20/44=45% of them to be obese, 9/44=20% overweight, 11/44=25% normoweight and only 4/44=9% underweight (Table 3).

5 Diabetes mellitus in Indonesia 223 Fig. 4. Age specific prevalence. TABLE 2. Soclo economic and sex specific prevalence TABLE 3. Sex and nutritional status specific prevalence Even after adjustment for age and sex, the obese group still shows a higher prevalence than other groups. Further analysis of the role of the risk factors - sex, socio-economic standing and obesity -in the development of diabetes mellitus showed that the greatest association occurred between obesity and diabetes mellitus.

6 224 S. Waspadji et al. Racial differences in the prevalence of diabetes mellitus have been observed in several studies. We found a prevalence of 4.95% in the Chinese origin group compared to 1.36% in the Indonesian group (p <0.01) (Table 4). A positive family history of diabetes mellitus was found in 27% of the diabetics and 15% of the control group (p>0.05). The complications in the diabetic patients in this survey will be reported in another paper. As for the dietary analysis, we found no significant difference between diabetics and controls regarding the total amount of caloric intake, percentage of carbohydrate, percentage of protein, percentage of fat intake or percentage of refined carbohydrate (Table 5). However in the high socio-economic-diabetic group, we found a significantly higher total caloric intake than in the high socioeconmic control group (p <0.05) (Table 6). DISCUSSION The prevalence of diabetes in this study (1.6%) was similar to that reported by Adam7), in Ujungpandang, Indonesia (1.5%), in an urban population at the TABLE 4. Prevalence of diabetes mellitus in different race origin TABLE 5.

7 Diabetes mellitus in Indonesia 225 TABLE 6. Dietary constituents on different socio-economic level * p <0.05 medium socio-economic level, using WHO criteria 1980, although his study dealt with a rather selective population 7). Sutardjo8) found a higher prevalence (2.3%) using the 75 g glucose load for the positive urine serene, setting the cut-off level at 160mg/100ml5). This higher prevalence seems to have been the result of cosanguineous marriages and the higher socio-economic conditions in his sample population and also the lower cut-off level. Bunnag in Thailand9), during a routine general check up of 1,330 government bank officers in Bangkok, found 3.2% to be diabetic. In Indonesia, general check ups for government officers are performed only on the high ranking officers. If this is also the condition in Thailand, the higher prevalence might be the result of the higher socio-economic level of the population studied. Mustaffa in Malaysia10) found a prevalence of 2.1% among 89,208 admissions to the Kualalumpur General Hospital, while Yeo11) in a national survey in Singapore found the prevalence of diabetes mellitus to be 1.99% based on 2-hr venous blood glucose z 140mg/100ml following administration of 50g glucose. Their findings agree quite dosely with ours. The tendency toward bimodal distribution in 2 hr plasma glucose values is similar to the results of studies on populations with a high prevalence of diabetes mellitus in Pima Indian") and Nauruan13). The lends support to the usefulness of the new WHO criteria As can be seen from the diagram, the intersection is also around 200mg/100ml. As for differences between the sexes, our male to female ratio (1.2: 1) is similar to that found by Adam (1.6:1)7) and also by Sutardjo in Semarang (1.2: 1)8). The same ratio was also true for other Asian countries studied by Yeo in Singapore (1.4: 1)") and Mustaffa (1.3: 1)10). In Thailand, however, diabetes was found to be more common in females (2.5: 1)9>. A slight male preponderance is similarly found in other Asian countries. The Shanghai Diabetes Research group found a ratio of 1.02:114). Gupta found an even higher male preponderance15). Although female preponderance is apparent in the modern American population, male preponderance was also reported. We found a significant difference between high and low socio-economic groups (p <0.01). Gupta15) also found that in urban populations the prevalence

226 S. Waspadji et al. of diabetes increases in the higher income groups (p <0.05) in contrast to the rural population in which he found no significant difference between different income groups.

8 226 S. Waspadji et al. of diabetes increases in the higher income groups (p <0.05) in contrast to the rural population in which he found no significant difference between different income groups. The majority of the studies reported a higher prevalence in the high socio-economic level groups, similar to our result. Obesity has been incriminated by several authors as an important factor in the development of diabetes mellitus1,2,12,13,16,18) In this study we also observed a relationship between higer B.M.I. values and higher prevalence rates of diabetes ; and after further determination of the degree of association between sex, socioeconomic conditions, obesity and the prevalence of diabetes, we found that obesity has the highest degree of association of all these factors. Obesity was seen in 45% of our diabetic patients. Adam reported similar results (obesity 39%, nor moweight 41% and underweight 19.5%)7). However, Sutardjo8) reported that only 21.8% of his diabetics were overweight. 44.3% of the diabetic patients in Singapore"), 52% of the diabetics in Malaysia10) and 42% of the diabetic patients studied by Bunnag in Thailand were reported to be overweight9). A higher prevalence of diabetes among the population of Chinese origin in our study (4.97%) was in contrast to the Singaporean study 1980, which reported the lowest prevalence in the Chinese group (1.55%)11,17), as compared to the Malay (2.43%) and Indian groups (6%). A study in Shanghai reported a low prevalence of diabetes among the Chinese (1.02%)' > This difference might be the result of higher socio-economic conditions in our sample of Chinese origin, of which most are merchants. The fact that positive history of diabetes did not differ significantly between diabetics and controls suggests that genetics is not the only factor in the develop ment of diabetes mellitus. Environmental factors also play an important role. Positive family history was found in only 11% of the Malaysians10), while in Singapore there were 12.7% with positive history in Indians, 10.9% in Malays and only 6% in Chinese"). Positive family history is rather difficult to obtain especially in the low socio-economic and uneducated groups. Our dietary analysis findings support the idea that quantitative dietary constituency was not critical in the development of diabetes mellitus1,18). Per centages of refined carbohydrate ingestion were not significantly different in our study in contrast to the famous Yemenite study by Cohen19) and the Hawaiian migrant study by Kawate20). A significantly higher total caloric intake was found in the high socio-econo mic diabetic group compared to the high socio-economic normal control group supporting the view that total caloric intake was important in the development of diabetes mellitus1,18). SUMMARY AND CONCLUSIONS The prevalence of diabetes in an urban population in Koja Utara subdistrict of Jakarta is 1.63%.

9 Diabetes mellitus in Indonesia 227 The prevalence of diabetes increases with age. The tendency toward bimodality in the age group of our study lends support to the usefulness of the WHO criteria There is no difference between the sexes. Male to female ratio was 1.2:1. There is a higher prevalence of diabetes among the obese, and the obese and overweight comprise 65.9% of diabetics. Obesity seems to be an important risk factor in the development of diabetes. There was a higher prevalence of diabetes in the high socio-economic level group than in the low one. The group of Chinese origin showed a higher prevalence of diabetes than the other groups. A positive family history of diabetes was found in 27% of our diabetic patients. Dietary recall analysis revealed no significant difference in the percentage of carbohydrate, protein, fat, or in the percentage of refined carbohydrate. However, total caloric intake was significantly higher in the high socio-economic diabetic group. Total caloric intake seemed to be more important than quantita tive dietary factors. Acknowledgments We are grateful to Ms. Rochamah B. Sc. for her help with the dietary survey and assessmest, and also to Albert Sarayar and Deddy Tejakusnadi for the socio-economic assessment. We are also grateful to Mrs. Azwini Kartoyo for the demographiconsulta tions, and to all the municipal, district and subdistrict personnel for their sincere help and support in the realization of this survey. We are indebted to Dr. Sudarmo-Radiologist and Dr. S. Harun-Cardiologist for their expertise. References 1) West, K.M. (1978) Prevalence and incidence. Factors associated with occurrence of diabetes. In : Epidemiology of Diabetes and Its Vascular Lesions, edited by K.M. West, Elsevier Amsterdam, London-New York, pp and ) WHO Expert Committee on Diabetes Mellitus (1980) Second report. Technical Report Series 646, WHO, Geneva. 3) National Diabetes Data Group (1979) Classification and Diagnostic of Diabetes Mellitus and other Categories glucose intolerance. J. Diabetes, 28, ) Bennet, P.H. (1979) Recommendations for standardization of methods and reporting of tests for diabetes and its microvascular complications in epidemiologic studies. Diabetes Care, 2, ) Central Bureau of Statistics (1981) Regional Statistics of Jakarta Special Province. Jakarta Statistical Publication No , p ) Central Bureau of Statistics (1981) Statistical Year Book of Jakarta, Jakarta Statistical Office, p ) Adam, J.M.F. (1982) Diabetic survey in a population in Ujungpandang, Hasanuddin University, Ujungpandang, Indonesia. Department of Internal Medicine Hasanuddin University. 8) Sutardjo, R.D.M. (1981) Diabetes mellitus in Pekajangan Subdistrict. In: Proceed-

228 S. Waspadji et al. ings of National Congress of Internal Medicine V, Semarang, edited by Department of Internal Medicine, Diponegoro University, Semarang, pp. 99-105. 9) Bunnag, S.C. (1981) Prevalence and clinical pattern of diabetes mellitus in Thailand.

10 228 S. Waspadji et al. ings of National Congress of Internal Medicine V, Semarang, edited by Department of Internal Medicine, Diponegoro University, Semarang, pp ) Bunnag, S.C. (1981) Prevalence and clinical pattern of diabetes mellitus in Thailand. In : proceedings of the Asian Diabetes Update 1981, Yogyakarta. In press. 10) Mustaffa, B.E. (1981) The pattern of diabetes in Malaysia. In : Proceedings of the Diabetes Update 1981, Yogyakarta. In press. 11) Yeo, P.B. (1981) Singapore influence of racial factors in the epidemiology of diabetes mellitus. In : Proceedings of the Diabetes Update 1981, Yogyakarta. In press. 12) Bennet, P.H., Rushforth, N.B. & Miller, M., Le Compte, P.M. (1970) Epidemiologic studies of diabetes in the Pima Indians. Rec. Prog. Horm. Res., 32, ) Zimmet, P., Taft, P., Guinea, A., Guthrie, W. & Thoma, K. (1977) The high prevalence of diabetes mellitus in a Central Pacific Island. Diabetologia, 13, ) Shanghai Diabetes Research Group, (1980) Diabetes mellitus survey in Shanghai, Chinese med. J. 93, ) Gupta, O.P., Dave, S.K., Gupta, P.S., Hedge, H.S., Agarwal, S.B., Joshi, M.N. & Sruvastava, Y. (1975) Aetiological factors in the prevalence of diabetes in urban and rural populations in India. In: Diabetes Mellitus in Asia. Proceedings of the Second Symposium, Kyoto, Japan, edited by S. Baba et al. Excerpta Medica, Amster dam, pp ) Bennet, P.H. (1980) Increasing prevalence of diabetes in the Pima Indian over a ten year period. In: Proceedings of the 10 th Congress of IDF. Vienna edited by W.K. Waldhausl. Excerpta Medica, Amsterdam. 17) Cheah, J.S. & Tan, B.Y. (1980) Diabetes among different races in similar environ ments. In: Proceedings of the 10th Congress of IDF. edited by W.K. Waldhausl, Excerpts, Medica, Amsterdam. 18) Cahil, G.F. (1977) Diabetes and nutrition. Charaka Lecture In: Proceeding of the 9th Congress of IDF, New Delhi edited by J.S. Bajaj, Excerpta Medica, Amsterdam, pp ) Cohen, A.M. (1961) Change of diet of Yemenite Jews in relation to diabetes and ischaemic heart disease. Lancet, 2, ) Kawate, R., Yamakido, M. & Nishimoto, Y. (1980) Migrant studies among the Japanese in Hiroshima and Hawaii. In: Diabefes 1979, edited by W.K. Waldhausl, Excerpta Medica, Amsterdam, pp

Table 3 Sum of plasma glucose values (ƒ BG) and insulin values (ƒ IRI) in oral glucose tolerance test (1.5g. glucose/kg body weight)

Table 3 Sum of plasma glucose values (ƒ BG) and insulin values (ƒ IRI) in oral glucose tolerance test (1.5g glucose/kg body weight) * p