2016 Taiwan Diabetes Prevention, Treatment and Prospect of a New Realm

DT-1 Prof. Chin-Hsiao Tseng, M.D., Ph.D.

Personal Information

Nationality: Taiwan

Position: Professor

Department: Department of Internal Medicine

Organization: National Taiwan University College of Medicine

Email: ccktsh@ms6.hinet.net

Educational background & professional experience (in sequence of the latest year)

2009.8- Department of Internal Medicine, National Taiwan University College Professor of Medicine 1993-1996 School of Public Health, National Taiwan University PhD 1979-1986 School of Medicine, National Taiwan University College of Medicine MD

Research Interests

1. Diabetes epidemiology 2. Cancer risk related to antidiabetic drugs 3. Arsenic and diabetes

Publications (5 important publications – latest sequence)

1. Tseng CH. Use of metformin and risk of kidney cancer in patients with type 2 diabetes. Eur J Cancer. 2016;52:19-25. 2. Tseng CH. Sitagliptin and pancreatic cancer risk in patients with type 2 diabetes. Eur J Clin Invest. 2016;46:70-79. 3. Tseng CH. Sitagliptin increases acute pancreatitis risk within 2 years of its initiation: A retrospective cohort analysis of the National Health Insurance database in Taiwan. Ann Med. 2015;47:561-9. 4. Tseng CH, Lee KY, Tseng FH. An updated review on cancer risk associated with incretin mimetics and enhancers. J Environ Sci Health C Environ Carcinog Ecotoxicol Rev. 2015;33:67-124. 5. Tseng CH. Obesity paradox: differential effects on cancer and noncancer mortality in patients with type 2 diabetes mellitus. Atherosclerosis. 2013;226:186-192.

DT-1 IDF Diabetes Atlas 2015 and the Trends of Diabetes and its Complications in Taiwan

從 IDF Diabetes Atlas 2015 看臺灣糖尿病盛行率與併發症之趨勢

CHIN-HSIAO TSENG 曾慶孝

Department Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan, ROC 臺大醫學院醫學系內科

Diabetes is a common non-communicable disease that affects hundreds of millions of people worldwide. In the year 2015, the International Diabetes Federation estimated a total global number of 415 million people suffering from diabetes, with 1 in 11 adults having diabetes. Nearly half of the people with diabetes do not know that they are having diabetes. What is worse is that approximately 5.0 million people died of diabetes in 2015, and nearly half of them (46.6%) were under the age of 60. The incidence and prevalence of diabetes is on the rise and the global prevalence of diabetes for adults (20-79 years) was estimated to rise from 8.8% in 2015 to 10.4% in 2040.

In Taiwan, a series of epidemiological screening programs have been conducted during the past five decades. In Taipei city, the prevalence of diabetes for residents aged 40 years or older has been increasing from 5.1% in 1970, to 7.1% in 1979 and to 8.2% in 1986. During 1993-1996 and 20052008, respectively, two cycles of the Nutrition and Health Survey in Taiwan (NAHSIT) based on similar sampling strategy were conducted among residents aged 19 years or older. The crude nation-wide prevalence of diabetes for residents aged 19 years or older increased from 5.33% (age-standardized rates: 6.21%) in the first NAHSIT survey to 9.05% (age-standardized rates: 7.80%) in the second NAHSIT survey. The increased prevalence of diabetes was especially striking for the older population aged 65 years or older, from 17.13% to 25.73%, for the first and second survey, respectively. Another national survey, the Taiwanese Survey on Hypertension, Hyperglycemia and Hyperlipidemia, was conducted in 2002, and from a random sample of 4683 residents aged 25-74 years, the crude prevalence of diabetes in men (9.1%) was significantly higher than that in women (5.6%).

By continuously following a large nationally representative cohort of patients with diabetes recruited since 1995 in Taiwan, approximately 70% of the diabetic death would not be ascribed to diabetes on death certificates in Taiwan. The diabetic men have higher risk of dying than women and diabetic patients have excess mortality while compared to the general population. A recent followup of the cohort for up to 17 years showed that 10.9% died under the age of 60. Age, insulin use and smoking significantly predicted cancer and non-cancer death; and hypertension, fasting glucose and dyslipidemia showed differential impacts on cancer and non-cancer death, and were significantly predictive for non-cancer death. Screen-detected diabetes and a higher body mass index provide a survival advantage, especially for non-cancer death.

DT-2 Shu-Ti Chiou, M.D., Ph.D.

Personal Information

Nationality: Taiwan

Position: Director-General

Organization: Health Promotion Administration, Ministry of Health & Welfare, Taiwan

Email: stchiou@hpa.gov.tw

Educational background & professional experience (in sequence of the latest year)

2014~Present School of Medicine, National Yang-Ming University, Taiwan Adjunct Associate Professor 2013~Present Health Promotion Administration, Ministry of Health and Welfare, Taiwan Director-General 2013~2014 School of Medicine, National Yang-Ming University, Taiwan Adjunct Assistant Professor 2013~Present The International Union for Health Promotion and Education (IUHPE) Global Vice President for Partnerships 2012~2014 International Network of Health Promoting Hospitals and Health Services (initiated by WHO) Chair of Governance Board 2010~2012 International Network of Health Promoting Hospitals and Health Services (initiated by WHO) Vice Chair of Governance Board 2009~2013 Bureau of Health Promotion, Department of Health, Taiwan Director-General

Research Interests

1. Health Policy 2. Quality of Medical Care Research

Publications (5 important publications – latest sequence)

1. Lee CC, Chiou ST, Chen LC, Chien LY. Breastfeeding-Friendly Environmental Factors and

Continuing Breastfeeding Until 6 Months Postpartum: 2008–2011 National Surveys in Taiwan.

Birth. 2015;42(3):242-8. 2. Chiou ST, Chen LC, Yeh H, Wu SR, Chien LY. Early Skin-to-skin Contact, Rooming-in, and

Breastfeeding: A Comparison of the 2004 and 2011 National Surveys in Taiwan. Birth. 2014; 41:3338. 3. Chiou ST, Wu CY, Hurng BS, Lu TH. Changes in the Magnitude of Social Inequality in the Uptake of Cervical Cancer Screening in Taiwan, a Country Implementing a Population-based Organized

Screening Program. International Journal for Equity in Health. 2014; 13: 4. 4. Chiou ST, Lu TH. Changes in Geographic Variation in the Uptake of Cervical Cancer Screening in

Taiwan: Possible Effect of “Leadership Style Factor＂? Health Policy. 2014; 114: 64-70. 5. Chiou ST, Chen LK. Towards age-friendly hospitals and health services. Archives of Gerontology and Geriatrics. 2009; 49 Suppl 2: S3-6.

DT-2

臺灣糖尿病之現況及展望

SHU-TI CHIOU 邱淑媞

Director-General, Health Promotion Administration, Ministry of Health and Welfare 衛生福利部國民健康署

全世界目前有 3 億 8,200 萬罹患糖尿病，如果這些人組成一個國家，那麼在國家人口來排名上， 「糖尿病國」的人口僅次於中國大陸及印度，位居世界第三 ! 所以糖尿病是一個嚴重威脅世界健 康之慢性病。在台灣，糖尿病是國人十大死因第 5 位，民國 103 年因糖尿病死亡的人數達 9,845 人。 依據 102-103 年「國民營養健康狀況變遷調查」發現，18 歲以上國人糖尿病盛行率為 12.4%，全國 約近有 150 萬名糖尿病友，且每年以 25,000 名的速度持續增加，糖尿病及其所引發的併發症影響 國人健康不容小覷。 糖尿病照護最重要的是增進病患自我照護能力，延緩糖尿病併發症之發生，政府為了提升照 護品質，辦理糖尿病共同照護網，宜蘭縣衛生局首當其衝在民國 85 年率其他縣市之先，全面推動 糖尿病共同照護，迄民國 92 年已推廣至全國 22 縣市，透過公共衛生部門、臨床醫療團隊、專業 組織、病友團體等的結合，強化縣市糖尿病防治工作。為落實糖尿病照護醫事人員能遵行一致性 的品質標準來照護病人，政府建立了醫事人員訓練及認證制度，迄今已完成 9,026 人認證。健康保 險署亦以糖尿病共同照護網為基礎，加上論質計酬設計，推動「糖尿病醫療品質支付服務方案」， 透過醫療院所對病人的追蹤管理，協助病患規律就醫與自我健康管理。國民健康署與縣市衛生局 以質量並濟方式全力推動，希望所有糖尿病病人都能獲得專業照護，訂定照護涵蓋率、糖尿病人 尿液微量白蛋白檢查率，及眼底檢查率等工作重點有系統的提昇服務品質，截至 103 年照護率已 達 40.4%，但仍須經各界齊心努力，讓所有病人都能獲得優質照護。 為了更有效提升照護率，國民健康署透過不同平台，國民健康從五大面向分進合擊：1. 跨單 位合作：如跨部會合作、縣市衛生單位協力、健康促進醫院計畫、高齡友善醫院計畫等，加強橫 向連結強化彼此合作。2. 指標管理：定期將醫療院所加入方案效益及各院所各項指標表現回饋予 各院所，以形成良性競爭互相學習氣氛，激勵院所向上提升照護品質。3. 增能縣市：辦理縣市推 動經驗分享會，強化縣市衛生單位糖尿病防治規劃與推動能力。4. 提升誘因：補助部分經費給機 構以推廣糖尿病健康促進機構，並舉辦「績優糖尿病健康促進機構表揚暨新加入機構授證典禮」 對優良院所酌予獎勵。5. 強化病友團體：為增進病人權能，於全國成立 514 個糖尿病友團體，分 佈於 360 個鄉鎮市區，達全國鄉鎮市區涵蓋率近 97.8%，強化糖尿病高危險群及糖尿病人「控糖」 之自我健康管理能力等。 在各界努力下，過去十年中，台灣糖尿病標準化死亡率已由 91 年之 30/ 每十萬人口下降至 103 年的 26/ 每十萬，降幅達 13%。惟，因應全球肥胖及人口老化浪潮，仍須於健保給付機制上強 化對品質之監測與獎勵，使品質成為一種習慣，使健康成為醫、病、健保、與社會多贏的支點。

DT-3 I-Chieh Mao, M.D.

Personal Information

Nationality: Taiwan Position: Chief

Department: Endocrinology and Metabolism Organization: Lukang Christian Hospital Email: 143814@cch.org.tw

Educational background & professional experience (in sequence of the latest year)

1998-2005 China Medical University 2007-2013 Changhua Christian Hospital 2013- Lukang Christian Hospital

DT-3 The Current and Future Prospects of Continuous Glucose Monitoring System (CGMS) in Diabetes Care

連續血糖監測系統的現在與未來展望

I-CHIEH MAO 毛羿傑

Department of Endocrinology and Metabolism, Lukang Christian Hospital, Changhua County, Taiwan, ROC 鹿港基督教醫院 內分泌新陳代謝科

Continuous glucose monitoring system (CGMS) technology has shown its potential in improving the he lives of people with type 1 diabetes. Because the real-time feedback it provides about therapeutic interventions and variations in lifestyle or dietary intake, CGMS has made the attainment of near-normal blood glucose concentrations an achievable goal for most patients with diabetes and reduces diabetic complications as well. Several challenges remain to be solved, including the accuracy of the readings,accessibility in wearing the devices, high economic burden, limited approved clinical use and absence of National Health Insurance reimbursement for the technology. In the near future, CGMS undoubtedly will show its power in diabetes care. In Lukang Christian Hospital, we have established a standard algorithm for CGMS interpretation. In the near future, customized service, smartphone connectivity, patients management app, weight control in pre-DM or obese population will highlight the revolution of CGMS and would be integrated into daily clinical practice.

DT-4 Prof. Chih-Cheng Hsu, M.D., Ph.D.

Personal Information

Nationality: Taiwan

Position: Deputy Director

Department: Institute of Population Health Sciences

Organization: National Health Research Institutes

Email: cch@nhri.org.tw

Educational background & professional experience (in sequence of the latest year)

2014 Institute of Population Health Sciences/ National Health Research Institutes Deputy Director 2000 Tulane School of Public Health DrPH 1986 National Yang Ming Medical College MD

Research Interests

1. Epidemiology of Diabetes Mellitus 2. Epidemiology of Chronic Kidney Disease 3. Geriatric syndrome

Publications (5 important publications – latest sequence)

1.Hsu CC, Almulaifi A, Chen JC, Ser KH, Chen SC, Hsu KC, Lee YC, Lee WJ. Effect of Bariatric Surgery vs Medical Treatment on Type 2 Diabetes in Patients With Body Mass Index Lower Than 35: Five-Year

Outcomes. JAMA Surg. 2015 Dec 1;150(12):1117-24. 2.Hung SC, Chang YK, Liu JS, Kuo KL, Chen YH, Hsu CC*, Tarng DC. Metformin use and mortality in patients with advanced chronic kidney disease: a national retrospective observational cohort study. Lancet

Diabetes Endocrinol. 2015 Aug;3(8):605-14. 3.Hsu CC*, Tai TY. Long-term glycemic control by a diabetes case-management program and the challenges of diabetes care in Taiwan. Diabetes Res Clin Pract. 2014 Dec;106 (Suppl 2):S328-332. 4.Hsu CC, Chang HY, Huang MC, Hwang SJ, Yang YC, Lee YS, Shin SJ, Tai TY. HbA1c variability is associated with microalbuminuria development in type 2 diabetes: a 7-year prospective cohort study.

Diabetologia. 2012 Dec;55(12):3163-3172. 5.Hsu CC, Lee CH, Wahlqvist ML, Huang HL, Chang HY, Chen L, Shih SF, Shin SJ, Tsai WC, Chen T, Huang

CT, Cheng JS. Poverty increases type 2 diabetes incidence and inequality of care despite universal health coverage. Diabetes Care. 2012; 35:2286–2292.

DT-4 Trend and Factors Associated with Healthcare Use and Costs in Type 2 Diabetes Mellitus: A Decade Experience of a Universal Health Insurance Program

從臺灣糖尿病治療、衛教現況看未來

CHIH-CHENG HSU 許志成

Institute of Population Health Science, National Health Research Institutes, Zhunan, Taiwan 國家衛生研究院 群體健康科學研究所

Little is known about how a universal national health insurance (NHI) program with costcontainment strategies affect costs and quality of diabetes care. To examine the trends of healthcare use and costs for patients with type 2 diabetes mellitus (T2DM) in Taiwan over the last decade, and to identify factors associated with high healthcare cost and poor diabetes care, this talk will delineate the pattern of healthcare use and costs for T2DM in 2000-2010. We used representative adult T2DM patients and age- and gender-matched non-diabetes individuals selected from the 2000, 2005, and 2010 NHI Research Databases to conduct this study. Healthcare use included physician visits, hospital admissions, and antidiabetic drug prescriptions. Indicators of diabetes management included completeness of recommended diabetes tests and medication adherence, assessed using medication possession ratio. Generalized linear and logistic regression models were used to identify factors associated with medical costs and diabetes care. The results of this study show the total healthcare cost per diabetes patient was approximately 2.8-fold higher than that for non-diabetes individual. The growth of healthcare cost per diabetes patient was significantly contained by about 3,694 NTD (3.6%) between 2005 and 2010, but diabetes care improved over the decade. Diabetes duration, income, place of residence, continuity of care, and enrollment to a pay-for-performance (P4P) program were associated with healthcare costs and diabetes management. The effects of P4P program and some public health measures implemented to support diabetes care were also discussed. This talk will conclude that healthcare costs can be controlled without sacrificing the quality of diabetes care by implementing P4P programs and effective health policies favorable for diabetes care.