Diabetes Control in Mongolia: Facts and Needs

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Editorial
Cent Asian J Med Sci. 2016 Nov;2(2):109-110.
Diabetes Control in Mongolia: Facts and Needs
Bayasgalan Tumenbayar1
1
Department of Third Internal Medicine, School of Medicine, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
This is an Open Access article distributed
under the terms of the Creative Commons
Attribution Non-Commercial License (http://
creativecommons.org/licenses/bync/4.0/)
which permits unrestricted non-commercial
use, distribution, and reproduction in any
medium, provided the original work is properly
cited. Copyright© 2016 Mongolian National
University of Medical Sciences
Vol.2• No.2• November 2016
Noncommunicable diseases (NCDs), commonly known as chronic or life-style related diseases
are the major global causes of both morbidity and mortality. Almost one third of global deaths
in 2015 were due to NCDs. The four major NCDs (cardiovascular disease (CVD), cancer, chronic
respiratory disease and diabetes) account for about 80% of total NCD deaths and share four
common modifiable risk factors: unhealthy diet, lack of physical activity, smoking and alcohol
consumption [1]. As a one of the major NCDs, prevalence of diabetes mellitus is increasing
worldwide. The estimated number of people with diabetes worldwide increased to 417 million
by 2016, as reported by the International Diabetes Federation (IDF), and that number is
expected to reach more than 642 million by 2040 [2].
Mongolia, the seventh largest country in Asia (by land area) only has a population of
3 million, making it the least densely populated country in the world. Since the 1990s it
has experienced rapid demographic and epidemiological transitions, as in many emerging
economies. These transitions led to the lifestyle of the population dramatically changing from
nomadic to urban. Before the 1950s there were no recorded documentations about diabetes
in Mongolia. However, the first nationwide prevalence study conducted in 1999 showed that
3.1% of the population has diabetes, and 9.1% have impaired glucose tolerance (IGT) as
evaluated by 2 hour, 75 gram oral glucose tolerance test (OGTT) [3].
In 2005, 2009 and 2013 the Mongolian government with collaboration of the World
Health Organization (WHO) and support of the Millennium Challenge Account Mongolia (USA)
conducted the nationwide STEPwise approach to Surveillance (STEPS) survey of NCD and injury
risk factors. According to this study, prevalence of diabetes was 6.9% of the population and
those with impaired fasting glucose (IFG) was 8.3% [4]. However, there are several limitations
for NCD STEPS survey. Firstly, the age of the subjects was limited to 25-64 years old, but most
diabetes cases occur in the senior population. Secondly, the fasting blood plasma was used to
evaluate hyperglycemia risks among subjects. By WHO and IDF recommendations, fasting blood
glucose and glycated hemoglobin (HbA1c) or OGTT should be used to evaluate diabetes. The
objective of NCD STEPS survey was to evaluate hyperglycemia risks, therefore, in some points
of view these data cannot give proper evidence of diabetes prevalence.
The Mongolian Diabetes Association (MDA) established in 2003, focuses on improving
the patient’s quality of life, glycemic control and medical service policy with collaboration
of government and/or nongovernment organizations. According to a randomized study on
diabetes control conducted in 2003, more than 80% of patients in Mongolia had an HbA1c
level above 7.5%, which indicates poor glycemic control [5]. There are several explanations
for such negative results: (1) even though the Mongolian government covers all expenditures
www.cajms.mn
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Diabetes Control in Mongolia
on glucose-lowering drugs and insulin to all registered patients
from the state budget, there is a lack of dosages to most of
patients due to systematic disarrangements of budget sharing
to secondary hospitals; (2) diabetes is a disease with a very high
burden on patients, their families and the country’s economy, and
since the majority of registered patients have middle or lower
income, taking sufficient dosages of glucose-lowering drugs and
insulin by patient is not common; (3) the lack of human resources
in primary and secondary hospitals specialized in endocrinology
and diabetes. Currently in the Mongolian healthcare sector only
endocrinologists are serving patients with diabetes. Mongolia
still lacks podiatrists, dietitians, physical trainers and diabetic
educators. Although in 2005 the MDA with support of WHO
organized a nationwide training to raise up diabetic educators,
the limitation of job positions in secondary hospitals for those
specialists did not allow them to find work. Hence, the shortage
of specialized health workers in the field of endocrinology and
diabetes results in a short contact time between doctors and the
patients.
Cross-sectional studies conducted in 2013 by the MDA
revealed that the prevalence of diabetic retinopathy was
29.3% and a risk factor for diabetic retinopathy was elevated
fasting blood glucose (OR = 2.9, p = 0.001). The prevalence of
diabetic nephropathy was 14.8% and risk factors for diabetic
nephropathy were HbA1C (OR = 4.57, p = 0.034), systolic blood
pressure (OR = 2.55, p = 0.032), diabetes duration (OR = 1.1,
p = 0.0021) and age (OR = 1.03, p = 0.0006). The prevalence
of diabetic peripheral neuropathy was 71.0%, sudomotor
autonomic neuropathy was 65.1% and cardiovascular autonomic
neuropathy was 52.7% among diabetic patients. Moreover,
impotence in males was 76.8%. Risk factors for neuropathy were
age (OR = 1.07, p = 0.0001), diabetes duration (OR = 1.07, p
= 0.024) and hyperglycemia (OR = 1.11, p = 0.039) by logistic
regression analysis. Prevalence of peripheral artery disease,
diabetes related foot ulcer and amputation were 32.1, 10.4 and
1.0%, respectively. Foot amputation was associated with being
male (p <0.05), diabetes duration (p <0.01), hyperglycemia
(p <0.01), hyperlipidemia (p <0.01) and hypercoagulation (p
<0.05). Prevalence of minor or toe amputation was 32%, below
knee amputation was 8% and above knee amputation was 56%
among all amputations [6]. This long list of chronic complications
had one common cause: POOR GLYCEMIC CONTROL.
So, what do we need to do to prevent such a devastating
disease with a high burden to both patients and country? As a
110
www.cajms.mn
researcher, and faculty at the Mongolian National University of
Medical Sciences, I think we need to change the whole system
of health service once for all. Although the Ministry of Health
enacted preventive policies through introducing free rapid blood
sugar tests to every person with health insurance aged 40 years
and above and made a decision to cover over 50% of out-ofpocket expenses on four types of oral diabetes medications
from the Health Insurance Fund, Mongolia still has a large need
to establish proper registration procedures of patients with
diabetes, to offer various choices for glucose-lowering drugs
and insulin and to create collaborative diabetes teams including
podiatrists, dietitians, educators, etc. in secondary hospitals. By
pursuing these achievable action points, Mongolia can work
toward preserving the quality of life for its people and brining
more sustainability to its future.
References
1. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, AdairRohani H et al. A comparative risk assessment of burden
of disease and injury attributable to 67 risk factors and
risk factor clusters in 21 regions, 1990-2010: a systematic
analysis for the Global Burden of Disease Study 2010.
Lancet 2012; 380: 2224-2260.
2. International Diabetes Federation. Diabetes Atlas, 7th
edition [accessed on 12 September 2016]. Available at:
http://www.idf.org/diabetesatlas.
3. Suvd J, Gerel B, Otgooloi H, Purevsuren D, Zolzaya H, Roglic
G, et al. Glucose intolerance and associated factors in
Mongolia. Diabet Med 2002; 19: 502-508.
4. Government of Mongolia. National Programme on
Integrated Prevention and Control of Noncommunicable
Diseases, Government Resolution No. 34 [accessed on 13
September 2016]. Available at: http://www.legalinfo.mn/
law/details/9799.
5. Khadbaatar Z. Diabetic Control Survey [dissertation],
Ulaanbaatar Mongolia: Health Sciences University of
Mongolia; 2003.
6. Sainbileg S, Suvd J, Altaisaikhan K. Diabetes related complications in Mongolia. P-1166 [accessed on 15 October
2016]. Available at: http://conference2.idf.org/MEL2013/
World%20Diabetes%20Congress%202013/data/HtmlApp/main.html#open-authors.
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