Wider World by CS

Diabetes Is the Price Vietnam Pays for Progress

Justin Mott for the International Herald Tribune

Phu Thi Hong Thuy, a 48-year-old diabetic, had to have her leg amputated after she cut herself on a closet at home. “Sometimes I feel my leg itching — but when I look, it’s not there,” she said. 

By THOMAS FULLER

Published: June 4, 2013

HO CHI MINH CITY — He survived the deprivation of the Vietnamese countryside and decades of war, but Pham Van Dang, 70, lay dazed in his hospital bed, the stump of his freshly amputated leg sewn up like the seams of a leather bag.

Mr. Dang and many younger patients in the diabetes ward here at Nguyen Tri Phuong Hospital are casualties of rising affluence, his doctor says.

“I see more and more patients with diabetes,” said Dr. Tran Quang Khanh, who is chief of the endocrinology department, whose ward receives 20 new patients a day.

The precise reasons for a spike in diabetes cases are hard to pin down — people are living longer, for one — but doctors in Vietnam say the prime culprits are “Westernization and urbanization.”

“Now we have KFC and many fast-food restaurants,” Dr. Khanh said.

In a country where limbs were once shattered by ordnance and land mines, hospitals in Vietnam are treating an alarming caseload of “diabetes foot,” an infection that often begins as a minor scrape but then develops into a gangrenous wound because the disease desensitizes patients and compromises the healing process.

In the most severe cases, legs are amputated. If the limb can be spared, doctors perform a debridement, a grisly operation that seems more fitting for the trenches of Verdun than for a dynamic, modern metropolis like Ho Chi Minh City. The procedure involves cutting away rotting flesh and is performed several times a day at Nguyen Tri Phuong and four other hospitals in Ho Chi Minh City that have wards dedicated to diabetes care.

Doctors and government officials say no statistics are available on the number of amputations linked to diabetes in Vietnam, but Dr. Thy Khue, a pioneering diabetes researcher in the country, says the problem is “severe” and a particular strain on the health system because patients with amputated feet or legs tend to stay in hospitals for weeks. Diabetes foot exists in the West, but rates may be higher in Vietnam and other tropical countries because people tend to wear sandals outside and go barefoot around the house, leaving their feet more susceptible to injury, Dr. Khue said.

Diabetes rates are surging in many countries, but it is a particularly poignant paradox that, after so many years of war in Vietnam, peace is now partly marred by the afflictions of rising prosperity: clogged hearts, obesity and diabetes.

Official statistics in Vietnam show a vertiginous increase in Type 2 diabetes overall, the form of the disease that is linked to diet and lifestyle and in the West has reached epidemic levels, especially among the obese.

From just 1 percent of the adult Vietnamese population in 1991 — the year the first nationwide survey of diabetes was done in Vietnam — the rate climbed to 6 percent last year. And in Ho Chi Minh City, a survey in 2010 estimated that 1 in 10 adults had the disease.

Dr. Khue said diabetes was once the preserve of the very wealthy. But as people have moved from rice paddies into factories and offices, her patients today are from all walks of life.

“It’s not the disease of the very rich anymore,” she said. “Now poor and rich — everyone — can get diabetes.”

Jesper Hoiland, senior vice president of Novo Nordisk, the world’s biggest maker of drugs to treat the disease, said the number of people with diabetes in Vietnam was expected to climb higher as the country’s economy continues to grow — and as more people adopt modern, urban lifestyles.

“We are going to see a real pandemic in Vietnam in the coming years,” he said.

The International Diabetes Federation, a group that keeps statistics on the disease, calculates that 371 million people were afflicted with diabetes worldwide last year. Four out of five people with the disease live in poor or middle-income countries like Egypt, Guyana or Vietnam, the federation said.

“In today’s world, many more people are dying from overeating than from starvation,” Mr. Hoiland said.

Among the most severely affected are Pacific Islanders, where diabetes rates can go as high as nearly one-third of the population, as is the case in the tiny island of Nauru in Micronesia. Arab countries also have very high rates, according to data published by the federation. Nearly a quarter of the adult population in Saudi Arabia has diabetes, according to the data. 

  Diabetes affects the body’s ability to manage sugar and can be brought under control with exercise, changes in diet and, ultimately, injections of insulin to regulate blood sugar levels. But symptoms, which include frequent thirst and urination and weight loss, often develop slowly, experts say, and many people have the disease for years without knowing it, especially in countries where health care systems are rudimentary.

The reason for the disparity in diabetes rates among nations — and among ethnic groups within nations — is related to genetic predisposition, diet and exercise, or lack of it, experts say.

But doctors in Vietnam say the spike in diabetes has not been fully explained.

“Our patients are not obese. Some are very thin,” said Dr. Khanh.

Because of different body types, the threshold of what is considered obese is lower in Asia than in the West — obese patients in Asia can appear only mildly overweight by Western standards. But that still does not explain many of the cases he sees, Dr. Khanh said.

During a reporter’s visit, a 26-year-old woman in skinny jeans and a plaid shirt, Lam Loc Mui, was diagnosed with diabetes.

Ms. Mui, who was born in the provinces but works as a dental assistant in Ho Chi Minh City, is rail thin with a 27-inch waist.

“This came as a real shock,” she said. “I rarely eat sweet things.”

Dr. Khanh speculated that she could fall into the category of what experts call the “migratory effect.” Ms. Mui worked on a farm when she was young. Now in the city, she walks very little and exercises almost never.

Hans Duijf, the head of operations for Novo Nordisk in Thailand, said some patients who had grown up in the countryside become diabetic after a move to an urban environment with marginal changes to their diets.

“If your body is programmed to live off of very little food you have a much higher chance of getting diabetes with relatively small changes in lifestyle,” he said.

Dr. Khue, the diabetes researcher, said another factor might be exposure to chemicals and pollution. Not enough studies have been done into their effects, she said.

None of those theories were comforting to Phu Thi Hong Thuy, a 48-year-old diabetic who sat in the ward listening to a doctor discuss with a reporter the possible causes of her condition.

Several weeks earlier, Ms. Thuy had brushed against the closet in her home and cut herself.

“I didn’t think it was that severe,” she said. But when she arrived at the hospital, doctors decided to amputate.

“I’m still dreaming that I still have my leg,” she said. “Sometimes I feel my leg itching — but when I look, it’s not there.”