Diabetes Research and Clinical Practice 50 Suppl.

2 (2000) S9 S16
www.elsevier.com/locate/diabres

The epidemiology and management of diabetes mellitus in

Indonesia
Dwi Sutanegara *, Darmono, A.A.G. Budhiarta
Indonesian Diabetes Association, Sari Dharma General Hospital, J1 Pulau Seram 1, Denpasar, Bali, Indonesia

Abstract

Predications indicate a potentially explosive increase in the prevalence of diabetes worldwide, especially in
developing countries such as Indonesia. Studies of people living in rural areas of East Java and Bali show a prevalence
rate of 1.5% in 1982 to 5.7% in 1995 among the urban population. Ujung Pandnag also experienced an increase and
recent studies in Manado found a dramatically high rate of 6.1% in urban areas. Preliminary results indicate varying
prevalence between those living in urban and rural areas. Currently, Indonesia has an estimated 1.2 2.3% prevalence
among people over 15 years. Geographically variation appears to be an influential factor, due to differences in
ethnics, race, culture and lifestyle. Studies of diabetic families show a significantly high prevalence and, clinically
speaking, the mode of treatment indicates the type of diabetes. Those who respond well to OHA among young
diabetics ( B40) are assumed to have the MODY variation of the disease. The level of obesity among the general
population has increased, due partly to increased calorie intake and is a significant factor in the increased rate of
diabetes. It is also more common among the elderly, as our results will show. The new types of the disease are
clinically more difficult to assess than the classical types 1 and 2, as they require relatively costly genetic and
immunological studies. The rate of LADA type diabetes was found to be relatively high (\ 20% for ICA and IAA,
and 2.3% for GADA). A consensus on diabetes management has now been formulated in Indonesia and these
guidelines are now used by all Indonesian health care professionals. 2000 Elsevier Science Ireland Ltd. All rights
reserved.

Keywords: Epidemiology; Indonesian diabetes management

It was predicted that there would be an epi-
demic explosion of diabetes prevalence in the
world, especially in developing countries [1]. In-
donesia is one of the developing countries that the
estimation implies to. The prevalence of diabetes
in urban areas of Jakarta was 1.7% in 1982 and
* Corresponding author. Tel: +62-361-226866/236494/
225615; fax: + 62-361-239586.
E-mail address: saridarma@denpasar.wasantara.net.id (D.
Sutanegara).
this increased to 5.7% in 1995 [2,3]. The epidemio-
logical studies of Diabetes in Manado recently
found the prevalence rate of 6.1% [3]. Similar
studies in some parts of Bali found the prevalence
rate of 1.5% among farmers in rural areas (Jenah
village, Denpasar), [4] and among people above
the age of 50 was 3%, and more than 5% among
retired government and army officials living in the
urban areas of Denpasar [5]. Studies in Ujung
Pandang found an increasing rate from 1.5 to

0168-8227/00/$ - see front matter 2000 Elsevier Science Ireland Ltd. All rights reserved.
PII: S0168-8227(00)00173-X
S10 D. Sutanegara, A.A.G. Budhiarta / Diabetes Research and Clinical Practice 50 Suppl. 2 (2000) S9 S16
5.4% in urban areas, and these changes were
mainly attributed to the changes in the lifestyle of
the people [3].
It was also estimated that there would be a
relatively wide variation of the level of diabetes
prevalence in the country. The heterogeneous eth-
nic, races, and ways of lifestyle of the Indonesian
population, living in more than 13 000 islands,
might be the influencing factors. It was also reck-
oned that in general the diabetes prevalence rate
in Indonesia was 1.2 to 2.3% or about 2.4 to 4.6
million people, among those above 15 years of age
[3].
Unfortunately, up to now, we dont have any
valid data from all the parts of the Indonesian
Archipelago, and this is partially due to the lack
of human resources interested in diabetes popula-
tion study and the lack of funds for these studies.
Besides, there are insufficient knowledge and skills
on diabetes management among most health
providers in Indonesia. The first step that needs to
be taken to confront these critical issues, is that
the Indonesian Endocrinology Society (Perk-
umpulan Endokrinologi Indonesia/Perkeni), has
initiated to publish book entitled The Manage-
ment of Type 2 and Type 1 Diabetes. These
guideline books will be disseminated to all health
providers in Indonesia, which was sponsored by
the Department of Health, Universities or Non
Government Organization (NGO).
The Guidelines of The Management of Dia-
betes in Indonesia, will be presented in the latter
part of this paper.
1. Epidemiology
1.1. Pre6alence
Valid data regarding the prevalence of diabetes
in Indonesia is minimal. There are only a few
medical centers in Indonesia, which are interested
in this area of study. We are using the WHO
criteria 1985, but there is variation in the ages,
and location of the target populations. Jakarta
conducted population diabetes prevalence studies
in urban areas, in 1982 and 1995 and found the
increasing number of diabetes prevalence rate
from 1.7 to 5.7%. The increasing prevalence rate
was also found in Ujung Pandang, which showed
1.5 to 5.4% in urban areas, in Manado showed an
exceptionally high prevalence rate of 6.1% in ur-
ban areas [3]. Data from villagers in Bali showed
the prevalence rate of 1.5% [4].
Data from rural and urban areas in East Java
[6] has shown the prevalence rate of 1.47% (n=
13.423) among those of above 20 year old, and in
urban areas (n= 13.423) was 0.26, 1.43, 4.16, and
5.23% among people at 620 years of age, above
20, above 40 and above 60, respectively.
1.2. Geographic 6ariations
It was estimated that relatively wide geographic
variations in several parts of Indonesia do occur,
and these variations promote differences in
lifestyles, food consumption patterns, social econ-
omy, as a consequence of different races, ethnic
backgrounds, that live separately in the archi-
pelago, from Sumatra in the West and West Irian
in the East, Nusa Tenggara in the South and
North Sulawesi in the North. The diabetic preva-
lences are 1.5% (Bali, and East Java), 35% in
Jakarta and 6.1% in North Sulawesi but there is
no data from the East (West Irian).
In fact, there is no sufficient data from the
eastern area of Indonesia especially East Nusa
Tenggara, Maluku and Irian Jaya (West Papua).
It shows an extremely wide variation of diabetes
prevalence from 0% in the mountainous areas to
40% in urban or coastal areas [7] on the same
island and the same ethnic background as Irian
Jaya, Papua New Guinea (East Papua).
1.3. Genetics
Diabetes is frequently found in diabetic
families. Studies of genetical aspects of diabetic
families and twins have proven that the involve-
ment of genetical factors is taking part in the
pathogenesis of diabetes mellitus. Genetical as-
pects of diabetes are to be investigated in some
medical centers in Indonesia i.e. Surabaya [8],
Malang [9], Bali [10] Lack of supporting fund
seems to be the main factor facing the studies.
 D. Sutanegara, A.A.G. Budhiarta / Diabetes Research and Clinical Practice 50 Suppl. 2 (2000) S9 S16
Modes of treatment in young diabetics ( B 40
years) in Out patients Department have shown a
satisfactory response with OHA for years. Of the
20 young diabetics treated with OHA, 6/20
(30.0%) showed a good response [11], Muin et al.
[12], observed 16 young diabetic patients that
gave a positive response to OHA, were diagnosed
as MODY type diabetes. The genetical studies are
to be carried out in order to confirm the type and
the other subtypes.
Based on history, the diabetes prevalence rate
of diabetic families in Bali was 14.7% (190/1338)
[13]. Risk of having diabetes amongst children of
diabetic parents is 40% and it is higher if mother
or both parents are diabetics [14].
1.4. Obesity
The prevalence of obesity among villagers in
Indonesia is low. This phenomenon is based on
the diet patterns of most Indonesian people, who
consume relatively low amounts of calories.
World Bank data showed in 1982 that the Indone-
sian people consumed 2173 kcal/day and this
increased to 2675 kcal/day in 1988, still below
that of what the Singaporean people have con-
sumed (2865 kcal/day) [15].
A survey that was carried out on the villagers
of Jenah village, Peguyangan Kangin, near Den-
pasar city in 1991, showed that the amount of
calories intake was 1691, consisting of 82% carbo-
hydrate, 19% protein and 19% fat [4].
The epidemiological study on the nutritional
status of people living in that village showed that
1.5% were obese [4], while a 3% rate was found
Table 1
Nutritional status of people with diabetes, in out patient
department of Denpasar Central General Hospitala
Nutritional status (BMI) N (frequency) %
Under 54 20.3
Normal 111 41.7
Over 75 28.2
Obese 26 9.8
Total 266 100.0
a
Source: medical record, out-patients department, RSUP
Denpasar 1999.
S11
among the people who consumed a lot of fish
living in the mountainous area near Lake Batur
(District of Bangli, Bali Province) [16]. The same
prevalence rate was found among farmers living
in Krambitan village, Tabanan Bali [17]. Studies
on the prevalence rate of nutritional status among
the population living in urban areas were carried
out in Jakarta. Those studies showed the preva-
lence of obesity was 4.2% in males and 17.1% in
females 1982, and 10.9% in males and 24.0% in
females (19921993), respectively [5].
Data from the National Statistical Bureau of
1989 and 1992 showed an increasing number of
obese people, from 4.6 to 6.3%, and from 2.9 to
3.6% in rural areas [18]. Meanwhile the number of
obese diabetic people registered in the out-patient
Diabetic Clinic in Central Hospital of Denpasar
Bali was 14.7%. (1997) and 28.2% over weighted
and 9.8% obese (1999) [19], Table 1.
1.5. Diabetes -age correlation
Glucose intolerance among the aged is fre-
quent, and a prevalence rate of 5% is found
among retired government and army officials
(above 60 years old) [5], and among the aged
groups of farmers (above 50) in Kerambitan vil-
lage [17].
A study carried out in Surabaya showed an
increasing diabetes prevalence related to different
levels of ages, i.e. 2.68, 4.48, and 5.33% among the
groups aged 4049, 5059 and over 60 years,
respectively [20].
The Monica study carried out in Central Java,
involving people living in rural areas and urban
areas, from 1203 recruited samples, found 3.3%
diabetes prevalence among the aged group (\ /=
60 years) [21].
1.6. Classification
The new diabetes classifications including type
1, type 2, gestational diabetes, and groups of
others are not always easy to assess. From prac-
tical point of view, the classification can be made
by looking into the modes of treatment.
From our observations, there are some 1020%
of type 2 diabetes requiring insulin to control
S12 D. Sutanegara, A.A.G. Budhiarta / Diabetes Research and Clinical Practice 50 Suppl. 2 (2000) S9 S16
their blood sugar level. This group may partly act
as a positive imunological indicator.
In preliminary reports we found the extremely
high prevalence of (31.6%) ICA positives among
NIDDM [22]. Recently in a cross sectional study,
results showed that among poorly controlled type
2 diabetes (ages at diagnosis \40 years) ICA,
GADA or IAA are positives in 23.7, 2.5 and
30.6%, respectively [23]. These groups might be
the slow onset of type 1 diabetes or LADA type.
We have to observe prospectively all of these
positive groups to evaluate the possibilities of a
progressive deterioration in 15 20% of the matu-
rity onset diabetes and 50% of those under
weight of maturity onset diabetes, who are LADA
type [24,25].
There is a wide variation of GDM prevalence in
the country. Using the WHO criteria we found
the prevalence rate of 9.8% [26], but a previous
study (using O Sullivan Mahan criteria) found a
prevalence rate of 1.9 3.6% [27].
1.7. Clinical manifestation
Type 1 diabetes (classical type) can be diag-
nosed immediately according to manifestations of
acute metabolic decompensation, but type 2 dia-
betes almost always comes late. They usually have
some chronic or even acute cardio cerebro vascu-
lar complication. Slow onset type 1 diabetes that
was formerly diagnosed as type 2 diabetes showed
a good response to oral therapy, but later they
had a clinical symptom consistent with absolute
insulin deficiency [25].
Type 2 diabetes is the most prevalent type of
diabetes. The clinical courses insidiously have
continued for years until they have brought up
with some acute metabolic symptoms such as
polyuria, polydipsia, weight loss and fatigue. They
might also present some chronic or other acute
complications such as diabetic neuropathy,
retinopathy (i.e. blurred vision), tooth problems,
or bad foot infections (i.e. gangrene), cardio-vas-
cular problem or strokes.
Hospital based data from Surabaya show that
neuropathy is the most prevalent of chronic com-
plications (51.4%), followed by sexual problems
(i.e. erectile dysfunction or impotency) 50.9%,
arthropathy 25.5%, cataract 16.3%, lung tubercu-
losis 12.8%, hypertension 12.1%, coronary artery
disease (CAD) 10.0% and others 12.5% [6].
2. Management
The first step is to overcome acute symptoms
such as, weakness polyuria, polydipsia, and to
create a general feeling of well being in the pa-
tients as the short-term aim of diabetes manage-
ment. The next step, as the so-called long-term
aim of diabetes management, is to prevent acute
or chronic complications such as macro and
microangiopathy.
The Indonesian Endocrinology Society was suc-
cessful in publishing an Indonesian consensus en-
titled Consensus Management of Type 2
Diabetes, which was first published in 1993, re-
vised, and republished in 1998 as the second
editions. This guideline book showed us how to
make diagnosis, screen, and manage people with
diabetes. All Indonesian health providers are rec-
ommended to use this guideline book.
The Association also was successful in publish-
ing other consensus books such as Management
Dyslipidemia in Diabetes 1996 and Diagnosis
and Management of Gestational Diabetes (1997).
The next consensus book to be issued is Consen-
sus Management of Type 1 Diabetes.
Four basic principles of diabetes management
are: education, diet or medical nutritional therapy
(MNT), exercise, and hypoglycemic agents (oral
hypoglycemic agent and insulin).
Non-medicated treatments are performed if
there is evidence of a mild blood sugar level or no
symptoms of acute metabolic decompensation. If
blood sugar level is significantly high with specific
diabetic symptoms, according to the consensus
guideline books, intensive insulin therapy should
be performed [3]. The flow chart guideline is
shown in annex (Fig. 1).
2.1. Education
The education program aims to change pa-
tients eating habits. They should avoid high
caloric food, saturated fat, sugar, salt, alcohol,
 D. Sutanegara, A.A.G. Budhiarta / Diabetes Research and Clinical Practice 50 Suppl. 2 (2000) S9 S16
Fig. 1. Management of type 2 diabetes.
and smoking. All of these leads to greater possi-
bilities called chronic non-communicable diseases
such as diabetes mellitus, hypertension, arte-
riosclerosis, coronary artery disease, and cerebral
stroke [28].
The education aims to improve the diabetics
knowledge and skills in diabetes management.
The education materials, strategies and methods
of evaluation can be seen in the education module
for training the diabetic educator candidates.
Doctors are always very busy and dont have
much time to manage the education program in
person. The other critical issue is how to recruit
qualified diabetic educators. We have more than
400 diabetic educators [29], who mostly live in
Jakarta and other big cities in Indonesia at the
moment. This number is relatively small com-
S13
pared to the large number of people with diabetes
in Indonesia.
2.2. Diet or medical nutritional therapy
MNT is integral to total diabetes care and
management [30]. The standard of MNT is a
balanced diet, composed of 6070% carbohy-
drate, 1015% protein, and 2025% fat [3].
The goals of MNT are to control blood glucose
levels, achieve optimal serum lipid level, and gain
adequate calories for maintaining or attaining
reasonable weights for adults, normal growth and
development in children and adolescents. It also
aims to increase metabolic needs of women during
pregnancy and the lactation or recovery of
catabolic illness, prevention and treatment of
acute complications from insulin treated diabetes
such as hypoglycemia, short-termed illness, and
exercise related problems. And the long-termed
chronic complications are renal disease, neuropa-
thy, hypertension and CAD and the overall im-
provement of patients health [30].
Principles for nutrition therapy include weight
control, fat and oils (2025%), protein (1015%)
and carbohydrate (6070%) of total daily calories
requirement, distribution of the food intake (36
times a day), non caloric sweeteners can be used
but small amount of nutritive sweeteners such as
sorbitol and fructose are only recommended in
those of good control, and restriction of salt,
especially in hypertensives [3].
2.3. Exercise
Exercise improves insulin sensitivity, thus im-
proving glicaemic control and may help with
weight reduction [31].
The goal or benefit of physical exercise will be
achieved in continuous or accumulative en-
durance training (34 times a weeks for about 30
min) [3].
The exercise program needs to be appropriate
to the persons age, based on social, economic,
cultural and physical status.
It should be maintained and encouraged to
have the adoption of healthy lifestyles such as
working in the fields or plantations, fishing, or
S14 D. Sutanegara, A.A.G. Budhiarta / Diabetes Research and Clinical Practice 50 Suppl. 2 (2000) S9 S16

walking upstairs instead of taking the elevator at
work. Particular attention should be given to
potential exercise hazards such as cuts, scratches,
and dehydration. And special care should be
devoted to the proper care of the feet, food intake
adjustment. Adjustememt of medications (oral or
insulin) should be given in vigorous training to
avoid hypoglycemia, and attention should be
given to high risk of getting cardio cerebro vascu-
lar events, and retinal or vitreous bleeding
[3,30,31].
2.4. Drug treatment
Drug treatment should be used only when the
diet / MNT and exercise have failed to achieve
individual treatment target. After 4 8 weeks, non
medicated treatments are performed.
The oral agents available in Indonesia are: Sul-
fonylurea (Chlorpropamide, Glibenclamide, Glip-
izide, Gliclazide, Gliquidone, and Glimepiride),
metformin (Diabex, Neodipar and Glucophage)
and Alfa Glucosidase inhibitor (Acarbose). Phar-
macodynamic of there agents are shown in Table
2.
2.4.1. Sulfonylurea
Sulfonylurea is the first line drug treatment in
type 2 diabetes, especially in non-obese or normal
and underweight people, but can also be given to
over weight diabetics. The mode of action is to
increase insulin secretion and improve insulin
action.
All sulfoylurea can cause hypoglycemia. Longer
acting sulfonylureas are particularly hazardous
for the elderly and in the presence of renal insuffi-
ciency. Therefore, it is advisable to use shorter
acting sulfonylurea [3,32].
The list of some types of sulfonylures available
in Indonesia and their pharmaco dynamic actions
are shown in Table 2.
2.4.2. Biguanide/metformin
The mode of action in metformin is to improve
insulin action and can therefore reduce hepatic
glucose production, and improve peripheral glu-
cose disposal.
Metformin is recommended as a single drug in
obese type 2 diabetes, but some side effects such
as gastrointestinal symptoms (nausea and vomit-
ing) are the main reasons for the patients to stop
taking this agent.
Metformin is contraindicated in severe hepatic
and renal function, and precaution is made in
elderly, cardiovascular impairment, major surgery
and septic shock due to the risk of lactic acidosis
[3,32].
2.4.3. Alfa Glucosidase inhibitor (Acarbose)
This agent was launched in Indonesia in 1994,
and its purpose is to delay carbohydrate absorp-
tion in the gut by selectively inhibiting disaccha-
rides in the intestinal brush border, so that it will
decrease postprandial hyperglycemias and thus
improve overall glicaemic control [3,32].

Table 2
Oral hypoglicaemic agent that available in Indonesiaa

OHA Initial doses (mg) Maximal doses (mg) Presentation/day

Sulfonylurea
Glibenclamide 2.5 1520 12 (od/bd)
Gliclasid 80 240 12 (od/bd)
Gliquidon 30 120 23 (bd/td)
Glipizid 5 20 12 (od/bd)
Glipizid GITS 5 20 1 (od)
Glimepirid 1 6 1 (od)
Chlorpropamid 50 500 1 (od)
Biguanid (metaformin) 500 2500 13 kali
a-Glucosidase inhibitor 50 300 3 kali

a
Adapted from Perkeni, 1990 [3].
 D. Sutanegara, A.A.G. Budhiarta / Diabetes Research and Clinical Practice 50 Suppl. 2 (2000) S9 S16 S15

Table 3 non ketotic and lactic acidosis), severe stress (in-

Criteria for diabetic controla fection, major surgery), chronic renal failure,
Criterias Good Fair/accepted Poor
pregnant, or chronic complication (renal failure),
and pregnancy [3].
2 h pp blood 110159 Fair/accepted 110159 Many insulin regimens have been proposed to
treat type 2 Diabetes. The major options include:
Fasting blood 80109 110139 \/=140 premixed short and intermediate acting insulin,
glucose
twice a day, multiple insulin injections (short act-
(mg/dl)
2 h pp blood 110159 160199 \/=200 ing insulin before meals, and isophane (NPH)
glucose insulin at bedtime) and combination therapy;
(mg/dl) comprising of NPH Insulin in the morning or
HbA1c (%) 45.9 68 \8 evening with daytime sulfonylureas, or NPH in
Total B200 200239 \/=240 the morning or evening with daytime metformin.
cholesterol
(mg/dl)
LDL cholesterol (mg/dl) 2.4.5. Combination therapy
Without CAD B130 130159 \/=160 Combination therapy with insulin and sulfony-
With CAD B100 100129 \/=130 lurea was used as long ago as in the 1950s.
HDL \45 3545 B35 Residual beta cell function is prerequisite for
cholesterol combination therapy and the effects seem to be
(mg/dl) mediated by enhanced insulin secretion [32].
Trigliseride Sulfonylurea, metformin and acarbose can be
Without CAD B200 200249 \/=250
used as combination oral therapy or with insulin,
With CAD B150 150199 \/=200
but as a single drug, they fail to fulfill the target
BMI of control [31], (Table 3).
Female 18.523.9 2425 \25/
B18.5
Male 2024.9 2527 \27/B20
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