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Original Article

EXTRAORDINARILY HIGH PREVALENCE OF TYPE 2 DIABETES MELLITUS


AMONG NATIVE BALINESE IN INDONESIA

IGP Suka Aryana1, K Suastika1, N Dwi Sutanegara1, Wira Gotera1, AAG Budhiarta1
Ratna Saraswati1, H Anzai2, N Kajiwara2, H Taniguchi3

1. Department of Internal Medicine, Medical Faculty of Udayana University, Sanglah Hospital, Bali,
Indonesia
2. Graduate School of Life Science, Kobe Women’s University, Japan
3. Department of Metabolism and Community Health Science, Faculty of Health Sciences, Kobe
University School of Medicine, Japan

ABSTRACT

Remarkably high prevalence of type 2 diabetes mellitus, which is comparable to or

much higher than that of the other developed countries in Asia, was found in Sembiran

village, where native Balinese have been residing long before the current Balinese came from

Java Island, Indonesia. This high prevalence did not seem to be due to environmental factors

such as low physical activity and excess calorie intake. Therefore, some genes closely related

to diabetes might be identified through further study of DNA analysis of the villagers in

Sembiran.

Key words: type 2 diabetes mellitus, Native Balinese, DNA analysis

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INTRODUCTION

Diabetes mellitus and obesity are expanding in number worldwide now. Obesity

emerges in parallel with the economic level, which is reflected by the number of cars

possessed and calorie intake from food. It causes insulin resistance to develop diabetes. 1 The

prevalence of diabetes is much more in the developed countries than in the developing

countries, though the latter is catching up to the former recently. In Asia, however, that of

Indonesia, one of the developing countries, is still low, i.e., 1.43% and 1.47% in urban and

rural district of Surabaya respectively.2 The other rural district of Tanah Toraja, Sulawesi

Island, the prevalence was only 0.8%. 2 These figures were low compared with that of Japan,

one of the most developed countries in Asia, where it is 7%.3

In the present communication we report an unexpectedly high prevalence of diabetes

in a mountainous village of Bali Island, which was found in our recent preliminary survey. It

is similar to or high above the prevalence of the developed countries. We studied underlying

factors of this extraordinarily high prevalence.

METHODS

We randomly selected 75 inhabitants (34 males, 41 females), aged above 20 years

(ranged between 21and 80) in Sembiran, Bali, Indonesia. They were about 2% of the total

inhabitants. All participants gave informed concent and approval was obtained from the ethics

committee of Udayana University, Indonesia. Blood was drawn after overnight fasting to

measure glucose by glucose oxidase enzyme electrode method in March 2002.

The anthropometric indices of body weight, body height and waist were measured to

calculate body mass index (BMI), visceral fat area (VFA) and body fat ratio (FAT) 4 using a

body fat monitor (type 215, Yamato Scale Company, Ltd., Akashi, Japan)(table 1). There was

no statistically significant difference in any of these indices except FAT between males and

females. Though FAT was higher in females, the actual weight of total body fat was not

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different between both genders.

RESULTS

12 subjects (7 males, 5 females) showed fasting blood glucose (FBG) above 126

mg/dl, while 4 subjects between 110 and 126 mg/dl. This implies that 16.0% of the villagers

were suggested to suffer from diabetes mellitus (DM) and 5.3% to have impaired glucose

tolerance (IGT) according to the criteria of WHO. Such a high frequency of DM was analyzed

in terms of obesity. There were 8 subjects with BMI of 25 kg/m 2 or more and 21 with BMI of

below 18.5 kg/m2, indicating 10.7% for obesity and 28.0% for underweight according to the

criteria of the Japan Society for the Study of Obesity respectively, which are applicable to

Asian populations.4 As many as one-fourth of the people in this village were in the range of

underweight. In terms of FAT only 2 subjects were in the range of obesity criteria, i.e., 25% or

more for males, 35% or more for females and also 2 subjects expressed VFA of 100 cm 2 or

higher, indicating obesity in only 2.7% subjects in this study according to the criteria of the

Japan Society for the Study of Obesity.4 There was no statistically significant correlation of

blood glucose level with BMI, FAT and VFA (table 2).

Table 1 Demography of subjects

M ales (n = Females (n = Males + Females (n = 75)

34) 41)
Age (years) 49.2 + 2.5 46.7 + 2.1 47.8 + 1.6
Weight (kg) 52.9 + 1.8 47.1 + 13 49.7 + 1.1
Height (cm) 158.2 + 1.0 152.1 + 1.0 154.9 + 0.8
Waist (cm) 72.9 + 1.6 70.8 + 1.1 71.8 + 0.9
BMI (kg/m 2) 21.0 + 0.6 20.3 + 0.5 20.6 + 0.4
VFA (cm ) 2
49.1 + 4.2 41.2 + 3.2 44.8 + 2.6
FAT (%) 16.2 + 0.6* 20.6 + 1.0* 18.5 + 0.7
Total body fat (kg) 8.8 + 0.6 10.1 + 0.8 9.5 + 0.5
Fasting blood glucose 103.6 + 5.6 93.5 + 3.7 98.05 + 3.2

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(mg/dl)
Values are expressed as mean + standard error.
* p < 0.05 between males and females

Table2 Correlation of category of fasting blood glucose (FBG) with category of body mass index
(BMI), body fat ratio (FAT) and visceral fat area (VFA)

BMI (kg/m2) FAT (%) VFA (cm2)

Normal
FBG Normal Under- High
Obesity 20>(males) High Normal Total
(mg/dl) 25>and weight >20(males)
>25 30>(females ≧100 < 100
>18.5 <18.5 >30(females)
)
DM
0 8 4 0 12 1 11 12
≧126
IGT

126> and 1 1 2 0 4 0 4 4

≧110
Normal
7 37 15 2 57 1 58 59
110>
Total 8 46 21 2 73 2 73 75
Values are number of subjects.
No significant difference was found by X2-test between the category of FBG and any of the
three categories of obesity indices.

DISCUSSION

Sembiran was a mountainous village located in the northern region of Bali Island. It

was isolated from its vicinal villages. The people called “Bali Aga” have been residing as

native Balinese long before the current Balinese came from Java Island. Lack of dietary

resources and geographical difficulty to obtain food from other neighboring regions have

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generated their specific custom of intake of poor food calorie and high grade of physical

activity as farmer.5 Thus, they have been living in protective situation from suffering obesity,

which was shown in our present study.

Nevertheless, they seemed to be susceptible to diabetes more easily than the other

Javanese in Indonesia. This prevalence was much higher than that in Japan and European

countries where people are usually exposed to the situation of low physical activity and high

calorie intake. From these considerations, high prevalence of diabetes in this native

population was suggested to be due to genetic factor. This might be explained by their

frequent intermarriage in the same clan, with which diabetes-related genes seem to

accumulate easily.

CONCLUSSION

In conclusion, very unique village, Sembiran, was discovered to have such a high

prevalence of diabetes as that of the developed countries, and this was considered to probably

be related to genetic factor. We expect that the diabetes genes could be identified more clearly

through the analysis of DNA of the village people.

References

1. Krawn MJ. Type 2 diabetes; overview and genetic. In: Turtle JR, Kaneko Y, Osato S,

editors. Diabetes in New Mellineum. Sydney: The Endocrinology and Diabetes Research

Foundation of University of Sydney; 1999. p.141-50.

2. Indonesian Association of Endocrinology. Consensus for management of diabetes

mellitus in Indonesia. Jakarta: PERKENI; 1998.

3. Itoh C. Guide-line of diabetes. Nutr Rev 2002; 10: 68-72.

4. The Examination Committee of Criteria for ’Obesity Disease’ in Japan, Japan Society for

the Study of Obesity. New criteria for ‘obesity disease’ in Japan. Circ J 2002; 66: 987-92.

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5. Covarrubias M. Island of Bali. Singapore: Alfred A.Knopf, Inc.; 1973.