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Artikel Penelitian

J Indon Med Assoc, Volum: 61, Nomor: 12, Desember 201147 4

Current Practice in the Management ofType 2 Diabetes in Indonesia:

Results from the International Diabetes

Management Practices Study (IDMPS)

Pradana Soewondo

International Diabetes Management Practices Study (IDMPS) Study Group

Abstract:Increasing obesity, sedentary lifestyle and aging population have significantly con-

tributed to the explosion of type-2 diabetes. In addition, the consequences of its complications

have caused substantial morbidity and mortality. The major goal of diabetes treatment is to

achieve good metabolic control, thus preventing the onset of the long-term complications. Un-

fortunately, there is still insufficient data on the quality of care of diabetic patients especially on

type-2 diabetic patients in Indonesia. This study focused on diabetic patients seen by general

practitioners, internists and endocrinologists, to assess its management, HbA1c achievement,

and resources used. This study was part of The International Diabetes Management Practices

Study (IDMPS) wave 2006, which was a cross-sectional study and also longitudinal follow up.

Sixty eight physicians, consisted of 48 general practitioners (GPs)/internists and 20 endocri-

nologists, have reported 674 patients with type-2 diabetes mellitus who are currently receivingvaried diabetes mellitus treatment. Among those patients, 21 patients only treated with lifestyle

modification, 523 patients received only Oral Glycaemic Lowering Drug (OGLD), and 130

patients received insulin with or without OGLD. The average HbA1c in this study was 8.27% and

only 37.4% reached the target value of HbA1c less than 7%. The majority of patients did not

attain the recommended glycaemic target. This indicates the presence of a gap between recom-

mendations of most recent guidelines and the actual practices.J Indon Med Assoc. 2011;61:474-

81

Keywords: Diabetes, Indonesia, Type of medication, Target achievement


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J Indon Med Assoc, Volum: 61, Nomor: 12, Desember 2011 47 5

Kondisi Pengelolaan Diabetes Melitus Tipe 2 di Indonesia:

Hasil dari International Diabetes Management Practices Study (IDMPS)

Pradana Soewondo

International Diabetes Management Practices Study (IDMPS) Study Group

Abstrak: Meningkatnya populasi dengan obesitas, gaya hidup sedenter serta usia lanjut sangat

memberikan pengaruh bagi peningkatan diabetes tipe 2 dan komplikasinya. Tujuan utama terapi

diabetes adalah untuk mencapai kontrol metabolik yang baik sehingga dapat mencegah terjadinya

komplikasi jangka panjang. Namun sayangnya, data di Indonesia mengenai kualitas penanganan

pasien diabetes tipe 2 masih belum mencukupi. Studi ini melibatkan pasien diabetes yang ditangani

oleh dokter umum, internis dan endokrinologis, untuk menilai pengelolaan, pencapaian target

HbA1c, dan pemanfaatan sumber daya. Penelitian ini merupakan bagian dari The International

Diabetes Management Practices Study (IDMPS) yang diselenggarakan pada tahun 2006, yang

merupakan suatu penelitian potong lintang dan kemudian dilanjutkan pemantauan secara longi-tudinal. Enam puluh delapan dokter yang terdiri dari 48 dokter umum/internis dan 20

endokrinologis, melaporkan 674 pasien diabetes tipe 2 yang mendapatkan pengelolaan diabetes

yang bervariasi, yang terdiri dari 21 pasien hanya diterapi dengan perubahan pola hidup, 523

pasien hanya mendapatkan obat hipoglikemik oral (OHO) dan 130 pasien mendapatkan insulin

dengan atau tanpa OHO. Rata-rata pencapaian kadar HbA1c sebesar 8,27% dan hanya 37,4%

pasien yang mencapai target HbA1c kurang dari 7%. Sebagian besar pasien diabetes tipe 2 tidak

mencapai target glikemik sesuai rekomendasi. Hal tersebut mengindikasikan adanya kesenjangan

antara rekomendasi dan praktik klinis sehari-hari.J Indon Med Assoc. 2011;61:474-81

Kata Kunci: Diabetes, Indonesia, Jenis obat, Pencapaian target

Introduction

The incidence of diabetes mellitus, particularly type-2

diabetes is increasing dramatically across the world because

of increasing obesity, sedentary lifestyle and population

aging, and is the cause of substantial morbidity and mortal-

ity. This explosive increase in the prevalence of type-2 dia-

betes and the consequences of its complications and asso-

ciated disorders represents the greatest health care chal-

lenge facing the world today. 1-6

The United Kingdom Prospective Diabetes Study

(UKPDS) reported that early treatment and good control of

diabetes can decrease the morbidity and mortality by de-

creasing its chronic complications.7 Each 1% reduction in

updated mean HbA1c was associated with risk reductions

of 21% for diabetes-related deaths, 14% for myocardial inf-

arction, and 37% for microvascular complications.8 There-

fore the major goal of treatment of diabetic patients is to

achieve good (near normal) metabolic control, thus prevent-

ing the onset of the long-term complications. Unfortunately,

there is still an insufficient data on the quality of diabetes

care, especially on type-2 patients in non-Western coun-

tries, including Indonesia.9,10

IDMPS study is one of the largest population-based

Current Practice in the Management of Type 2 Diabetes in Indonesia

studies of diabetic patients in developing countries. The aim

was to assess the therapeutic management of type-2 diabe-

tes mellitus in the current medical practice in 27 countries in

Asia, Latin America and the Middle East and Africa. In Indo-

nesia, the current diabetes practice was based on recommen-

dation from the PERKENI (The Indonesian Society of Endo-

crinology). PERKENI had developed the type 2 diabetes

guidelines since 1993 and it had been revised several times

until 2006.11

In Indonesia, this study was one of few studies that

was done to investigate the disease burden and quality of

care in diabetes. The results would be very important to im-

prove the quality of diabetes care in Indonesia.

Method

The IDMPS conducted in five waves which focuses on

diabetes patients seen by general practitioners (GPs) and

diabetic specialists who are experienced in insulin therapy. It

provided an international perspective to identify practices

variations across countries, and evaluated compliance to

international guidelines of management of diabetes in differ-


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ent areas of the world. This study was performed as a cross

sectional study and followed by a longitudinal study (ob-

servational study) for a period of 9-month, each doctors

might use different diabetic guidelines that mirror real lifemanagement of these subjects who were currently treated

for diabetes mellitus. In Indonesia, majority of doctors used

national guidelines which developed by PERKENI.

A random sample of physicians experienced in insulin

therapy was selected in each participating countries and

asked to enroll the first 10 patients with type 2 diabetes

within 2 weeks period. Patients exclusion criteria were less

than 18 years of age, concomitant participation in another

clinical study, participation in previous wave of the IDMPS

Table 1. Distribution of Subjects Based on Demographic Characteristic

Variable Type 2

Lifestyle modification OGLD Insulin + Total

Gender

Male (%) 10 (50.0) 229 (43.9) 65 (50.8) 304 (45.4)

Female (%) 10 (50.0) 293 (56.1) 63 (49.2) 366 (54.6)

Age

Less than 40 yrs (%) 3 (14.3) 31 (5.9) 9 (6.9) 43 (6.4)

40 - 65 yrs (%) 16 (76.2) 410 (78.4) 91 (70.0) 517 (76.7)

More than 65 yr (%)s 2 (9.5) 82 (15.7) 30 (23.1) 114 (16.9)

Mean (SD) 51.4 (10.8) 55.0 (10.1) 56.4 (10.4) 55.2 (10.2)

Median 52.0 54.0 56.0 55.0

Family history of DM

No (%) 6 (30.0) 216 (41.3) 49 (37.7) 271 (40.3)

Yes (%) 14 (70.0) 307 (58.7) 81 (62.3) 402 (59.7)

Duration of DiabetesLess than 1 yrs (%) 7 (33.3) 143 (28.5) 16 (12.6) 166 (25.6)

1 - 10 yrs (%) 11 (52.4) 290 (57.9) 77 (60.6) 378 (58.2)

More than 10 yrs (%) 3 (14.3) 68 (13.6) 34 (26.8) 105 (16.2)

Mean (SD) 4.7 (4.6) 5.5 (6.1) 8.7 (7.3) 6.1 (6.4)

Median 3.0 4.0 7.0 4.0

Smoking habit

Smoker (%) 1 (4.8) 27 (5.2) 12 (9.2) 40 (5.9)

Ex smoker (%) 5 (23.8) 56 (10.7) 13 (10.0) 75 (11.0)

Non smoker (%) 15 (71.4) 440 (84.1) 105 (80.8) 560 (83.1)

Obesity

Under weight (%) 1 (4.8) 14 (2.7) 8 (6.2) 23 (3.5)

Normal weight (%) 12 (57.1) 271 (52.6) 67 (51.9) 350 (52.6)

Over weight (%) 6 (28.6) 175 (34.0) 47 (36.4) 228 (34.3)

Obese (%) 2 (9.6) 55 (10.7) 7 (5.5) 64 (9.7)

BMI Mean (SD) 24.9 (4.9) 24.8 (3.8) 24.6 (4.8) 24.8 (4.0)BMI Median 24.9 24.4 24.6 24.5

Waist circumference

Mean (SD) 88.1 (11.1) 88.6 (11.4) 90.7 (11.8) 89.0 (11.5)

Median 88.0 88.0 90.0 88.0

Systolic blood pressure

Mean (SD) 130.1 (22.6) 132.8 (19.8) 132.2 (23.1) 132.6 (20.5)

Median 120.0 130.0 130.0 130.0

Diastolic blood pressure

Mean (SD) 80.6 (9.1) 83.4 (9.7) 81.1 (9.4) 82.9 (9.7)

Median 80.0 80.0 80.0 80.0

Latest HbA1C

Mean (SD) 7.0 (1.2) 8.1 (2.1) 8.9 (2.4) 8.3 (2.2)

Median 8.0 8.0 7.0 8.0

Fasting blood glucose

Mean (SD) 156.1 (47.9) 171.1 (77.1) 169.0 (75.2) 170.3 (76.1)

Median 147.1 150.1 142.7 148.1

and current temporary insulin treatment because of condi-

tions such as gestational diabetes, pancreatic cancer or sur-

gery.

A cross-sectional survey of management practices wasconducted for all patients during the 2-week recruitment pe-

riod using standardized paper case report forms completed

by the recruiting physicians. Descriptive analysis was per-

formed on the database. Qualitative data were summarized in

frequency tables, and quantitative data were summarized in

quantitative descriptive statistics (frequency, mean, standard

deviation, median, range). Statistical analyses were conducted

with the SAS Software version 8.02.

Results


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J Indon Med Assoc, Volum: 61, Nomor: 12, Desember 2011 47 7

This wave of the cross-sectional study was carried out

in 27 countries (Algeria, Argentina, Bulgaria, Chile, China,

Colombia, Dominican Republic, Egypt, Guatemala, Gulf coun-

tries, Hong Kong, India, Indonesia, Lebanon, Malaysia,Mexico, Morocco, Panama, Romania, Saudi Arabia, South

Africa, South Korea, Taiwan, Thailand, Tunisia, Turkey, Ven-

ezuela). Overall 1538 physicians included at least one pa-

tient. A total of 21791 patients was recruited and 20739 of

them were included in the whole population for analysis.

In this article, we only analyzed Indonesian data. A to-

tal of sixty eight physicians, consisted of 48 general GPs/

internists and 20 endocrinologists, have reported 674 pa-

tients with type-2 diabetes mellitus who are currently receiv-

ing varied diabetes mellitus treatment. Study analyzed from

all data which consist of 21 patients received lifestyle modi-

fication through dietary and exercise, 523 patients received

only Oral Glycaemia Lowering Drug (OGLD) and 130 pa-

tients received insulin with or without OGLD.

Among all subjects, there were almost equal number of

Table 2. Distribution of Subjects Based on Co-morbid and Complication

Variable Type 2

Lifestyle modification OGLD Insulin + Total

Hypertension

Yes with treatment 8 (38.1) 230 (44.2) 59 (45.4) 297 (44.3)

Yes but no treatment 0 17 (3.3) 5 (3.8) 22 (3.3)

No hypertension 13 (61.9) 273 (52.5) 66 (50.8) 352 (52.5)

DislipidemiaYes with treatment 8 (40.0) 179 (42.6) 53 (50.0) 240 (44.0)

Yes but no treatment 4 (20.0) 36 (8.6) 12 (11.3) 52 (9.5)

No dislipidemia 8 (40.0) 205 (48.8) 41 (38.7) 254 (46.5)

Late complication

At least one 9 (69.2) 290 (70.6) 97 (85.8) 396 (73.7)

No complication 4 (30.8) 121 (29.4) 16 (14.2) 141 (26.3)

male and female, and most of them were on 40-65 years old

age group. The number of active and non active smoker dia-

betes patients was low. In addition, almost half of diabetic

patients were overweight and obese. HbA1c is relatively highwith level 8.3% and uncontrolled fasting blood glucose. (See

Table 1 for details)

Dislipidemia and hypertension are the two most preva-

lent concomitant conditions of diabetes. More than 50% cases

also suffered from dislipidemia and almost 48% have high

blood pressure. Most cases suffered from at least one dia-

betic complication. (See Table 2 for details).

Neuropathy is the most common complication among

type-2 diabetic cases with more than 50% of subjects show

abnormal neurological signs. The second most common com-

plications are retinopathy and nephropathy with more than

30% of cases. (See figure 1 for details).

Most of patients had visited GPs/ internists, while only

30% visited endocrinologists. Nevertheless the patients who

visited endocrinologists were likely more frequent to visit

0 .0 1 0 .0 2 0 .0 3 0 .0 4 0 .0 50 .0 60 .0 7 0 .0

Per iphera l VD

Stroke

Heart fa i lure

Myoc ard in fa rc

An g in a

Am putat ion

Foot u lcer

Dialys is

Pro te inur ia

Ne u ro p a th y

Ret inopathy

O G L D I ns u li n p lu s D i et /E x e rc is e


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J Indon Med Assoc, Volum: 61, Nomor: 12, Desember 2011


47 8

the physicians. In addition, more than 60% of patients had

never had diabetes education session. The patients who

were given insulin were more frequent to attend the diabetes

education session. (See table 3 for details).Diabetes mellitus has reduced the productivity of the

Table 3. Distribution of Subjects Based on Physicians Specialty,

Diabetes Education and Follow up Visit

Variable Type 2

Lifestyle OGLD Insulin + Total

modification

Specialty

GPs/ internists 1 3 ( 61 .9) 3 87 ( 74 .0 ) 7 1 ( 54. 6) 471 (69.9)

Endocrinologists 8 (38.1) 1 36 ( 26 .0 ) 5 9 ( 45. 4) 203 (30.1)

Diabetes education

Given 8 (40.0) 168 (34.6) 49 (41.2) 225 (36.1)

None 12 (60.0) 317 (65.4) 70 (58.8) 399 (63.9)

Mean (SD) 6.8 (4.7) 4.1 (3.3) 4.3 (3.9) 4.2 (3.5)

Median 3.0 3.0 7.0 3.0

Follow up in the last 3 months

By GPs/ internists

Followed up 1 (33.3) 105 (60.7) 23 (47.9) 129 (57.6)

None 2 (66.7) 68 (39.3) 25 (52.1) 95 (42.4)

By endocrinologists

Followed up 13 (100.0) 332 (95.4) 96 (98.0) 446 (96 .1)

None 0 16 (4.6) 2 (2.0) 18 (3.9)

Table 4. Distribution of Subjects Based on Working Productivity

and Hospitalization

Variable Type 2

Lifestyle OGLD Insulin + Total

modification

Working productivity

Unemployed 13 (61.9) 283 (54.2) 63 (48.5) 359 (53.3)

Normal work 8 (38.1) 195 (37.4) 31 (23.8) 234 (34.8)

Sick leave 0 32 (6.1) 32 (24.6) 64 (9.5)

Unable to work 0 12 (2.3) 4 (2.3) 16 (2.4)

Hospitalized

Yes 2 (12.5) 41 (12.5) 26 (28.0) 69 (15.8)

No 14 (87.5) 288 (87.5) 67 (72.0) 369 (84.2)

Mean (SD) 2.5 (2.1) 1.2 (0.4) 1.0 (0.2) 1.1 (0.5)

Median 1.0 1.0 2.5 1.0

sufferers. Only less than 35% of patients had a formal work,

furthermore almost 10% of them had to take sick leave due to

diabetes. (See table 4 for details).

Success rate of the diabetic treatment is measured by

achievement of HbA1c target less than 7%. This value was

refered to international diabetes societies (ADA, EASD)

which have made global recommendations aiming to achieve

optimal levels of glycaemic control. The HbA1c average was

8.27% and only 37.4% had reached the HbA1c target of


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lence in Asia. Chan et al12 reported that cigarette smoking

was one of risk factors for the increasing diabetes preva-

lence in Asia.12 This study found 5.9% and 11% of patients

were active smokers and ex smokers respectively, which waslower than national figure of smokers (45.8% of adult male

population).13 Obesity is also confirmed as a common risk

factor for diabetes in Asia.11 This study found that 34.3%

and 9.7% of diabetes patients were overweight and obese

respectively. The mean of BMI was 24.8 (SD 4) kg/m2, and

the mean waist circumference was 89.0 (SD 11.5) cm. The

DiabCare study reported lower mean BMI, which was 23.4

kg/m2.

This study found high HbA1c level (8.3%) and high

fasting glucose level (170.3 mg/dL). These findings were in

line with the DiabCare study, who reported HbA1c level of

8.1% and fasting blood glucose of 142.2 mg/dL. The OGLD-

only treated groups achieved better HbA1c level compare to

insulin-treated group. This might be caused by the bias of

indication, in which patients with better glycemic control

were still given the OGLD, while patients with worse glyce-

mic control were switched to insulin regimen or were given

insulin from the start. In addition, there might be a lack of

optimal insulin titration in the real life setting.

The DiabCare study reported that the mean of SBP was

131.4 (SD18.1) mmHg. There were 57.4% of patients received

anti hypertension medication. Our study reported the same

finding that the mean of SBP was 132.6 (SD 20.5) mmHg.

Nevertheless our study reported lower percentage of hyper-

tension treatment, 47.6% had hypertension, 44.3% receivedtreatment, while 3.3% without treatment. The DiabCare study

reported that there were 54% and 14.1% of patients had LDL

and TG above target respectively. In addition, 11.3% male

and 21.1% female had HDL above target. Among those pa-

tients, 34% of them received lipid lowering treatment. 10 Our

study reported 53.5% patients with dyslipidemia, but only

44% received treatment while 9.5% were without treatment.

These findings show us that the metabolic control of dia-

betic patients were not good enough to prevent diabetic

chronic complications.

In all countries of Asia region including China, Hong

Kong, Indonesia, India, South Korea, Malaysia, Taiwan andThailand, the presence of microvascular complications (47%)

was also identified as a significant predictor of resource use,

but to a lesser extent than macrovascular complications

(20%).14 Our study found microvascular complications, such

as neuropathy, retinopathy and nephropathy, more often than

the macrovascular complications. This finding supports pre-

vious findings on the DiabCare study. Our study reported

that neuropathic symptoms are frequent initial causes of

medical consultation that lead to diagnosis. Therefore neur-

opathy was the most prevalent diabetic complication among

subjects in Indonesia followed by retinopathy, and nephro-

pathy.

Our study also found that the rate of screening for dia-

betic complications were still low, the same finding from the

DiabCare study. Diabetes management needs an implemen-

tation of strategies of prevention or delay of macro- and

microvascular complications and adequate control ofhyperglycaemia. Our study reported that diabetes caused

9.5% of sick leave 2.4% loss of employment. Diabetes also

caused hospitalization in 15.8% of patients. These two find-

ings suggested that diabetes is associated with a significant

amount of direct and indirect expenses. The substantial im-

pact of complications on resource use clearly provides an

economic rationale for concerted efforts for earlier diagnosis

and implementation of appropriate treatment, considering

that most Indonesian diabetic cases were undiagnosed. In

addition, for prevention of further complications, we need to

perform diabetic complications screening among all diabetic

patients. 15

Most of the type-2 diabetes cases in this study were

treated by GPs/internists. Nevertheless, the patients who

were treated by endocrinologist were more likely to visit the

physicians frequently. This findings might be explained by

the fact that most of the patients who visited endocrinolo-

gist had already had advanced diabetes, been given com-

plex treatment regimen and insulin therapy. The Indonesian

GPs/internists preferred to prescribe their diabetic patients

with OGLD that is much simpler compared to the use of insu-

lin. On the other hand, the endocrinologists tend to be more

courageous to try various regimen types. They prescribed

insulin for some of type-2 diabetes patients with or without

OGLD.In ensuring that diabetes patients will comply with their

life time medication, education session was organized by

specially trained diabetes educators during their clinic vis-

its. The diabetes educator provided important information

about the disease, the need for life time medication, and

trained the patients in managing the disease properly. Pa-

tients who were only prescribed OGLD got the least educa-

tion session compared to those relied to insulin or those

were given only lifestyle modification. 16 The endocrinolo-

gists have more contacts with the diabetes patients for the

last three months compared with the GPs/internists, espe-

cially among the type-2 diabetes patients who relied onlifestyle modification. The GPs/internists have been visited

more by type-2 diabetes patients who used only OGLD as

their treatment.

However, the average of last HbA1c in this study was

8.27% and among all patients, it appeared that only 37.4% of

type-2 diabetes patients reached the target value of HbA1c

less than 7%. It was lower than China which has the highest

number (44%) of patients reached the target value of HbA1c

in Asia, followed by South Korea (40%).12 IDMPS demon-

strated that a minority of patients meet glycemic targets. As

reported in regions in the world, lack of glycemic control was

a strong predictor of resource use, with patients not at guide-

line-recommended HbA1c target significantly more likely to


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consume healthcare resources. 12 The highest number (58%)

of patients reached glycemic control was achieved in Panama,

meanwhile Egypt achieved the lowest number (16%).12 The

DiabCare study (n=1785) in 2008, a hospital based studyinvolving 18 hospitals from all around Indonesia, reported

that only 34.45% of diabetic patients reach the A1c target

less than 7%.

Our study showed that the mean of HbA1c levels were

different across treatment regiment, in which the A1c level

were lowest among lifestyle modification group and highest

among insulin group. Nevertheless, the proportion of sub-

jects achieved the A1c target was highest among OGLD

group and lowest among lifestyle modification group. Nev-

ertheless, lifestyle modification is the basic foundation in

diabetes management. Lifestyle modifications should be

implemented across all diabetes treatment regiments to

achieve glycemic control and to prevent diabetic complica-

tions.

Finally, Diabetes is a chronic health condition with

comorbidities and it is also associated with micro and

macrovascular complications. We can learn from this study

that diabetes lead to a huge resource use and also associ-

ated with significant direct and indirect cost.17 These conse-

quences could be reduced through early diagnosis, prompt

treatment, effective metabolic control and screening for dia-

betic complications. Even we have already had type 2 diabe-

tes guidelines since 1993, nevertheless the comprehensive

management of type 2 diabetes in Indonesia was not as we

expected. Our study showed that we still need to improvequality of diabetes care in Indonesia. An integrated public

health approach and family medicine approach are crucial to

raise awareness of the wide reaching economic conse-

quences of diabetes-related complications, to increase fam-

ily support and participation, to educate patients and

healthcare workers and to allocate appropriate resources for

disease management.

Conclusion

In Indonesia, the majority of type-2 diabetic patients

were treated by GPs/internists. Most patients were given

OGLD alone. The average HbA1c in this study was high andthe majority of patients did not attain the recommended gly-

cemic target. This indicates the presence of a gap between

recommendations of most recent guidelines and the actual

practices. An integrated public health and family medicine

approach are crucial in improving quality of diabetes care in

Indonesia.

Acknowledgement

The author is especially grateful to all investigators who

have participated in IDMPS study: Prof. Dr. Askandar

Tjokroprawiro, SpPD, KEMD. Prof. Dr. RR Djokomoeljanto,

SpPD, KEMD. Prof. DR. Dr. Karel Pandelaki, SpPD.KEMD,

Prof. Dr. Ketut Suastika, SpPD. KEMD, Prof. DR. Dr. Agung

Pranoto, SpPD. KEMD, Prof. DR. Dr. Djoko Hardiman, SpPD.

KEMD, Prof. Dr. Asman Manaf, SpPD. KEMD, Prof. Dr. Syafril

Syahbuddin, SpPD. KEMD, Dr. K. Heri Nugroho, SpPD.

KEMD, Dr. Aris Wibudi, SpPD. KEMD, Dr. Ida Ayu Kshanti,SpPD. KEMD, Dr. Wira Gotera, SpPD. KEMD, Dr. Sony

Wibisono, SpPD. KEMD, Dr. Dharma Lindarto, SpPD. KEMD,

Dr. Gatut Semiardji, SpPD. KEMD, Dr. Roy P. Sibarani, SpPD.

KEMD, Dr. Alwi Shahab, SpPD. KEMD, Dr. Tony Suhartono,

SpPD. KEMD, Dr. Sri Murtiwi, SpPD. KEMD, Dr. Mardianto,

SpPD. KEMD, Dr. Tjokorda Gde Pemayun, SpPD. KEMD, Dr.

Zulfahmi Wahab, SpPD, Dr. Nono Matarungan, SpPD, Dr.

Dedy K.Kurniawan, SpPD, Dr. ND Pangesti, SpPD,Dr. Tuty

Kuswardhani, SpPD. KGer, Dr. Ratna Saraswati, SpPD, Dr.

Suroto Lim, SpPD, Dr. Marwani Bratasaputra, SpPD, Dr. Maria

Riastuti, SpPD, Dr. Eva Decroli, SpPD, Dr. Irfani Riza, SpPD,

Dr. Imam Faturakhman, SpPD, Dr. Paul Harijanto, SpPD, Dr.

Ratni Rahim, SpPD, Dr. Yuanita Langi, SpPD, Dr. Hadi

Sulistyanto, SpPD, Dr. Eddy Prijambodo, SpPD, Dr. Jerahim

Tarigan, SpPD, Dr. Luthfan B.Purnomo, SpPD, Dr. Rizky

Perdana, SpPD, Dr. Abdullah Ammarie, SpPD, Dr. Zuhrial

Zubir, SpPD, Dr. Imam Suprianto, SpPD, Dr. Sapto Priatmo,

SpPD, Dr. Dasril Effendi, SpPD, Dr. Sunu Sugiyanto, SpPD,

Dr. Kuntjoro Yakti, SpPD, Dr. Budi Santoso, SpPD, Dr.

Sulistyawati Ohnio, SpPD, Dr. Pendrik Tandean, SpPD, Dr.

Zulkhair Ali, SpPD. KGH, Dr. Bimanesh Sutarjo, SpPD. KGH,

Dr. Abdurrahim Lubis, SpPD. KGH, Dr. Anton Cahaya, Dr.

Budi Ikhwansyah, Dr. Ervin Tampubolon, Dr. Gunawan

Arsyadi, Dr. Atyah Rasyid, Dr. G. Kunar Abadi, Dr. Davis

Ajiaribowo, Dr. Zulkarnaen, Dr. Sutrisno, Dr. Jalil Alfani, Dr.Djoko Rahardjo, Dr. Sulhani Nurul Aini, Dr. Husaini Umar.

References

1. Nataniel Winer MD, James R, Sowers MD, Epidemiology of Dia-

betes. Journal of Clinical Pharmacology. 2004; 44 (4): 397-405.

2. Zimmet P. The burden of type 2 diabetes: are we doing enough?

Diabetes Metabolism. 2003,29;6S9-18.

3. UK Prospective Diabetes Study (UKPDS) group. Intensive blood

glucose control with sulphonylureas or insulin compared with

conventional treatment and risk of complications with subjects

with type 2 diabetes (UKPDS 33). The Lancet. 1998;352:837-

53 .

4. Stratton IM, Adler AI, Neil HA, Matthew DR, Manley SE, Cull

CA, et al. Association of glycaemia with macrovascular and mi-crovascular complications of type 2 diabetes (UKPDS 35): pro-

spective observational study. BMJ. 2000;321:405-12.

5. ADA. Clinical Practice Recommendations 2003. Diabetes Care.

2003;26:Suppl 1.

6. Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud

PA C, et al. Why dont physicians follow clinical practices guide-

lines? A framework of improvement. JAMA. 1999;282(15):

1458-65.

7. Perkumpulan Endokrinologi Indonesia. Konsensus Pengelolaan

dan Pencegahan Diabetes Melitus Tipe 2 di Indonesia, 2011.

8. International Household Survey Network (IHSN). Indonesia, 2007

- Demographic and Health Survey (DHS). Available from http://

www.surveynetwork.org/home/index.php

9. Soewondo P, Soegondo S, Suastika K, Pranoto A, Soeatmadji

DW, Tjokroprawito A. et al. The DiabCare Asia 2008 Study -

Outcomes on Control and Complications of Type 2 Diabetic

48 0


8/8



Patients in Indonesia. Med J Indones. 2010; 19: 235-44

10 . Chan JCN, Gagliardino JJ, Baik SH, Chantelot JM, Ferreira SR,

Hancu N, et al. Multifaceted Determinants for Achieving Glyce-

mic Control: The International Diabetes Management Practices

Study (IDMPS). Diabetes Care 2009; 32:227-23311 . Zimmet P, Alberti KGMM, Shaw J. Global and societal implica-

tions of the diabetes epidemic. Nature. 2001;414:782-7.

12 . Chan JCN, Malik V, Jia W, Kadowaki T, Yajnik CS, Yoon KH, et

al. Diabetes in Asia. JAMA. 2009; 301:2129-40

13. Departemen Kesehatan Republik Indonesia: Badan Penelitian

dan Pengembangan Kesehatan. Laporan Nasional: Riset

Kesehatan Dasar (RISKESDAS) 2007. Jakarta: Depkes RI, 2007.

14 . Ringborg A, Cropet C, Jonsson B, Gagliardino JJ, Ramachandran

A, Lindgren P. Resources Use Associated with Type 2 Diabetes in

Asia, Latin America, the Middle East and Africa: Results from

the International Diabetes Management Practices Study (IDMPS).

Int J Clin Pract, 2009;63:980-2

15 . Javitt JC, Chiang Y. Impact of Diabetes - Chapter 30. Available

from http://www.diabetes in-america.s-3.com/adobe/chpt30.pdf

16. Mottur-Pilson C, Snow V, Bartlett K, Physician Explanationsfor failing to comply with best practices. Eff Clin Pract, 2001;

4:207-13.

17 . Wild S, Roglic G, Green A, Sicree R, King H. Global Prevalence of

Diabetes: Estimates for the Year 2000 and Projections for 2030.

Diabetes Care 2004;27:1045-53.

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