Inside a shopping mall on a Saturday afternoon in Tan Phu District, Ho Chi Minh City, several groups of Vietnamese children and their families are perched on plastic chairs eating burgers and fries and sipping fizzy drinks. Outside in the shade, a group of men take a smoke break from shopping. It’s a sign of the times in Vietnam, and it’s a scene that reveals several red flags for diabetes.
The Vietnam Association of Diabetes and Endocrinology (VADE) recently reported that in Vietnam there are now 5 million diabetics, which accounts for around 5.4% of the population. It’s believed that the real figure could be closer to 10%, after factoring in those who are living undiagnosed. It’s an alarming rise from the figure of 3.3% just three years ago, and it means that Vietnam has one of the fastest- growing rates of diabetes in the world.
The main concern is type 2 diabetes, which used to be called Adult-Onset Diabetes before its rapid rise began to be charted in children. Unlike the genetic nature of type 1 diabetes, type 2 is characterised by lifestyle choices; eating refined sugars and flour, high-fructose corn syrup, heavily processed food, lack of dietary fibre and smoking. Fast-food outlets get most of the blame, but look around your local Family Mart or Circle K and see how much of the food and drink is quietly crammed with sugar.
The problem is stark; just 30 years ago, Vietnam was in the grip of malnutrition, and now it faces obesity and diabetes problems, with over 50,000 deaths attributed to diabetes in Vietnam in 2015, according to the World Health Organisation (WHO). That number is sure to rise as the country gets wealthier. The list of complications of diabetes is long; ulcers, gangrene and resulting amputations, cardiovascular diseases, blindness and kidney failures.
Dr Pedro Trigo, a hepatology and internal medicine specialist at Family Medical Practice in District 1, has been practising in Vietnam for seven years, and in that time he’s seen great changes in lifestyle for the general population. Vietnam is on the road to becoming a developed country, and a burgeoning middle class have new money in their pockets.
“When the culture says ‘wow you are wealthy, you have to enjoy your time, your car etcetera’, they become lazy, eat more proteins and fatty foods and become obese,” he says.
Cigarettes and Alcohol
Another key risk factor in developing type 2 diabetes is smoking, but the link between smoking and diabetes is one that is often overlooked by both the public and by doctors.
“I think sometimes even doctors are not aware [of the risk],” says Dr Trigo.
A 2015 Global Adult Tobacco Survey (GATS) survey estimated that 22% of Vietnam’s population are smokers (45% of men, 1.1% of women), a figure that is not declining, as in the West. The link between drinking alcohol and type 2 diabetes is disputed. In moderation, many studies suggest you are safe. But doctors agree that binge drinking and excessive consumption of alcohol is a big risk factor, particularly when looking at the link between diabetes, pancreatitis and heavy drinking.
With new eating, drinking and overall lifestyle habits come many differing risk factors, which are now combining to create a perfect storm for diabetes in the country. Dr Trigo says these can create further problems, such as depression and anxiety, which can also contribute to the disease.
Worse, Asians are at risk from diabetes due to a lower Body Mass Index (BMI) than Caucasians, meaning looks can be deceiving. You may look relatively healthy, but inside your body, you may already be suffering the consequences without showing the signs that you might expect.
Symptoms of diabetes are often subtle and range from irritability to increased thirst to frequent urination. But Dr Trigo says patients are never surprised when they receive the diagnosis.
“Nowadays everyone knows, if you have bad habits you will get in trouble,” he says. “Even poor people know that if you eat well, sleep well, you will be healthy. If you drink and smoke a lot it will be a problem. Human beings pretend this will not happen to them.”
Additionally, with resources stretched, many diabetics may be too far from the services that they require, which Dr Trigo says has cost lives in Vietnam. Diagnosis rates are also low, as it’s uncommon in Vietnam for people to go for a check-up.
“The people live quite far [away], and the roads are often bad,” he adds. “The problem is how much they comply with the treatment, even to pick up the medication. They don’t go because, an hour and a half on a motorbike [is too far] so they don’t go, and they die.”
Living with Diabetes
Dang Ngoc Tran is 56 years old, and was diagnosed with type 2 diabetes towards the end of last year.
“I felt tired. I was losing weight without control for a couple of months,” says Tran.
“I drank three to four times per week. That is the big factor plus family medical history. I smoke, but I’m not a smoker, and only smoke one when seeing friends and I wasn’t aware of the link between them [smoking and diabetes],” he adds.
“Of course, it was difficult at the beginning when I had to care about what I eat.”
Even though he worries about complications that may arise from his diagnosis, he is retired and still hopes to enjoy life. “You can’t ask people to stop eating nice food or stop drinking which is the fun part when you hang out.”
Marvin Mesina is 35 and was born in the Philippines but grew up in Canada. He was diagnosed with type 2 diabetes aged 24 and it came as a big shock.
“The main symptoms were sudden weight loss, always thirsty and hungry, frequent urination, especially at night and being unable to concentrate,” he says, “My family has a history of diabetes. My father and grandfather had it, but I think what triggered it was that level of stress I was under back at that time.
“I felt devastated when I heard the news, I thought I was going to be immune from it regardless of our family history, so when I heard the confirmation from the doctor, I felt depressed and was in denial for a while.”
Living as a foreigner with diabetes in Vietnam comes with its own challenges. Mesina struggled to find a proper endocrinologist when he first arrived in the country, and it was also difficult to find the same brand of medication that he was taking back in Canada; the cost of his insulin and oral medication is higher than it was back home. But Marvin says the hardest aspect of life for a diabetic in Vietnam, is trying to maintain a suitable diet.
“I feel like it’s hard to adopt a diet here in Vietnam, in Saigon in particular,” he says. “People here love eating rice and anything sweet. I feel like they put sugar in everything. I have yet to try an authentic ca phe sua da.”
Marvin and Tran are fortunate in that they both receive their care at a local clinic, but diabetes is a condition where the poorest suffer disproportionately. According to the International Diabetes Federation, in 2015 diabetes-related expenditures in Vietnam were on average US$162.70 per patient, per year. This is more than the average monthly salary of US$150 in Vietnam, and the public hospitals that treat the poorest are not being built and new doctors are not being trained at a rate that can support the need.
“To create a new generation of doctors takes six years, but to build a hospital takes one year,” says Dr. Trigo. “There are massive needs. They are building new universities but there is a big gap between the needs and the ability to support these needs. It’s very difficult.”
He adds: “When I arrived in Vietnam I was in shock when I visited a local hospital. There were horrible corridors, horrible beds, no mattresses, everything dirty, chaos. Now it’s the opposite, except the chaos. Because they have everything new but the doctors and nurses are extremely overloaded. You can have the best F1 race car, but if you don’t have someone who can manage the car, it’s a disaster.”
Dr Trigo believes it’s inevitable that there will be more and more blind people in Vietnam due to diabetes, and there will be more cases of diabetics who require kidney dialysis or amputations.
“The best is to be prepared to avoid this, not to deal with the consequences,” he says. “The doctors have good training, but it’s not enough.”
Malnutrition and Obesity
Vietnam’s lightning-fast but unequal development means that it is a country that deals with malnutrition at one end of the economic scale, and obesity and diabetes at the other.
Efforts to educate the citizens on the consequences of an unhealthy lifestyle have so far been ineffective, and the diabetes rates are relentlessly climbing. If old habits die hard, then new habits will die even harder.