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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
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.
1
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,
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
METHODS
(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
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
2
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).
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
3
(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)
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
4
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,
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
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
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.
5
5. Covarrubias M. Island of Bali. Singapore: Alfred A.Knopf, Inc.; 1973.