Professor Juliana Chung Ngor Chan: Tireless Trailblazer for Diabetes Research, Care, and Education in Asia Free

• “I stand on the shoulder of many giants to achieve through others’ achievements” (adapted from Sir Isaac Newton).

• “The more you know, the more you know you don’t know.”

• “Research answers some questions but leads to many more.”

• “Empowered by knowledge and inspired by love” (adapted from Bertrand Russell).

• “Think, follow your heart, and do something.”

• “TEAM: Together Everybody Achieves More” (first shared by Rebecca Wong).

Throughout her career, Juliana has made many important contributions to diabetes research, care, and education. Her first major contribution was the role she played in redefining diabetes care delivery. Despite the availability of efficacious treatment, one of the biggest treatment challenges is the organization of diabetes care and access to care, which remains haphazard and fragmented even for most developed health care systems.

As a passionate advocate of data-driven and integrated care, Juliana led the team to systematically collect data during routine clinical practice in order to improve service quality and to establish registers for surveillance, prevention, and treatment. In the early 1990s, she set up the Hong Kong Diabetes Register (HKDR) using a “trio team” of clinician, nurse, and clerical staff. Her working style, including her persistence and great organization, enabled the team to make these clinical data to become more meaningful and easier to interpret. The HKDR used simple assessment tools and structured case report forms to collect a detailed set of risk factors and actionable items. The information then helps to stratify risk, classify disease subtypes, identify specific needs, and personalize care according to patient risk profile and to support shared decision-making between patients and health care providers (1,2).

Apart from providing a reference to clinicians for managing and communicating with patients, the information from the HKDR serves as an excellent tool for self-management. On a broader view, the register also drives actions at system and policy levels via identifying care gaps, benchmarking performance, and monitoring disease patterns and burdens. This approach was later adopted in the public health care system by the Hong Kong Hospital Authority (HA), the health care organization that looks after more than 70% of people with diabetes in the territory, through implementation of a structured assessment and screening program for diabetes complications at all its diabetes centers. This program later expanded into the primary care clinics, known as the Risk Assessment and Management Program (RAMP) for diabetes (2,3). This approach was later adopted by various institutions in China and other Asian countries (4–6). This reform has contributed to the continuous improvement in metabolic control and a 4.2% (95% CI −4.1, −4.3) annual reduction in age- and sex-standardized mortality of people with diabetes in Hong Kong between January 1995 and December 2016, one of the biggest improvements among 16 high-income countries or jurisdictions (7).

Juliana is also particularly concerned for people with young-onset diabetes, as she has always felt for those who suffer from the potentially preventable complications. With their long disease duration and suboptimal metabolic control, this group of patients harbors nearly fourfold increased risk of diabetes-related admissions in their lifetimes, with sevenfold and twofold increased risk for admissions for renal and cardiac complications, respectively (8). In the late 1990s, together with our nurses, notably Rebecca Wong, Juliana initiated an intensive insulin treatment program at our diabetes center at the Chinese University of Hong Kong (CUHK) and Prince of Wales Hospital (PWH) on Saturdays for young patients to intensify insulin therapy, including the use of continuous subcutaneous insulin infusion. This change in setting allowed patients to have decent contact time with the multidisciplinary team, where they received personalized medical consultations and education from nurses and dietitians, together with regular complication assessment (9,10). These group meetings aim to facilitate peer support. Patients share and learn from each other concerning how to cope with stress, day-to-day issues, and life events such as pregnancy during their journey of living with diabetes. The mutual support and empowerment enhances their resilience in self-management (11) and provides the impetus for peer support to be included as an integral part of diabetes management at our center and beyond (12).

Considering the rising incidence of end-stage renal disease due to diabetes, especially in Asian patients, she adopted the model of the landmark Steno-2 study, whereby control of multiple risk factors resulted in nearly 50% reduction of cardiorenal events and mortality (13,14). A diabetic nephropathy clinic was established, with support from a clinical pharmacist, to intensify medical therapy and patient compliance for renal protection. She engaged other local diabetes centers in Hong Kong through implementation of the multicenter Structured Versus Usual Care on Renal Endpoint in Type 2 Diabetes (SURE) study using the same protocol and promulgated the practice in a territory-wide manner (15) and in Asia (16).

For the vast number of relatively stable patients, she established the concept of shared care with community general practitioners as well as a peer support program enhanced by technology to provide continuing care. By increasing quality contact time, this multicomponent care model addressed the psychosocial and informational needs of patients with improved self-care and treatment adherence through engagement, especially in those with poor motivation (17). Supported by protocol-driven risk assessment and education by nurses, both patients and general practioners were better informed in making decisions, resulting in a 50% reduction of clinical events compared with usual care (12,17). In the evaluation of a territory-wide program, this multicomponent care model resulted in an average reduction of USD 7,000 per patient by preventing costly complications at 5 years (18).

All these reforms provided ample opportunities for professional development and career advancement for health care providers specializing in diabetes. As an example, there were only a few diabetes workers in Hong Kong in the 1980s. By 2008, there were 18 diabetes centers across all the public hospitals, and the number of diabetes educators continued to grow, with the formation of their own association to support the care of people with diabetes. Juliana’s enthusiasm to improve diabetes care did not stop at the local level. Following in the footsteps of Professor Clive Cockram in advocacy work, she spearheaded the Western Pacific Declaration on Diabetes and its work plan (19). Her advocacy and the approach that she took to use data to guide and inform diabetes care delivery gained increasing attention and led to an invitation from The Lancet to lead the Lancet Commission on diabetes, together with Dr. Edward Gregg. She led the preparation of the Commission report, authored by 44 global experts in the field of diabetes and public health, entitled “The Lancet Commission on Diabetes: Using Data to Transform Diabetes Care and Patient Lives,” which was published in November 2020 (20). The report encapsulated her philosophy of combining research, clinical care, and advocacy to benefit patients.

Juliana is energy and zeal personified. As an endocrinology trainee years ago, I witnessed her debating relentlessly in clinical rounds on what would be the best treatment plan for each patient. She is always ready to share her fascinating and intriguing ideas, and we would talk until well beyond midnight, so much so that we had a few near-miss car accidents when she became so excited sharing her ideas while driving. She is not just my mentor but has been my friend throughout my training and beyond, sharing with me not as an eminent clinician scientist but as a daughter, wife, and mother. She has shared her values on family ties and motherhood and on the importance of education and playing team sports, like football, in shaping a child’s growth as an inquisitive yet collaborative person. This, in turn, has tremendous influence on the path that I chose for myself and my own family.

Inspired by the many experts she interacted with and learned from, Juliana launched a series of research programs that helped shape our understanding of diabetes, especially in Asia. She recalls that one of the first things that struck her and her mentor, Professor Clive Cockram, was how the disease characteristics of people with type 2 diabetes they were treating seemed so different from those of patients with type 2 diabetes they had treated back in the U.K. This led to her decades of investigation to advance the understanding of diabetes in Asian populations, particularly in helping to define the “Asian phenotype,” which shows an increased predisposition to visceral adiposity and β-cell insufficiency (21,22). She and Dr. Gary Ko undertook a series of important studies in defining cutoffs for BMI in Asians associated with increased metabolic risk, culminating in a World Health Organization (WHO) expert consultation and establishing an appropriate range for BMI for Asian populations (23,24).

Her research is characterized by a combination of astute observations, uncanny intuition, great foresight, and remarkable perseverance. Back in the 1990s, when she established the structured assessment and quality improvement program for the HKDR, she had the foresight to seek ethics approval and obtain consent from patients to donate their blood and DNA for diabetes research, thereby starting the biobanking of samples to accompany the HKDR. Over the years, through long-term follow-up of subjects and linking of their electronic medical records (EMR) and clinical data in the register, the HKDR has become a unique resource for epidemiology, genetics, and biomarker research. Work from the HKDR, including more than 300 publications, has highlighted the burden of cardiorenal complications in Asian patients with type 2 diabetes (25), atypical features of type 1 diabetes in Asians (26,27), the link between diabetes and cancer (28), the alarming rates of young-onset diabetes and associated complications (29–31), and, more recently, the bidirectional links between diabetes and depression (8,32). Working closely with our obstetrician colleague Dr. Wing Hung Tam, we also highlighted in our early work the significant burden and long-term complications in women with gestational diabetes mellitus, including effects on the offspring (33–35). These early observations have been confirmed by work from many other researchers and have opened different research areas that continue to be pursued by our group to the present day.

Juliana’s identification and report of one of the first cases of maturity-onset diabetes of the young (MODY) in Asia (36,37), and her encounters with patients with a strong family history of diabetes, sparked her interest in studying the genetics of diabetes. Encouraged by the late Professor Robert Turner and assisted by Dr. June Li, she initiated the Hong Kong Diabetes in Family Study (HKDFS), which formed the basis for subsequent studies on the genetics of diabetes, including linkage analyses led by Dr. Maggie Ng to map diabetes and metabolic syndrome risk to a locus near chromosome 1q (38,39). With the subsequent advent of genome-wide association studies in the mid-2000s and with the available samples from the HKDR and HKDFS, she was well placed to embark on these efforts and made important contributions to the early waves of discovery of novel loci for type 2 diabetes through genome-wide association studies, especially in East Asian populations (40–42). Through the Molecular Diabetology in Asia (MDIA) study group, she collaborated with other Asian investigators on genetic studies in diabetes, which formed the basis for subsequent East Asian meta-analyses (43–45). Another major area of interest was the genetics of diabetes complications, in particular diabetic nephropathy and cardiovascular complications. Over the last three decades, she has led studies ranging from candidate gene studies to studies utilizing genome-wide approaches and sequencing to identify susceptibility loci for diabetes complications (46–50). The group is now actively investigating how to use this body of information to inform clinical care for precision medicine in diabetes treatment (51).

Juliana often remarked on how her early exposure to industry through the conduct of clinical trials helped her realize the power of academic–industrial partnerships (52–54). Supported by many physician scientists, including Drs. Risa Ozaki, Andrea Luk, Alice Kong, and Elaine Chow, her team has led, coordinated, and conducted a large number of clinical trials in the last two decades to contribute Chinese-relevant data to the diabetes treatment landscape, especially data on diabetic kidney disease. She has taken to heart the careful planning and execution of these clinical trials and incorporated the systematic collection of data in the many clinical research projects, including very large multicenter studies in a real-world setting (4,5,16).

In recognition of her great contribution, Juliana has received a number of international awards, including the Peter Bennett Award from the International Diabetes Epidemiology Group (2015), the Xiaoren Pan Distinguished Research Award for Epidemiology of Diabetes in Asia from the Asian Association for the Study of Diabetes (2015), the Harold Rifkin Award for Distinguished International Service in the Cause of Diabetes from the American Diabetes Association (2019), the International Diabetes Federation (IDF) Award Lecture in Epidemiology (2019), and the Hellmut Mehnert Award, founded by the German Diabetes Union and sponsored by UNESCO and the United Nations Council on Healthy Ageing (2021), to name but a few.

My recollection of my first encounter with Juliana almost 25 years ago is the sheer energy and enthusiasm that she exuded. Colleagues would share stories of how she took extraordinary efforts to try to provide what was best for her patients. As endocrine fellows, we were fortunate to learn from her careful assessment and how she communicates with patients. As young academics, we benefited tremendously from her guidance and mentorship and learned from her attention to detail. Many times we would send off our draft manuscripts or grant applications in the middle of the night, only to find a painstakingly polished version in the inbox by the next morning. Witnessing her extraordinary vision and drive first-hand has provided us the impetus to try harder and to search deeper for answers. When discussing research results, she would challenge us to ask, “So what?” This relentless pursuit of answers has been very important in shaping our outlook on what really matters and how to strive to make a difference. I think these “six E’s” collectively provide an appropriate description: energy, enthusiasm, explorer, excellence, entrepreneurial, and extraordinary. Indeed, one cannot but marvel at what she has achieved. However, in her typical understated fashion, she attributes her achievements to the mentorship from and collaborations with renowned epidemiologists and to early exposure to clinical trials when there were few clinical researchers in the field of diabetes in Asia, which she said provided the network and opportunities for her to pursue a lifelong journey of learning, questioning, and exploring. It is fair to say that by leading by example, she has inspired and mentored a whole generation of doctors and researchers to follow this path of discovery.

I first met Juliana in 2004. I had just returned from Australia, where I was working as a medical registrar, to join as an endocrinology trainee at the PWH in Hong Kong. I vividly remember my first impression of Juliana. She was so full of energy, and her enthusiasm and passion were dazzling. One of Juliana’s greatest contributions to service and research in diabetes in Hong Kong was the establishment of a diabetes complication assessment program, which later became the HKDR, which has since enrolled more than 30,000 people with prospective follow-up over 20 years. The assessment program was later adopted by other hospitals and outpatient clinics in Hong Kong and has made a territory-wide impact on improving the health of people with diabetes, including major declines in death and complication rates in the local population (2,55). Juliana’s vision to improve the care of people with diabetes has no boundaries. In 2007, she and others set up the Asia Diabetes Foundation, a charitable foundation governed by the Chinese University of Hong Kong (CUHK) Foundation, to develop the Joint Asia Diabetes Evaluation (JADE) Program (56,57). This disease management tool, consisting of a web-based portal with templates to guide complication assessment and risk engines to predict 5-year probabilities of major clinical events, is an amalgamation of findings and insights from the HKDR. To facilitate its use in non-English-speaking countries, the JADE portal was translated into eight languages and distributed for use in 10 Asian countries or regions.

Juliana made unparalleled contributions to the understanding of diabetes in the Chinese population. Using the HKDR, she developed and validated risk equations to project future risks of diabetes complications, and these predictions have been implemented in clinical practice for risk stratification (58–60). The real-world data accrued through the JADE portal contributed to important observations related to disparities in risk factor control, treatment, and complication risks in this locality (29). Juliana inspired me to develop my interest in diabetes epidemiology. The HA, which governs most of the public health services in Hong Kong, collects patient information in its EMR system. At the time in the early 2010s, however, the data were not easily accessible to academia for research. Together we had to jump through many hoops to finally gain access to the EMR and curated the Hong Kong Diabetes Surveillance Database, which comprises data of over 4 million people (61). Under Juliana’s guidance, we described trends in diabetes incidence and complications, identified treatment gaps, and made recommendations on how we could best prioritize our limited health care resources (61–64).

We wanted to understand the growing problem of young-onset diabetes in our population. In the early 1990s, Juliana published one of her first articles on diabetes occurring in young people (65). She reported the clinical features of 60 patients diagnosed before the age of 35, many of whom had already developed kidney complications at a young age. She told us that she had to submit the work to over 30 journals before the article was eventually accepted. Twenty years later, using multiple cohorts, we confirmed that young people fared much worse than older people with diabetes (8,29–31). In our quest to understand the genetic and environmental causes of young-onset diabetes, we have obtained several grants to undertake clamp experiments, measure biomarkers, and conduct genetic sequencing in our young cohorts. In our every encounter, I have witnessed her commitment and unrelenting drive to seek answers and to improve the quality of life of those living with diabetes.

Juliana is a wonderful teacher. She is a firm believer that knowledge should be disseminated. In 2005, she founded the Hong Kong Institute of Diabetes and Obesity under the governance of the CUHK. Through the Institute, she set up education programs, including master’s and diploma courses, on diabetes and metabolic health. These accredited professional programs have since been used to train hundreds of health care workers, including doctors, nurses, and dietitians. The CUHK-PWH Diabetes and Endocrine Centre was one of the first diabetes centers designated an IDF Centre of Education, in recognition of its academic excellence in using research to change practices and influence policy. The Institute has also organized the annual East Meets West (EmW) Symposium, now recognized as one of the most important local meetings that covers the latest advances in the fields of diabetes and atherosclerosis.

Despite her very busy clinical work and research commitments, Juliana has always managed to juggle her time between her different commitments. She has two sons, William, who is now a lawyer working in London, and Henry, who is a designer working in Shanghai.

William shared that one of the most enduring memories of his childhood is the image of Juliana at his primary school football practices. She sat in the bleachers and watched his efforts, offering the occasional word of encouragement while simultaneously marking a teetering pile of her students’ academic papers. This image aptly sums up Juliana’s admirable dedication to both motherhood and her career and that the two were not mutually exclusive: no matter how busy, Juliana always made time to be a great mother. Another fond memory shared was the eloquent bilingual speech she delivered at her son’s wedding that had all the guests enthralled, highlighting her ability to inspire awe in everyone around her.

The family enjoys traveling and visiting historical places, while Juliana likes watching movies or documentaries with stories about people. She is fascinated by humanity, i.e., what, why, and how people think, feel, and behave. During her quiet moments on a plane, she enjoys reading books outside medicine, especially nonfiction works on social phenomena and psychology. This may be influenced in part by her mentor Professor Cockram’s love of philosophy and anthropology, which inspired her to read some books by Bertrand Russell and other philosophers during her early career. Given the busy and chaotic setting of the clinic, she also read a lot of books on management and read the Harvard Business Review to learn principles of motivation, goal setting, and team building in order to realize one’s vision.

What is perhaps less well-known is her love for the arts and appreciation for creativity. One of her sons shared how she might watch a documentary or read a book, which would ignite her interest in a particular person, topic, or event and lead her to undertake research into it, including exhausting almost every song in an artist’s anthology in a short time. This highlights how, despite her relentless focus on her work, Juliana has a never-ending thirst for knowledge, with a yearning to appreciate and learn about broader issues beyond her area of expertise. Perhaps it is also this incessant willingness to learn that has molded her career and contributed greatly to her outstanding success.

Her love of challenges and exploration of the unknown may have framed her working style. She once commented that she relies very much on intuition, and she always hopes for the best and prepares for the worst while continuing to persevere with resilience and optimism. She reflected that the diversity of attributes and characters in her big family and her appreciation of how a life-transforming drug is born has convinced her of the importance of inclusion and diversity in order to create impact, and that as a supervisor or mentor, her role is to recognize the strengths and attributes of her coworkers, identify opportunities, and create an environment to bring out the best in all team members while nurturing a collegiate spirit for the common good. The large number of clinicians, researchers, and scientists that she has mentored and taught, and the diverse research programs that she initiated, are testaments to her success in establishing this nurturing environment.

One of us (R.C.W.M.) recently had the opportunity to share a consultation room with her in our busy teaching hospital. I happened to come across one of the patients she first diagnosed as having MODY3 more than three decades ago (36). I took the opportunity to bring the patient to meet with Juliana, who was at the other end of the large consultation room. It was wonderful to witness the warm exchange at their reunion and the great appreciation from the patient for all that she has done in providing the best care possible for her and her family. This moment provided a poignant reminder of her statement on the philosophy and motivation behind her trailblazing work:

Acknowledgments. The authors express their sincere thanks to Professor Juliana Chan as well as her husband Kenny Chung and sons William Chung and Henry Chung for providing invaluable comments, input, and photographs that contributed to the preparation of this article. The authors acknowledge the medical and nursing staff of the PWH Diabetes and Endocrine Centre for their professionalism and dedication. The authors apologize for not being able to include acknowledgment of all the collaborators who have kindly supported the team over the years.

Funding. This work was supported by the Liao Wun Yuk Diabetes Memorial Fund and Hong Kong Foundation for Research and Development in Diabetes, under the auspices of the CUHK, which provided key support to research development in the group. R.C.W.M. acknowledges support from the RGC Research Impact Fund (R4012-18) and a Croucher Foundation Senior Medical Research Fellowship.

Duality of Interest. No potential conflicts of interest relevant to this article were reported.