This is a large scale cross-sectional study on diabetes patients firstly attending the primary diabetes clinics in 5 big cities in China over 3 years. It provided an overview of the prevalence and the control status of ASCVD risk factors in these diabetes specific primary settings.
Nearly 95% diabetes patients had one or more ASCVD risk factors (hypertension, dyslipidemia, overweight or obesity, and smoking) other than hyperglycemia, and around 73% of them had two or more. These were similar to the results reported in literatures. Lechauncy D et al[24]. found that 92.2% diabetes patients had one or more comorbidities (hypertension, ischemic heart disease, hyperlipidemia). REACTION study [25] found that 88.8% diabetes patients had at least one additional condition (hypertension, hyperlipidemia, hypothyroidism, hyperthyroidism, or renal insufficiency) was, 53.2% of patients had two or more comorbidities. Harry HX Wang et al. [26] reported that one or more chronic conditions (a total of 52 other chronic diseases including hypertension, hyperlipidemia and coronary heart disease) experienced by 71% diabetes patients in communities.
In consistence with the REACTION research[25], our study showed that the number of ASCVD risk factors increased with the older age, longer diabetic duration, larger waist circumference and higher BMI. In contrary, the control rate of blood glucose was lower as the number of risk factors increased. In addition, the risk factors numbers increased in patients with diabetic family history, which was consistent with the literatures[27–30].
In this study, the control of blood pressure, blood lipid and blood glucose of diabetes patients was poor. Only 26.5% patients attained HbA1C target. It was similar to that (25.9%) in Shaanxi Province in western China[31]. However, it was much lower than the national-wide data (36.7% [25]-47.8% [2, 12, 32]). The reason accounting for the discrepancy might be those data either from a tertiary / secondary hospital[12] or from epidemiological study[32], which might under-estimate a real-world worse situation. Because the former one may represent patients with better medical resources[12], and the later one included a lot of new-diagnosed diabetes patients who had relatively low HbA1C[32]. The achievement of HbA1C control was much lower than that form Americans (55.5%) reported from 2009–2010 NHANES survey [33] and from Spain in 2009 (56.1%)[34]. In addition, 27.9% and 42.6% of diabetes patients achieved blood pressure < 130/80 mmHg and LDL-C < 2.6 mmol/l in our study, respectively. These were nearly the same as those in CCMR-3B study (28.4% and 42.9%) [12] and in Spain (31.7% and 37.9%)[34]. They were also much lower than those in the United States (52.8% and 54.4%)[33]. Regarding the global control rate of HbA1C, blood pressure, and LDL-C, only 4.1% of patients reached all 3 ABC targets in our study, as low as that in Shaanxi Province (4.5%)[31]. And it was even lower than that in CCMR-3B study (5.6%) [12] conducted 10 years ago. The proportion of patients reached all 3 targets was only about one third of the proportion in Spain (12.1%)[34], or was one sixth of the proportion (24.9%) in the United States [33] and Canada (21%)[35]. The unsatisfactory control status may also be due to the selection bias, that is, patients with poor controlled blood glucose might prefer to visit the specialized diabetes clinics instead of general hospital. It was interesting to find the difference among these 5 hospitals. Particularly, patients in Chengdu had the best control of HbA1C, blood pressure and all 3 ABC targets. Better health insurance policy may contribute the achievement in Chengdu. The patients diagnosed with diabetes were granted a special quota for diabetes care by local municipal insurance agency.
We found that patients with older age, shorter duration of diabetes, lower BMI, non-smoking, and oral hypoglycemic agent, had a higher proportion to achieve all 3 therapeutic goals. These were consistent with the findings from other studies[12, 31]. Thus, lifestyle intervention such as stopping smoking and losing weight played an important role in the control of ASCVD risk factors. Cholesterol lowering medicine prescription should increase possibility attained all 3 targets but not found in this study. In other literatures, non-Hispanic Whites rather than Black/African Americans, and Filipino and Hispanics/Latinos[36], men rather than women [37] were more likely to achieve all three goals. This could be due to the low dose of statin used in this country. Patients lived in different area manifested a big difference of achievement ABC target. Here Chengdu was the best, which may due to better health insurance policy in Chengdu. Furthermore, we found that patients under insulin therapy had a lower HbA1C control rate at 17.6%. Patients under antihypertensive and lipid lowering therapy also had a lower control rate. These data suggested that the more ASCVDRFs patients had the harder for achievement of the three targets.
This study has been the first large-scale study from the primary care setting ever in China. The limitation was obvious. Because patients were those visiting hospitals, especially primary diabetes clinics, representing those who need to be treated, the worse situation may be exaggerated. Patients with severe complications and those have well controlled risk factors may not be proportionally recruited in our study. So the participants may not represent the whole T2DM population. In addition, this study lacked individual information of the medical insurance status and economic situation which would also affect the control rate of ASCVD risk factors.