CLINICAL RESEARCH

e-ISSN 1643-3750
Med Sci Monit, 2015; 21: 1440-1446
DOI: 10.12659/MSM.892246

Glycemic Control Rate of T2DM Outpatients in

China: A Multi-Center Survey

Received:2014.08.14
Accepted:2014.10.22
Published:2015.05.19

Authors
Contribution:
Study Design A
Data Collection B
Analysis C
Statistical

Data Interpretation
D
Manuscript
Preparation E
Literature Search F
Collection G
Funds

ABCDEF1
B2
B3
B4
B5
B6

B7

B8

B9

B10

B11

B12

B13

B14

B15

B16

B17

B18

B19

AB1

Corresponding Author:
Source of support:

Background:

Material/Methods:

Results:

Conclusions:

MeSH Keywords:

Full-text PDF:

Rong Chen
Linong Ji
Liming Chen
Li Chen
Dehong Cai
Bo Feng
Hongyu Kuang
Hong Li
Yiming Li
Jing Liu
Zhongyan Shan
Zilin Sun
Haoming Tian
Zhangrong Xu
Yancheng Xu
Yuzhi Yang
Liyong Yang
Xuefeng Yu
Dalong Zhu
Dajin Zou

1 Department of Endocrinology, Changhai Hospital of Second Military Medical

University of Chinese PLA, Shanghai, P.R. China
2 Department of Endocrinology, Peking University Peoples Hospital, Beijing, P.R. China
3 Department of Metabolic Disease, Tianjin Medical University, Tianjin, P.R. China
4 Department of Endocrinology, Qilu Hospital of Shandong University, Jinan,
Shandong, P.R. China
5 Department of Endocrinology, Zhujiang Hospital of First Military Medical
University, Guangzhou, Guangdong, P.R. China
6 Department of Endocrinology, Shanghai East Hospital, Shanghai, P.R. China
7 Department of Endocrinology, Harbin Medical University, Harbin, Heilongjiang,
P.R. China
8 Department of Endocrinology, Sir Run Run Shaw Hospital, School of Medicine,
Zhejiang University, Hangzhou, Zhejiang, P.R. China
9 Department of Endocrinology, Huashan Hospital of Fudan University, Shanghai,
P.R. China
10 Department of Endocrinology, Gansu Provincial Hospital, Lanzhou, Gansu, P.R. China
11 Department of Endocrinology, First Affiliated Hospital of China Medical
University, Shenyang, Liaoning, P.R. China
12 Department of Endocrinology, Zhongda Hospital Southeast University, Nanjing,
Jiangsu, P.R. China
13 Department of Endocrinology, West China Hospital, Sichuan University,
Chengdu, Sichuan, P.R. China
14 Department of Endocrinology, 306th Hospital of PLA, Beijing, P.R. China
15 Department of Endocrinology, Zhongnan Hospital of Wuhan University, Wuhan,
Hubei, P.R. China
16 Department of Endocrinology, Heilongjiang Provincial Hospital, Harbin,
Heilongjiang, P.R. China
17 Department of Endocrinology, First Affiliated Hospital of Fujian Medical
University, Fuzhou, Fujian, P.R. China
18 Department of Endocrinology, Tongji Hospital, Wuhan, Hubei, P.R. China
19 Department of Endocrinology, Nanjing Drum Tower Hospital, Affiliated Hospital
of Nanjing University Medical School, Nanjing, Jiangsu, P.R. China

Dajin Zou, e-mail: zoudajinmedsci@163.com

Departmental sources

Type 2 diabetes mellitus (T2DM)-associated mortality and morbidity are strongly dependent on glycemic control. With T2DM prevalence increasing in China, we aimed to assess glycemic control rates in Chinese T2DM
outpatients.
A total of 9065 adult T2DM outpatients (5035 men) were assessed in 26 Chinese medical centers between August
2010 and April 2012. Patients were stratified according to BMI (kg/m2): <24, 2428, and >28. Successful glycemic control was defined as glycated hemoglobin A1c (HbA1c) 7% or fasting plasma glucose (FPG) <7.0 mmol/L.
Among the participants included in this study, 2939 had BMI <24, 3361 had BMI of 2428, and 2764 had BMI
>28. The glycemic control rate was only 32.6%, and the triple control rate for glycemia, blood pressure, and
lipidemia was only 11.2%. Glycemic control rates by BMI group were 33.7% (<24), 33.8% (2428), and 30.2%
(>28) (p=0.005), and corresponding incidences of cardiovascular diseases (CVD) were 12.2%, 15.7%, and 15.9%
(p<0.001). Multivariate logistic regression analysis demonstrated that older age (p<0.001), higher BMI (p=0.026),
larger waist circumference (p<0.001), less education (p<0.001), and recent diagnosis (p<0.001) were independent risk factors for poor glycemic control.
The T2DM glycemic control rate in China is currently low, especially in older obese patients with poor education and recent diagnosis.
China Diabetes Mellitus, Type 2 Epidemiology Obesity
http://www.medscimonit.com/abstract/index/idArt/892246

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Chen R. et al.:
Management of Chinese patients with T2DM
Med Sci Monit, 2015; 21: 1440-1446

CLINICAL RESEARCH

Background
Diabetes is a worldwide epidemic, and China is no exception
[1,2]. Type 2 diabetes mellitus (T2DM), the most common form,
accounts for nearly 90% of all cases [3]. T2DM incidence is increasing not only in adults but also in youths [4], making it the
most urgent public health issue in both developed and developing countries. T2DM is caused by insufficient insulin production from beta cells due to insulin resistance [5]. A combination of lifestyle factors, most notably obesity, and genetic
factors has been shown to exacerbate T2DM incidence [6,7].

Despite the increasing prevalence of T2DM in China, with over

110 million adult patients to date [19], limited information is
available on the status of glycemic control and management
of this population. Therefore, this study aimed to assess glycemic control status and risk factors associated with T2DM
management in China.

Material and Methods

Study design and participants

A new term, diabesity, has been coined to describe the close

association between increasing diabetes incidence and obesity
[8]. In UK patients diagnosed with T2DM, for example, almost
90% were also obese or overweight [9]. The increasing prevalence of obesity contributes substantially to the ongoing epidemic of type 2 diabetes [10]. According to current statistics, diabesity will become the major cause of chronic diseases worldwide
by the year 2020 [11], and thus represents a substantial current
and future economic burden in both developed and developing
countries [8]. The deleterious health effects of T2DM are largely due to comorbidities and complications such as hypertension,
cardiovascular diseases (CVD), nephropathy, neuropathy, retinopathy, obstructive sleep apnea-hypopnea syndrome (OSAHS), and
dyslipidemia, which can result in poor quality of life and reduced
life expectancy. Therefore, we examined the associations of diabetes complications and comorbidities such as smoking, drinking, and diabetes duration. Diabesity has important diagnostic
and therapeutic implications, as it links various pathophysiological mechanisms associated with insulin resistance and hyperinsulinemia [12]. Obesity worsens insulin resistance and thus
promotes the development of diabetes [13,14]; therefore, prevention of obesity is critical for reducing the incidence of T2DM.

This multicenter study assessed patients with T2DM in 26 outpatient medical centers in mainland China, including tertiary hospitals and community health service centers, between August 2010
and April 2012. We performed the surveys by face-to-face interviews and all laboratory indicators were measured in the local
hospitals. For study purposes, we defined diabetes mellitus as
FPG concentration 7.0 mmol/L, 2-h plasma glucose 11.1 mmol/L
during an OGTT, random plasma glucose 11.1mmol/L with classic
symptoms of hyperglycemia, HbA1c value 7.0%, by self-reported history of physician-diagnosed T2DM or history of drug treatment for diabetes (insulin or oral hypoglycemic agents). All participants gave informed written consent. The protocol was approved
by the Ethics Committee of all included centers, and the study
was conducted in accordance with the Declaration of Helsinki.

Management of T2DM involves controlling risk factors such as

hyperlipidemia, and maintaining plasma glucose levels within the normal range [6]. Self-control of glycemia by T2DM patients is recommended [15,16], but its success is generally unknown and the efficacy of self-monitoring in particular groups
of patients is controversial [16]. Age, degree of education, and
duration of diabetes could impact patient self-control and glycemia control practices. However, little is known about the current status of diabesity in China.

Assessments and outcome measures

Body mass index (BMI), which is commonly used to identify excessive weight and obesity, is strongly associated with diabetes [17]. Other factors, including hyperglycemia, elevated blood
HbA1c, fasting plasma glucose (FPG), and triglyceride (TG), are
also indicators of T2DM and some are even more closely correlated with diabetes than BMI [18]. However, studies exploring the association of BMI with other indicators of T2DM or
factors affecting T2DM management are scarce.

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Inclusion criteria were confirmed T2DM, age 18 years, body mass

index (BMI) over 18, and written informed consent. Patients with
gestational diabetes mellitus, secondary diabetes (steroid-induced, cystic fibrosis, hemochromatosis, and chronic pancreatitis),
or type 1 diabetes were excluded. Stratified sampling survey was
applied during grouping according to the Chinese BMI standard
(normal BMI: 1824, overweight: 2428, and obese: >28) [20].

Individual demographic characteristics, including level of education, duration of T2DM, medications, self-monitoring status,
and other parameters were obtained by a standardized interview. Patients were also required to report specific information about T2DM treatments since their diagnosis, including
the types of insulin and oral anti-diabetic drugs. Comorbidities
and complications of diabetes such as hypertension, coronary
heart disease, and diabetic neuropathy were also recorded. The
diagnosis of hyperlipidemia and hypertension was carried out
according to Chinese guidelines [21,22].
Cigarette smoking was defined as having smoked a lifetime
total of at least 100 cigarettes. Information was obtained on
the amount and type of alcohol consumed during the previous year, and alcohol drinking was defined as the consumption of at least 30 g of alcohol per week for at least 1 year.

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Management of Chinese patients with T2DM
Med Sci Monit, 2015; 21: 1440-1446

CLINICAL RESEARCH

Fasting blood samples were collected at 7:009:00 AM for measurement of FPG, blood lipids (TG, triglyceride; TC, total cholesterol; HDL, high-density lipoprotein; LDL, low-density lipoprotein), and glycosylated hemoglobin HbA1c. Blood samples
were obtained 120 min after meals to measure postprandial glycemia (PPG). Plasma glucose was measured immediately and remaining blood samples were frozen at -80C until
assayed for blood lipids. Body height, weight, and waist circumference were measured. Blood pressure was measured
with the participant sitting for at least 5 min and at least 30
min after exercise; it was measured 3 times and the average
was recorded. The study participants refrained from cigarette
smoking and drinking of coffee, tea, and alcohol for at least 3
h before BP measurement. Successful glycemic control was
defined as glycated hemoglobin A1c (HbA1c) 7% or fasting
plasma glucose (FPG) <7.0 mmol/L
Statistical analyses
Demographic and clinical characteristics of participants are
expressed as mean standard deviation for continuous variables and percentages for categorical variables. Groups and
subgroups were compared using t-tests and chi-square tests,
as appropriate. The adjusted correction of glycemic control
rate and BMI was analyzed by partial corrections. A univariate
analysis was conducted to identify associations between diabetes control status and demographic and clinical variables.
We performed a multivariable logistic regression analysis to
identify independent risk factor for poor glycemic control rate
by adjusting for age, BMI, waist circumference (WC), level of
education, duration of diabetes, smoking, drinking, and hypertension. We present 95% confidence intervals (CI). All P values
are 2-tailed, and a P<0.05 was considered statistically significant. Statistical analyses were performed using the statistical software package SPSS for Windows, version 17.0 (IBMSPSS, Chicago, IL).

Results
Characteristics of eligible patients
A total of 9644 subjects with T2DM were enrolled in this study,
and 9065 (55.5% male) completed the survey, laboratory tests, and
physical measurements used for the final analyses. Demographic
data and baseline characteristics of participants are shown in
Table 1. Among them, 2764 patients had BMI >28 kg/m2, 953 had
BMI >30 kg/m2 (34.5%), and 420 had BMI >32 kg/m2 (15.2%).
Glycemia, lipidemia, and blood pressure control status
Only 656 (7.2%) subjects had never received any oral anti-diabetic drugs (OADs) or insulin, with 221, 243, and 192 subjects

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in the BMI <24, BMI 2428, and BMI >28 groups, respectively.
In the whole study cohort, 60.32% had never received OADs
and 41.03% were insulin naive. The lowest usage rates were
in the BMI >28 group only 36.09% patients used OADs and
only 35.05% were on insulin (Table 1).
The glycemia control rates among study subjects are shown
in Table 2. According to Chinese criteria, 1809 of 8434 (32.6%)
achieved glycemic control and 943 of 8434 (11.2%) achieved
triple control of glycemia, blood pressure, and lipidemia. Next,
we evaluated the impact of BMI on the glycemic control rate.
Glycemic control rates differed among BMI groups, with 33.7%
in the <24 group, 33.8% in the 2428 group, and 30.2% in
the >28 group (p=0.005), even after partial corrections analysis adjusting for age, degree of education, duration of diabetes, HbA1c, and FPG (p=0.006). The glycemic control rates
also differed significantly across subgroups defined by age,
level of education, and duration of diabetes (p=0.015, <0.001,
and <0.001, respectively). Glycemic control rates differed significantly in the 3 BMI subgroups of patients 75 years old
(p=0.022), with high school education (p=0.019), <3 year disease duration (=0.007), and with 35 years disease duration
(p=0.026). Glycemic control rates also differed significantly
across age groups (p=0.015), education levels (p<0.001), and
disease durations (p<0.001) (Table 2). With increasing BMI, triple control rate decreased significantly 12.8% was recorded
for BMI <24, while 12.1% and 8.5% were obtained for the BMI
2428 and BMI >28 groups (p<0.001, Table 2).
Comorbidities and complications
The incidences of CVD differed significantly in the 3 BMI groups,
with 12.2% in the <24 group, 15.7% in the 2428 group, and
15.9% in the >28 group (p<0.001). The incidences of CVD also
differed significantly across disease duration groups (8.1%
at <3 years, 19.7% at 35 years, and 15.8% in the >5 years
group; p<0.001). Moreover, the incidences of CVD varied significantly by BMI within the 35 years disease duration group
(p<0.001). Overall, 7.2% of T2DM outpatients had nephropathy, regardless to the BMI value (7.1% in the <24 group, 6.6%
in the 2428 group, and 7.9% in the >28 group; p=0.153).
Overall incidences of retinopathy and neuropathy were 9.2%
and 11.5%, similar across BMI groups (p=0.256, p=0.199, respectively) (Table 1).
Risk factors of good glycemia control
Age, BMI, WC, level of education, and duration of diabetes
were significant risk factors according to univariate analysis.
In agreement with this, multivariate logistic regression demonstrated that age (OR: 1.170, 95%CI: 1.0941.251, p<0.001),
BMI (OR: 1.100, 95%CI: 1.0111.195, p=0.026), WC (OR: 0.983,
95%CI: 0.9770.989, p<0.001), education level (OR: 1.380,

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Management of Chinese patients with T2DM
Med Sci Monit, 2015; 21: 1440-1446

CLINICAL RESEARCH

Table 1. Baseline characteristics of included patients.

Characteristics
Number of patients
Age(Year)

BMI <24 kg/m2

2428 kg/m2

BMI >28 kg/m2

2939

3361

2764

58.9017.95

58.8312.59

56.0113.37#

Age <45

13.3%

12.4%

19.2%

45 age <60

39.2%

39.0%

41.2%

60 age <75

34.9%

37.0%

31.3%

Age 75

12.6%

11.6%

8.6%

Male (%)

51.3%

58.3%

58.2%

Duration of diabetes (year)

<0.001

<0.001
<0.001

<3 y

22.3%

21.7%

24.0%

35 y

43.4%

43.6%

32.3%

>5 y

34.3%

34.8%

43.7%

3.3%

3.5%

3.7%

Family history

0.723

Weight (kg)

60.518.63

71.618.29

84.2911.90

<0.001

Waist circumference (cm)

82.518.7

90.578.4

99.579.8

<0.001

Hip circumference (cm)

91.618.83

97.899.18

104.879.96

<0.001

Waist to hip ratio

0.900.07

0.930.07

0.950.07

<0.001

Degree of education (%)

Illiteracy

<0.001
5.4%

5.4%

5.4%

Primary school

16.0%

12.4%

12.9%

high school

60.6%

60.0%

59.7%

College and higher

18.0%

22.3%

22.0%

Smoking (%)

23.7

26.1

26.9

Drinking (%)

14.1%

17.1%

20.4%

0.006
<0.001

FPG (mmol/L)

11.44.7

10.94.2

11.14.4

<0.001

PPG (mmol/L)

16.035.69

15.275.06

15.655.21

<0.001

HbA1c (%)

9.242.41

8.882.12

9.092.17

<0.001

LDL-c (mmol/L)

2.841.02

2.931.18

2.931.12

0.003

HDL-c (mmol/L)

1.310.75

1.200.59

1.190.90

<0.001

TC (mmol/L)

4.792.66

4.842.77

5.2513.78

0.078

TG (mmol/L)

2.067.67

2.498.98

9.082.17

0.008

OADs

45.12%

37.88%

36.09%

<0.001

Insulin

52.43%

35.97%

35.05%

<0.001

Retinopathy

8.6%

9.3%

9.9%

0.256

Neuropathy

12.3%

11.0%

11.1%

0.199

Nephropathy

7.1%

6.6%

7.9%

0.153

Cardiovascular diseases

12.2%

15.7%

33.1%

<0.001

Hypertension

38.5%

52.8%

61.2%

<0.001

0.2%

0.6%

2.6%

<0.001

OSAHS

FPG fasting plasma glucose; PPG postprandial hyperglycemia; TG triglyceride; TC total cholesterol; HDL high density
lipoprotein; LDL low density lipoprotein; OADs oral anti-diabetic drugs; OSAHS obstructive sleep apnea-hypopnea syndrome.

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Management of Chinese patients with T2DM
Med Sci Monit, 2015; 21: 1440-1446

CLINICAL RESEARCH

Table 2. Glycemia control rates of each groups and subgroups in T2DM patients.
Total

BMI <24

24 BMI <28

BMI 28

Triple control rates

11.2%

12.8%

12.1%

8.5%

<0.001

Glycemia control rates

32.6%

33.7%

33.8%

30.2%

0.005

Age <45 y

29.4%

32.1%

29.3%

27.6%

0.353

45 age <60

32.3%

32.0%

33.9%

30.7%

0.261

60 age <75

34.5%

34.9%

35.8%

32.0%

0.212

Age 75

32.9%

37.8%

32.2%

26.6%

0.022

Age

0.015

Degree of education
Illiteracy

23.4%

24.6%

24.5%

20.9%

0.709

Primary school

27.7%

28.4%

28.3%

26.2%

0.774

High school

32.7%

33.8%

34.2%

29.9%

0.019

College and higher

38.2%

39.3%

40.5%

34.4%

0.088

<0.001

Duration of diabetes
<3 y

39.7%

41.6%

42.9%

34.5%

0.007

35 y

31.4%

31.6%

33.6%

27.7%

0.026

>5 y

32.3%

32.6%

32.4%

31.8%

0.939

<0.001

Table 3. Univariate and multivariate logistic regress analysis for risk factors of glycemia control.

Variables

Univariate

Multivariate

OR (95%CI)

OR (95% CI)

Age

1.017 (1.0161.029)

0.011

1.170 (1.0941.251)

<0.001

BMI

0.923 (0.8710.978)

0.006

1.100 (1.0111.195)

0.026

Waist circumference

0.988 (0.9840.992)

<0.001

0.983 (0.9770.989)

<0.001

Degree of education

1.169 (1.1201.220)

<0.001

1.380 (1.2801.489)

<0.001

Duration of diabetes

0.863 (0.8110.919)

<0.001

0.841 (0.7850.901)

<0.001

Smoking

1.073 (1.0171.131)

0.01

1.068 (0.9971.144)

0.061

Drinking

1.079 (0.9541.219)

0.225

1.016 (0.8661.191)

0.846

Hypertension

1.044 (0.9531.143)

0.357

1.044 (0.9321.169)

0.458

95%CI: 1.2801.489, p<0.001), and recent diagnosis (OR: 0.841,

95%CI: 0.7850.901, p<0.001) were significant independent
risk factors for poor glycemic control (Table 3).

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Discussion
Diabetes is becoming a major public health issue and economic burden in China. Glycemia control is closely associated

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Management of Chinese patients with T2DM
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CLINICAL RESEARCH

with complications and prognosis [2325], so efficient glycemia control is considered a cornerstone of diabetic treatment.
The results of this multi-center investigation revealed an unsatisfactory overall glycemia control rate for T2DM patients;
most patients did not meet the management criteria of the
American Diabetes Association (ADA) or Chinese glycemia control of HbA1c <7%. Moreover, the glycemia control rate was
very low for obese patients, particularly those with BMI >28
kg/m2. Level of education, duration of T2DM, waist circumference, and HbA1c level were found to be major factors affecting glycemic control rate in T2DM patients.
The overall glycemia control rate in our study was 32.6%, lower
than the 39.7% obtained in a study assessing individuals with
HbA1c <7% [26]. In a more recent study in China, only 31.78%
of 238 639 diabetes patients exhibited HbA1c <7% after treatment [27]. The latter study assessed drug use (OADs and/or insulin) but did not include education level or lifestyle data. To
explore possible risk factors influencing the management of
glycemia, we evaluated age, educational level, BMI, WC, duration of T2DM, smoking, drinking, and hypertension, which are
factors strongly linked to T2DM risk in previous studies and
easily measured in large cohorts. We found that high level of
education, recent diagnosis of T2DM, young age, and low BMI
were strongly related to good glycemia control. Here, the cutoff BMI value for obesity was set at 28 kg/m2, in accordance
with a study reporting the most effective index for T2DM in
China [28]. Due to the diversity of Chinese diet and difficulty in quantifying exercise, exercise and diet control were not
taken into consideration in this analysis. Multivariate logistic
results also demonstrated that age, education, BMI, and duration of T2DM were important risk factors for glycemia control.
Therefore, significant efforts should be undertaken to monitor
and encourage elderly patients, patients with low-level education, long-term T2DM patients, and high BMI patients to improve glycemic control, which would ameliorate treatment outcome in these individuals and decrease T2DM prevalence. The
observation that individuals with high education levels have
reduced risk of hyperglycemia may results from their better
understanding of diabetes, obesity risks, and glycemic control
[29]. These findings stress the importance of education in the
epidemiology of T2DM. At this point, it is not clear why higher
BMI and elderly individuals were reluctant in applying glycemia control. However, this phenomenon was more pronounced
in diabesity patients >75, indicating that poor general fitness
might play a role in the reduced glycemia control. Further studies need to address this point. A recent study showed that age
and BMI are less important factors that can influence quality
of life; a weak positive relation was determined for these factors only with 4 of 10 fields of quality of life, including social

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functioning, emotional state, physical health, and mental health

[30]. A study conducted in the USA indicated that 84.5% of the
hospitalized type 2 diabetes patients were overweight or obese
(BMI 25 kg/m2), suggesting the need for effective weight loss
intervention in this population [31].
As smoking and drinking are proven risk factors for several
chronic diseases, we evaluated their roles in diabetes complications. In this study, we found no significant effects for smoking
and drinking, possibly due to the limited sample size and the
larger impacts of other parameters studied, including education level, WC, and duration of T2DM. It is possible that proper patient education could also help patients control drinking
and smoking when these habits put them at risk.
High BMI is a known important risk factor for comorbidities
and complications of T2DM [32]. In agreement, higher BMI was
found to be associated with increased prevalence of CVD and
other comorbidities, indicating that weight loss strategies are
an important component of both T2DM prevention and treatment. Interestingly, acupuncture therapy was recently shown
to be effective in preventing the development of type-2 diabetes mellitus in a rat model [33], suggesting an alternative
method that might be widely accepted by the Chinese population. However, it should be noted that acupuncture did not
reduce body weight in rats.
There are several limitations in this study. First, we did not
use multistage cluster sampling methods. Second, data derived from interviews rather than tests may have been affected by recall errors or bias. Descriptive analyses were applied
throughout this study without attempting to control for confounding factors. Nonetheless, we present a comprehensive
portrait of current glycemic control rates in Chinese outpatients and identify risk factors affecting control of blood glucose and other aspects of disease management.

Conclusions
The T2DM glycemic control rate in China is currently poor, especially in older obese patients with poor education and recent
diagnosis. Efforts to achieve good glycemic control and reduce
risk factors are highly recommended. Educational interventions for glycemic control and weight loss could help patients
with low-level education and decrease diabetes prevalence.
Conflict of interests
All authors declare that they have no any conflict of interests.

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Chen R. et al.:
Management of Chinese patients with T2DM
Med Sci Monit, 2015; 21: 1440-1446

CLINICAL RESEARCH

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