| BackgroundIn the past 30 years,the prevalence of type 2 diabetes and obesity has been increasing rapidly as a result of rapid economic growth,acceleration of urbanisation and lifestyle changes.Now they are the main factors that threaten human health.As the rapid growth of GDP,the prevalence of non-communicable chronic disease is also on the rise in Guangdong province.Recently,a cross-sectional survey performed by Guangdong’s Diabetes Society has found 10.8%of adults in Guangdong have suffered diabetes,which is higher that reported in the whole nation(9.7%).It’s reported that the prevalence of overweight and obesity have been 15.0%and 1.7%,respectively in Guangdong province.According to 2010 nationwide census,with a population of more than 104 million,Guangdong is currently China’s most populous province.Thus,it’s estimated that the numbers of diabetic patients have reached to 10 million,and people with overwight and obesity have reached to 15 million and 1.7 million,respetively.On one hand,diabetes,obesity and related complications can bring heavy economic burden to family and health system.On the other hand,patients with diabetes and obesity often gather other metabolic abnormalities,such as raised blood pressure and dyslipidemia,and so on.A variety of abnormal components together constitutes the metabolic syndrome.The metabolic syndrome is a constellation of closely related metabolic abnormalities including obesity,glucose intolerance,dyslipidemia,and raised blood pressure.Various definitions of the metabolic syndrome have been proposed by different organizations,such as World Health Organization(WHO,1998),the third report of the US National Cholesterol Education Program Expert Panel on Detection,Evaluation,and Treatment of High Blood Cholesterol in Adults(ATPⅢ,2001),International Diabetes Federation(IDF,2005),Chinese Diabetes Society(CDS,2004),and ect.The prevalence of the metabolic syndrome has increased markedly over the last decades,with concomitant increases in the prevalence of diabetes and obesity.Two U.S.National Health and Examination Survey(NHANES)has shown prevalence of metabolic syndrome increased over time from approximately 29.2%(1988-1994 cohort)to 34.6%(1999-2002 cohort).The InterASIA Collaborative Group did a cross-sectional survey in a nationally representative sample of 15540 Chinese adults aged 35-74 years in 2000-2001.They have found that the age-standardised prevalence of metabolic syndrome was 9.8%in men and 17.8%in women.In 2002,the prevalence of metabolic syndrome in Guangdong province were 5.67%,7.55%and 2.82%based on IDF,ATPⅢ and CDS criteria,respectively,which raised to 20.3%,24.3%and 11.4%,respectively in 2009.The prevalence of the metabolic syndrome was higher in urban than rural residents.The metabolic syndrome is also independent risk factor for cardiovascular diseases.Recently,it has become the hotspot of attention.ObjectiveOverweight,obesity and diabetes are not only the part of metabolic syndrome,but also affect the prevalence of metabolic syndrome and related complications.Unfortunately,there is still a lack of data about metabolic syndrome based on overweight and obese type 2 diabetic population.Because of the rapid economic development,huge population,rapidly growing prevalence of diabetes,obesity and metabolic syndrome in Guangdong province,our study intends to investigate the status of metabolic syndrome in overweight and obese type 2 diabetic patients in Guangdong province.We aimed to:(1)compare predictability of four different metabolic syndrome diagnostic criteria for abnormal component cluster and cardiovascular and cerebrovascular disease,and choose the most suitable diagnostic criteria for type 2 diabetic patients with overweight and obesity;(2)estimate the prevalence of the metabolic syndrome and influence factors in investigated population;(3)investigate the association of features of the metabolic syndrome with the prevalence of diabetic chronic complications;(4)analyze the control of glycemia,blood pressure and lipid.We hope that this survey could provide evidence for comprehensive intervention strategies and gather some experiences for further research.Study PopulationFrom August 2011 to March 2012,overweight and obese type 2 diabetic patients,who visited the diabetic clinic of 62 hospitals across 21 cities in Guangdong province,were recruited.Inclusion criteria are as follows:(1)permanent residents in Guangdong province;(2)patients who had been diagnosed with type 2 diabetes;(3)patients with a body mass index(BMI)of 25 kg/m2 or greater,or waist circumference of 90 cm or greater in men and 80 cm or greater in women;(4)patients whose age at diagnosis was 18 years or older;(5)patients who were able to complete the questionnaire.MethodsThis study was a multicenter cross-sectional survey in Guangdong province.Astandard questionnaire was administered by trained staff to obtain information on demographic characteristics,personal and family medical history,diagnosis and treatment of diabetes,chronic complications,behavior habits,and so on.During the clinical examination,height,weight,blood pressure,waist circumference and hip circumference were obtained by trained and certified observers by use of standard protocols and techniques.Blood samples were analyzed for fasting plasma glucose(FPG),2-hour postprandial glucose(2hPG),glycosylated hemoglobin A1c(HbA1c),total cholesterol(TC),triglyceride(TG),high-density lipoprotein cholesterol(HDL-C),low-density lipoprotein cholesterol(LDL-C),and ect.Statistical analysisSPSS(version 18.0)software was used for statistical analysis.Data were presented as(x±s),M(P25,P75),or percentage.Descriptive statistics were subjected to student’s t test,one-way ANOVA,or Kruskal-Wallis test.The χ2-test was used to compare categorical variable.Multivariate Logistic regression analyses were performed to identify risk factors.The Kappa test was used to assess the degree of agreement of four different metabolic syndrome criteria.The area under the ROC curve was used to evaluate four diagnostic criteria.A P value<0.05(two-tailed)was considered significant.Results1.Comparison of different diagnostic criteria for metabolic syndromeThe metabolic syndrome prevalence was 84.8%,89.4%,82.2%and 72.4%in overweight and obese type 2 diabetic patients in Guangdong province under the WHO,ATPⅢ,IDF and CDS criteria,respectively.The agreement rate between CDS and IDF was 76.8%,κ value was 0.520.The agreement rate between CDS and WHO was 83.6%,κ value was 0.351.The agreement rate between CDS and ATPⅢ was 80.2%,κ value was 0.391.The agreement rate between IDF and ATPⅢ was 92.8%,κ value was 0.706.The agreement rate between IDF and WHO was 83.5%,κ value was 0.399.The agreement rate between ATPⅢ and WHO was 88.9%,κ value was 0.501.Under WHO criteria,the prevalence of more than 3 risk factors,cardiovascular disease and stoke was 48.1%,13.2%and 10.0%,respectively.Under ATPⅢ criteria,the prevalence of more than 3 risk factors,cardiovascular disease and stoke was 53.4%,13.1%and 9.7%,respectively.Under IDF criteria,the prevalence of more than 3 risk factors,cardiovascular disease and stoke was 52,4%,13.4%and 9.6%,respectively.Under CDS criteria,the prevalence of more than 3 risk factors,cardiovascular disease and stoke was 64.0%,14.0%and 10.3%,respectively.For forecasting more than 3 risk factors aggregation,the area under the ROC curve was 0.731 using CDS criteria,which is larger than others.For forecast:ing cardiovascular disease,the area under the ROC curve was 0.546 using CDS criteria,which is much the same with IDF criteria and WHO criteria,but larger than ATPIII criteria.For forecasting stroke,the area under the ROC curve was 0.555 using CDS criteria,which is much the same with WHO criteria,but larger than ATPIII and IDF criteria.Taken togerther,CDS criteria is more suitable than others for overweight and obese type 2 diabetic patients.2.The prevalence of metabolic syndrome and influence factors in overweight and obese type 2 diabetic patientsUnder CDS criteria,the prevalence of metabolic syndrome was 71.4%in men and 73.3%in women.There was no statistically significant difference between gender(χ2=1.824,P=0.177).The prevalence of only 1 metabolic syndrome component(i.e.,only patients with type 2 diabetes)was 5.4%.The prevalence of two metabolic syndrome components was 22.2%.The prevalence of three metabolic syndrome components was 41.6%.The prevalence of four metabolic syndrome components was 30.8%.The median age was 60 years and the median duration since diagnosis with diabetes was 6 years.Median BMI was 26.97 kg/m2.Median waist circumference was 95 cm.Median HbAlc was 8.2%.Patients with MS had a older age and longer diabetic duration than those without MS(P<0.001).BMI,waist circumference,waist-to-hip ratio,systolic blood pressure,diastolic blood pressure,TG,TC were significantly higher and HDL-C weresignificantly lower in patients with metabolic syndrome than those without metabolic syndrome(P<0.001).There was no statistically significant difference between the two groups in HbA1c and LDL-C level(HbA1c/LDL-C:P=0.129/P=0.274).In women,metabolic syndrome prevalence continued to increase with age into the seventh decade,with decline after that.Patients under forty had the lowest metabolic syndrome prevalence(61.4%),while patients aged 70-79 had the highest metabolic syndrome prevalence(78.9%)(χ2=37.987,P<0.001).There was no statistically significant difference among age in men(χ2=7.808,P=0.167).Prevalence of metabolic syndrome was higher in Pearl River Delta region that that in other area(74.1%vs.66.3%,χ2=22.243,P<0.001).In men,those who had higher educational status and comfortable manual work had a higher metabolic syndrome prevalence,while there was no statistically significant difference among levels of education and occupation in women(Education/Occupation:P=0.067/P=0.887).On the income respect,women with higher household income had a lower metabolic syndrome prevalence(χ2=8.242,P=0.041),while there was no statistically significant difference in men(χ2=5.660,P=0.129).In women,metabolic syndrome prevalence continued to increase with diabetic duration(χ2=24.371,P<0.001),while there was no statistically significant difference in men(χ2=4.374,P=0.192).In men and women,metabolic syndrome prevalence was lower in non-overweight or obese patients(29.4%vs.39.0%)than that in obese patients(95.3%vs.93.9%)(χ2=114.354,P<0.001).In men,smoker had a higher metabolic syndrome prevalence(74.9%)than non-smoker(67.1%),while there was no statistically significant difference in women(χ2=0.031,P=0.860).There was no statistically significant difference on alcohol intake in men and women(Male/Female:P=0.062/P=0.159P values were 0.062 and 0.159).After adjusting for gender,geographic distribution,education level,occupation,household income,the multivariate Logistic regression analysis showed that the risk factors for metabolic syndrome were:age,duration of diabetes,BMI,TG,systolic blood pressure,diastolic blood pressure,the odds ratio values were 1.022,1.020,1.846,2.801,1.037,1.023,respectively.HDL-C,the non-pearl river delta region were the protective factors,the odds ratio values were 0.530,0.665,respectively.3.Metabolic syndrome and diabetic chronic complicationsCompared with Overweight and obese type 2 diabetic patients without metabolic syndrome,those who sufferd metabolic syndrome had a higher prevalence of diabetic retinopathy(22.8%vs.18.2%),diabetic nephropathy(24.6%vs.14.6%),diabetic peripheral neuropathy(33.0%vs.27.9%),cardiovascular disease(14.0%vs.8.6%)and stroke(10.3%vs.6.0%).The more metabolic syndrome features(one,two,three or four),the higher proportion of diabetes complications exist:diabetic retinopathy:13.9%,19.3%,20.1%,26.5%;diabetic nephropathy:8.3%,16.1%,20.4%,30.2%;diabetic peripheral neuropathy:21.6%,29.5%,30.1%,36.9%;cardiovascular disease:4.3%,9.6%,10.6%,18.6%;stroke:2.6%,6.9%,8.8%,12.3%(P<0.001).Logistic regression was performed to control for age,duration of diabetes,HbAlc and LDL-C.The metabolic syndrome was associated with diabetic retinopathy(OR=1.220,P=0.033),diabetic nephropathy(OR=1.781,P<0.001),diabetic peripheral neuropathy(OR=1.272,P=0.003),cardiovascular disease(OR=1.549,P=0.001)and stroke(OR=1.686,P<0.001).4.Control of glycemia,blood pressure and lipid in patients with metabolic syndromeOf type 2 diabetic patients with overweight and obesity in Guangdong province,26.1%had HbAlc values<7%.Patients with metabolic syndrome had a lower glycemic attainment rate(25.0%)than those without metabolic syndrome(28.9%)(χ2=6.496,P=0.011).In women,glycemic attainment rate was lower in patients with metabolic syndrome than those without metabolic syndrome(χ2=5.277,P=0.023),while there was no statistically significant difference in men(χ2=1.680,P=0.212).23.7%of the investigated population reached the target of blood pressure.Patients with metabolic syndrome had a lower blood pressure attainment rate than those without metabolic syndrome(χ2=167.661,P<0.001)in both men and women.Of the total population,45.7%achieved TG target and patients with metabolic syndrome had a lower attainment rate than those without metabolic syndrome(32.1%vs.81.2%,χ2=852.586,P<0.001).45.5%of the total population achieved HDL-C target and patients with metabolic syndrome had a lower attainment rate than those without metabolic syndrome(39.9%vs.60.4%,χ2=142.744,P<0.001).31.3%of the total population achieved LDL-C target and there was no statistically significant difference between patients with metabolic syndrome and without metabolic syndrome(χ2=0.045,P=0.832).Only 7.9%of the total population achieved above three target and patients with metabolic syndrome had a lower attainment rate than those without metabolic syndrome(4.3%vs.17.3%,χ2=194.629,P<0.001).Of overweight and obese type 2 diabetic patients in Guangdong province,6.7%achieved the target levels of both glycemia and blood pressure,2.8%achieved the target levels of both glycemia and lipid,2.0%achieved the target levels of both blood pressure and lipid,only 0.9%achieved all target levels of glycemia,blood pressure and lipid.Patients with metabolic syndrome had a lower attainment rate of both glycemia and blood pressure than those without metabolic syndrome(5.0%vs.11.6%,χ2=52.413,P<0.001).Patients with metabolic syndrome had a lower attainment rate o of both glycemia and lipid than those without metabolic syndrome(1.3%vs.6.6%,χ2=83.672,P<0.001).Patients with metabolic syndrome had a lower attainment rate of both blood pressure and lipid than those without metabolic syndrome(0.6%vs.5.8%,χ2=112.157,P<0.001).Patients with metabolic syndrome had a lower attainment rate of all the glycemia,blood pressure and lipid than those without metabolic syndrome(0.2%vs.2.9%,χ2=55.864,P<0.001).Conclusions1.The metabolic syndrome prevalence was 84.8%,89.4%,82.2%and 72.4%in overweight and obese type 2 diabetic patients in Guangdong province under the WHO,ATPⅢ,IDF and CDS criteria,respectively.CDS criteria is more suitable for the investigated population.2.Under CDS criteria,the prevalence of metabolic syndrome was 71.4%in men and 73.3%in women.The multivariate Logistic regression analysis showed that the risk factors for metabolic syndrome were:age,duration of diabetes,BMI,TG,systolic blood pressure,diastolic blood pressure.HDL-C,the non-Pearl River Delta region were the protective factors.3.Prevalence of diabetic retinopathy,diabetic nephropathy,diabetic peripheral neuropathy,cardiovascular disease and stroke in type 2 diabetic patients with overweight and obesity were 22.8%,24.6%,33.0%,14.0%,10.3%,respectively.The more metabolic syndrome features,the higher proportion of diabetes complications exist.The metabolic syndrome was associated with all the diabetic chronic complications.4.Of overweight and obese type 2 diabetic patients with metabolic syndrome in Guangdong province,25.0%had HbAlc values<7%.18.5%had controlled blood pressure,32.1%,39.9%and 31.2%achieved TG,HDL-C and LDL-C target,Only 0.2%reached all target levels of glycemia,blood pressure and lipid.This survey confirms the chasm between guidelines and practice.As the increasing prevalence of metabolic syndrome,there is an urgent need for a comprehensive management for these people. |
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