2017 International Conference on Medicine Sciences and Bioengineering (ICMSB 2017) ISBN: 978-1-60595-508-7

Investigation on Current Situation of T2DM in City and Countryside and Analysis of Correlation Factors Ming-Hua DONG1,a,#, Xiao-Ting LUO2, Qin HUANG3, b,# , Zheng-Chun HUANG4, Jian LI4, Qin WU1, Si-Si LI1 and Shu-Mei LI1,c,* 1The Department of Epidemiology in Preventive Medicine, Ganzhou, , 2The Department of Biochemistry and Molecular Biology, Ganzhou, Jiangxi, China 3The Department of General Medicine, Deltahealth hospital, , China 4The Department of Anatomy, Gannan Medical College, Ganzhou, Jiangxi, China [email protected], [email protected], [email protected] #These authors Contributed equally to this study and share first authorship *Corresponding author

Key words: T2DM, IFG, Prevalence, Risk factor, Ganzhou city.

Abstract. Objective: to study the current situation and distributional characteristics of T2DM in Ganzhou city and countryside and to explore the correlation factors of T2DM. Methods: the baseline of T2DM and its correlation factors was investigated in the 35- to 64-year-old residents in Ganzhou by multiple horizon Hierarchies random sampling method from 2009 to 2016. The WHO diagnostic code of 1999 was adopted for the diagnosis of T2DM. Results: the prevalence of T2DM and IFG in Ganzhou was 7.7% (683/8906) and 13.1% (1,167/8,906) respectively. The prevalence of T2DM was 9.6% (283/2947) and 14.9% (112/751) in overweight population and obesity population respectively which was higher than in BMI normal population [6.7% (289/4317), x2=62.185, P<0.001]. The prevalence of IFG was 21.5% (634/2947) and 25.5% (192/751) in overweight population and obesity population which was obviously higher than in BMI normal population [16.2% (699/4317), x2=55.191, P<0.01]. The prevalence of T2DM and IFG in hypertension population was 12.4% (306/2469) and 23.7% (457/1929) which was obviously higher than in non-hypertension population [7.0% (369/5274),x2=19.309, P<0.001 and 17.1%(705/4121),x2= 14.474, P<0.001]. The prevalence of T2DM and IFG in hyperlipemia population was 12.3% (297/2412) and 23.7% (451/1902) respectively which was obviously higher than in non-hyperlipemia population [6.2% (319/5152),x2=61.709, P<0.001 and 17.7% (709/4003), x2=15.674 , P<0.001]. The prevalence of male T2DM and IFG was 8.5% (383/4504) and 13.2% (479/3630) respectively. The prevalence of female T2DM and IFG was 7.0% (296/4224) and 19.4% (660/3404) respectively. There was not statistically significant between the male and female T2DM (x2 =3.208, P=0.073), but there was statistically significant between the male and female IFG (x2 =29.222, P<0.001). The prevalence of T2DM and IFG in city was 8.0%(349/4366) and 20.0% (670/3350). The prevalence of T2DM and IFG in countryside was 7.3%(240/3293) and 19.4% (490/2527) respectively. There was not significant in T2DM or IFG between in the city and in the countryside (x2=0, P=1 and x2=0.193, P=0.660). Conclusion: the prevalence of T2DM and IFG in Ganzhou city and countryside was severe. The health education should be carried out for moderate and small city which has just recently transformed and been rich. The early screening for T2DM should be evolved through the onset risk prediction model of T2DM in order to decrease the prevalence of T2DM.

131 Introduction With the rapid development of economy, the alteration of lifestyles and dietary pattern and the intensification of aging of the population, the prevalence of type 2 diabetes mellitus (T2DM) has upgraded in the world. T2DM has become the third serious disease which threatens the human health and life safety after the cardiovascular and cerebrovascular diseases and tumor. The prevention and cure of T2DM has become the imminent task in the Public Health territory because of the longtime of therapy, the large expense, multitude and serious complication. The abroad generous epidemiology data revealed the correlated risk factors of T2DM from different horizons, but T2DM had obvious region and race difference [1]. China had wide area and numerous people, epidemiologic studies of T2DM carried out late, the everywhere economic development had disproportion, the culture and national custom had obvious difference, and the risk factors of T2DM were not analyzed thoroughly through the data due to the different adoptive sampling method and diagnostic criteria, so it is necessary to investigate T2DM of the local residents. Ganzhou city is one of lagging economic area in China. The local medical treatment and health service had been relative backward especially in the extensive countryside and far mountain area because of the history and regional circumstance. The pathogenic current situation and distributional characteristics of T2DM in Ganzhou is unclear so far that is disadvantageous for prevention and cure of T2DM. With regards to this, a comparatively large epidemiological study of T2DM was undertaken for Ganzhou residents. The consequence was reported as follow.

Materials and Methods The investigated subjects were 34- to 64-year-old local registered permanent residents excluding the acute disease, other endocrine system disease (hyperthyroidism, systemic lupus erythematosus, rheumatoid arthritis, and so on), connective tissue disease, malignant tumor, psychiosis and gravida. Sampling Design The multiple horizon Hierarchies random cluster sampling method was applied. According to the economic development of each county of Ganzhou in 2007, 19 districts or county of Ganzhou were divided into three different economic hierarchies (the first hierarchy contained , Huangjin District, and Congyi County; the second hierarchy contained City (county-level city), Nankang City (county-level city), , , Ganxian County, Xinfeng County and Longnan County; the third hierarchy contained , Dingnan County, Quannan County, , , , and ). One district or county was extracted randomly from the each hierarchy. According to the different economic development of each extracted district or county, this district or county was divided into three hierarchies and one street or town was extracted from each hierarchy. According to the different economic development of each extracted street or town, this street or town was divided into three hierarchies and one community or village was extracted as basic sampling group from each hierarchy. 18 communities or villages were basic sampling groups extracted from 6 districts or counties including Zhanggong District, Huangjin District, Nankang City (county-level city), Xingguo County, Yudu County and Shangyou County.

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Investigated Content ① Questionnaire: general demography data, history of smoking and alcohol drinking, history of previous medical illness, family history of diabetes, physical activity, physical training and so on. ② physical examination: body height, body weight, waist circumference, hip circumference, blood pressure, and so on; trained investigators measured each object by corrected correlative instrument; body height was measured by getting out of the shoes and hat and the reading is precise to 0.5 cm; body weight was measured by only wearing underwear or simple clothes and pants and the reading is precise to 0.5 cm; waist circumference was measured at 1 cm above the umbilicus when the object breathed gently and didn’t contract the abdomen, hip circumference was measured at the most chubby hip and the reading is precise to 0.1 cm; the measured person, who had no smoking, drinking or eating for 30 min before measurement and evacuated the urinary bladder, took a rest for 5 min and then the blood pressure was measured by sitting position; ③ laboratory detection: 5 ml venous blood was collected from each investigated person on an empty stomach (fasting for 8 hours at least) to detect the blood sugar, total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C) and triglyceride (TG); blood sugar was tested by modified glucose oxidase method, TC and TG were tested by enzyme colorimetric technique, LDL-C and HDL-C were tested by clearance method. The instrument was Hitachi 7600 automatic biochemistry analyzer. Index Definition and Diagnostic Criteria Diagnostic criteria of diabetes and injury of fasting blood glucose (IFG) was the diagnostic and separate criteria of WHO diabetes epidemiological study in 1999: diabetes was defined at the fasting blood glucose (FPG) ≥ 7.0 mmol/L, IFG was defined at 6.1 mmol/L≤ FPG<7.0 mmol/L; diagnostic criteria of hyperlipidemia was the correlative diagnostic criteria in “Practical Internal Medicine” (the 11st edition, Chen Haozhu, editor in chief), hyperlipidemia was defined when one kind of item in fasting serum was overproof (TC ≥ 5.20mmol/L, TG ≥ 1.70 mmol/L, HDL-C ≤ 1.04 mmol/L, or LDL-C ≥ 3.12mmol/L); diagnostic criteria of hypertension was WHO criteria in 1999; diagnostic criteria of overweight and obesity was the correlative diagnostic criteria in “Nutrition and Food Hygiene” (the 6st edition, Sun Changhao, editor in chief), overweight was defined when BMI is 24.0～27.9, obesity was defined when BMI ≥ 28, obesity of upper body was defined when WHR ≥ 0.85 (female), WHR ≥ 0.90 (male). Quality Control and Statistical Treatment Investigators were medical professionals trained and examined before the investigation; the data were checked again at investigating day and were marked by the number and corresponding record, however the unqualified questionnaires were supplemented or rejected; Microsoft SQL Server database was applied, web enter system was edited by ourselves, investigative data were entered duplicate, and the quality control was used by logic testing for bug and random rechecking. All data were analyzed by SPSS 14.0 statistical software. The essential characteristics of investigated person were analyzed by t test. The difference of prevalence among different age groups, sexual groups, and city - countryside groups was 2 detected by x test. The correlation between T2DM and overweight, obesity, hypertension, 2 hyperlipidemia was analyzed by tendency x test, and OR and 95%CI were calculated.

133 Results Essential Characteristics 9801 persons were investigated including 5056 male and 4745 female. After unqualified data were rejected, the number of persons was 8906. Table 1 showed different sex, age, body height, body weight, waist circumference, hip circumference, waist/hip ratio, contractive pressure, diastolic pressure, fasting blood glucose, HDL-C, LDL-C, TC and TG. Comparison of Prevalence of T2DM and IFG in Age Groups and Sexual Groups Respectively 683 T2DM cases were detected from this investigation. The prevalence of T2DM was 7.7% including 8.5% in male and 7.0% in female. There was not statistically significant between male and female (x2 =3.208, P=0.073); 1,167 IFG cases were detected and its prevalence was 13.1% including 13.2% in male and 19.4% in female. Difference between male and female had statistical significance (x2 = 29.222, P<0.001). According the age layer, difference of IFG prevalence between male and female had statistical significance only at 40~44 years old, 45~49 years old, 50~54 years old and 60~64 years old. Whether the prevalence of T2DM or that of IFG had obviously increasing tendency accompanied by the increment of age (Table 2). Relationship between T2DM and BMI, WC, WHR Respectively When BMI<24kg/m2, 24-28 kg/m2 and ≥28kg/m2, the prevalence of T2DM in male was 7.3％, 9.9％ and 17.2％ respectively, the prevalence of T2DM in female was 6.2%, 9.3% and 14.4% respectively, difference of prevalence of T2DM in overweight group and normal group had no statistical significance (male: x2 =2.937, P=0.087; female: x2 =3.794, P=0.051), the prevalence of T2DM in obesity group was higher than in normal group (male: x2 =13. 364, P<0.001; female: x2 =9. 255, P=0.002); in normal waist circumference (male<85cm, female <80cm) and in augmentation of waist circumference (male≥85cm, female≥80cm), the prevalence of T2DM was 7.0% and 12.2% in male (x2 =10. 505, P=0.001), 4.0% and 12.2% in female (x2 =26.669, P<0.001) respectively; in normal waist/hip ratio (WHR) group (male<0.80, female<0.75), augmentation group (0.80≤male<0.90, 0.75≤female<0.85) and obesity group (male≥0.90, female≥0.85), the prevalence of T2DM was 6.7％, 7.5％ and 14.0％ in male ( x2 =0.208, P=0.648; x2 =7.917, P=0.005), 1.9%, 5.7% and 14.3% in female (x2 =5.695, P=0.017; x2 =23.576, P<0.001) respectively, difference of prevalence of T2DM between in the female augmentation of WHR group or in the female obesity group and in normal WHR group had statistical significance, but difference of prevalence of T2DM between in male obesity group and in normal WHR group had statistical significance. Relationship between T2DM/IFG and Hypertension/Hyperlipemia The prevalence of hypertension was 30.5%. The prevalence of T2DM and IFG in hypertension group was 12.4% and 23.7% respectively which was higher than in non-hypertension group [7.0% (369/5274), x2=19.309, P<0.001 and 17.1% (902/5274), x2= 14.474, P<0.001] (Table 4, 5); the higher contractive pressure, the more risk for T2DM (male OR=2.201, 95%CI:1.421-3.410; female OR=2.54,95%CI: 1.683-3.833), there was no statistically significance between the contractive pressure and the prevalence of T2DM. 32.79% (male 30.93%, female 34.11%) persons’ serous TC ≥5.20mmol/L, 29.84% (male32.08%, female28.06%) persons’ serous TG≥1.70 mmol/L, 5.87% (male9.58%, female

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3.10%) persons’ serous HDL-C≤1.04 mmol/L, 23.84% (male 23.70%, female 23.98%) persons’ serous LDL-C≥3.12mmol/L; the prevalence of T2DM and IFG in hyperlipidemia population was 12.3%(297/2412) and 23.7%(572/2412) respectively which was obviously higher than in non-hyperlipidemia population [6.2% (319/5152), x2=61.709, P<0.001 and 17.7% (709/4003), x2=15.674, P<0.001]. Comparison the Prevalence of T2DM/IFG in City and in Countryside Compared with city and countryside, the prevalence of T2DM in city was 8.0% (349/4366) including 8.1% in male and 7.8% in female, difference between male and female had no statistically significance (x2=3.525, P=0.074); the prevalence of IFG in city was 19.9% (670/3350) including 16.6% in male and 22.3% in female, difference between male and female had statistically significance (x2=8.041, P<0.005); the prevalence of T2DM in countryside was7.3% (240/3293) including 7.4% in male and 7.2% in female, difference between male and female had no statistically significance (x2=0.036, P=0.850); the prevalence of IFG in countryside was 19.9% (x2=0.036, P=0.850) including 14.3% in male and 24.1% in female, difference between male and female had statistically significance (x2=19.759, P<0.001); difference of the prevalence of T2DM and IFG between city and countryside had no statistically significance (x2=1.316, P=0.2514; x2=0.193, P=0.660).

Discussion This study was the first large-scale T2DM epidemiological investigation in Ganzhou city and countryside. It was shown that T2DM prevalence rate of this area in 35~64 years old was 7.7% including 8.5% in male and 7.0% in female. Chinese National Nutrition and Health Survey in 2002 showed that prevalence of T2DM was 2.6% in above 18-year-old population including 2.5% in male and 2.7%in female [2]; the prevalence of T2DM in was 4.23% in older than 20 years population [3]; the prevalence of T2DM in was 5.5% in 20~74 years old population [4] ; the prevalence of T2DM Lhasa was 6.8% [5]; the prevalence of T2DM in Shanghai was 8.6% in 15~74 age population [6]; the prevalence of T2DM in was 6.07% in 15~74 age population [7]; In 2008, T2DM investigation of 14 provinces in China demonstrated that prevalence of T2DM in older than 20 year population was 9.7% including 10.6% in male and 8.8% in female. Compared with these studies, the prevalence of T2DM in Ganzhou was obvious higher than average level of China in 2002, which equaled as other cities, but was lower than at the national same period. This epidemiology investigation sample was comparatively large, we used T2DM`s diagnosis formulated by WHO in 1999, and tested fasting plasma glucose. If we could test 2-hour postprandial glucose, it would reflect more accurate current situation about T2DM and IGT in Ganzhou, In the analysis of every factor, ① sex had no significant relation with T2DM, but female prevalence of IFG was higher than male, IFG was the previous stage of T2DM, it indicated that T2DM abnormal risk factors should been active intervened on female, and female blood sugar should been tested periodical. ② age was an individual risk factor, this was coincided with many foreign studies [4,7,9]. ③ BMI, waistline, WHR were related to T2DM and IFG, and overweight and obesity are high risk factors. Disease risk of T2DM of overweight was 1.46 higher than crowd in male, and 1.49 higher than in female, disease risk of T2DM of obesity was 2.92 higher than in male, and 2.27 higher than in female. Along with national living standard rising and diet structure changing, the consumption of high-protein and high-fat was increasing, cereals was decreasing, fresher fruits and vegetables which were full with dietary fiber and micronutrients

135 were less intake [10], food with more fat and less other nutrient density was major factor of obesity. ④ Prevalence of T2DM and IFG in high-blood pressure crowd was significant higher than normal, disease risk of T2DM and IFG was rising (T2DM: male 1.79times, female 1.91times; IFG: male 1.70times, female 1.46 times), this was consistent with other foreign reports [3,6,9,11]. ⑤ disease risk of T2DM and IFG in hyperlipidemia was rising (T2DM:male 2.12times, female 3.55times; IFG: male 1.62times, female 1.55 times). ⑥ disease risk of T2DM and IFG around urban and rural area had no statistical significant, reason may be that diet habit and living method at urban and rural in same distinct had no distinction, but this needs more research to prove. Most T2DM patient got body form change in previous, but sympathetic nervous system function, body fluid and endocrine were major changes. Obesity can lead different degreases insulin resistance and obstacle of using glucose and rising blood glucose. This study pointed that preventing over-weigh, dropping weigh of obesity, reasonable lifestyle and balance diet can prevent or defer occurrence and development of T2DM. American-European study predicted that all people BMI decrease 1%, 210~240 thousands new diabetes would be avoided.

Acknowledgements This study was supported by scientific fund from Department of Education of Jiangxi Province in China (No.GJJ09583) and National Natural Science Fund in China (No.30860246 and No.81550045).

References [1] Diamond J. The double puzzle of diabetes [J]. Nature. 2003; 423(6940):599-602. [2] Li Liming, Rao Keqin, Kong Linzhi, et al. A description on Chinese national nutrition and health surveys in 2002 [J]. Chinese Journal of Epidemiology. 2005; 26(7):478-484. [3] Peng Ji, Zhou Hua, Cheng Jinquan, et al. Epidemiological feature on diabetes mellitus among permanent inhabitant in the Special Economic Zone of Shenzhen [J]. Chinese Journal of Epidemiology. 2000; 21: 34-36. [4] Diabetes epidemiological investigating group in Qingdao City. Prevalence of diabetes in Qingdao [J]. Chinese Journal of Diabetes. 2004; 12: 39-42. [5] Yang Lihui, Hu Xuejun, Zhao Yuhua, et al. A screening survey of diabetes mellitus in the middle elderly population of Lhass city. Chinese Journal of Endocrinology and Metabolism. 2003; 19: 24-26. [6] Li Rui, Lu Wei, Jia Weiping, et al. Cross-sectional investigation of type 2 diabetes in Shanghai. Chinese Medical Journal. 2006; 86(24): 1675-1680. [7] Zhi Xinyue, Wang Jianhua. A study of prevalence and its risk factors of type 2 diabetes in Tianjin. Chinese Journal of Diabetes. 2009; 17(4): 275-277. [8] Yang WY,Lu JM,Weng JP,et al. Prevalence of diabetes among men and women in China [J].N Engl J Med, 2010, 362(12):1090-1101.

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[9] Glümer C, Jørgensen T, Borch-Johnsen K. Prevalences of diabetes and impaired glucose regulation in a Danish population: the Inter99 study [J]. Diabetes Care.2003; 26(8): 2335-2340. [10] Zhai Fengying, He Yuna, Ma Guansheng, et al. Study on current status and trend of food consumption among Chinese population [J]. Chinese Journal of Epidemiology. 2005; 26(7): 485-488. [11] Kumar P, Mallik D, Mukhopadhyay DK, et al. Prevalence of diabetes mellitus, impaired fasting glucose, impaired glucose tolerance, and its correlates among police personnel in Bankura district of west Bengal[J].Indian J Public Health. 2013; 57(1): 24-28. [12] Wang YC, McPherson K, Marsh T, et al. Health and economic burden of the projected obesity trends in the USA and the UK. Lancet. 2011; 378: 815-825. Table 1. Essential Characteristics in study population.

Value ( ± sx ) Variable P male female age 50.120±8.604 49.720±8.395 0.102 body height (cm) 164.269±6.011 154.085±6.275 <0.01 body weight (kg) 64.289±9.851 56.705±8.773 <0.01 BMI 23.790±3.151 23.939±4.977 0.065 waist circumference (cm) 81.891±9.633 78.572±9.825 <0.01 hip circumference (cm) 92.997±7.834 92.510±8.415 0.110 waist/hip ratio 0.868±0.246 0.850±0.271 <0.01 contractive pressure (mmHg) 126.779±51.354 124.777±48.002 0.277 diastolic pressure (mmHg) 81.868±11.088 79.755±11.323 <0.01 fasting blood glucose 6.422±2.898 7.329±2.957 0.622 HDL-C 1.545±0.515 1.657±0.446 <0.01 LDL-C 2.484±0.880 2.568±0.874 0.269 TC 4.524±1.531 4.678±1.382 <0.01 TG 1.637±0.425 1.449±0.387 <0.01

137 Table 2. Sex Distribution of T2DM and IFG in different age group. T2DM（%） IFG（%） Age x2 P x2 P group male female male female 35~ 2.8 3.5 0.297 0.586 6.1 9.3 2.243 0.134 40~ 5.5 2.7 4.031 0.045 8.2 14.8 7.849 0.005 45~ 5.9 5.2 0.153 0.695 10.5 18.6 9.707 0.002 50~ 8.1 7.1 0.219 0.640 14.7 23.4 7.064 0.008 55~ 12.8 8.6 3.992 0.046 19.7 24.9 2.922 0.087 60~ 14.0 15.7 0.414 0.520 19.4 26.1 4.108 0.043

Table 3. Relationship between T2DM and BMI, WC, WHR respectively. T2DM（%） Varia Level ble male OR 95%CI female OR 95%CI BMI <24 7.3 1 6.2 1 24~28 9.9 1.460 (0.945-2.256) 9.3 1.493 (0.995-2.239) >28 17.2 2.921 (1.608-5.305) 14.4 2.270 (1.322-3.896) WC normal 7.0 1 4.0 1 big 12.2 1.842 (1.215-2.791) 12.2 2.799 (1.846-4.245) WHR normal 6.7 1 1.9 1 augmen 7.5 1.155 (0.622-2.146) 5.7 3.300 (1.170-9.305) tation obesity 14.0 2.408 (1.286-4.508) 14.3 8.473 (3.057-3.484)

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Table 4. Relationship between T2DM and hypertension/hyperlipemia. T2DM（%） Variable Level male OR 95%CI female OR 95%CI Blood normal 7.7 1 7.0 1 pressure hyperte 12.9 1.786 (1.189-2.681) 12.6 1.910 (1.309-2.786) nsion Blood normal 6.9 1 4.6 1 lipid hyperli 13.5 2.116 (1.478-3.030) 14.7 3.551 (2.532-4.981) pemia

Table 5. Relationship between IFG and hypertension/hyperlipemia. IFG（%） Varia Level ble male OR 95%CI female OR 95%CI Blood normal 12.6 1 20.6 1 press ure hyperte 19.7 1.699 (1.190-2.425) 27.3 1.455 (1.100-1.925) nsion Blood normal 13.1 1 20.0 1 lipid hyperli 19.5 1.616 (1.188-2.197) 27.9 1.545 (1.224-1.949) pemia

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