1. Current status and epidemic trend of diabetes mellitus
Diabetes mellitus is a metabolic disease characterized by elevated blood glucose caused by defective insulin secretion and/or action. Diabetic patients with long-term poor glycemic control may suffer from various organs, especially eye, heart, blood vessel, kidney and nerve damage or organ insufficiency or failure, leading to disability or premature death. Huang Guibao, Cardiac Arrhythmia Treatment Center, Guangdong Provincial Hospital of Traditional Chinese Medicine
I. The current situation and epidemic trend of global diabetes
According to the recommendations of the World Health Organization (WHO) and the International Diabetes Federation (IDF), diabetes can be divided into four types: type 1, type 2, other special types and gestational diabetes. In recent years, with the socio-economic development of countries around the world and the improvement of residents’ living standards, the incidence and prevalence of diabetes has increased year by year, becoming a major social problem threatening people’s health and attracting the attention and focus of governments, health departments and medical workers in various countries.
The prevalence of type 1 diabetes is much lower than that of type 2 diabetes. Since the symptoms of type 1 diabetes in children are generally more obvious and not easily missed, most scholars advocate the use of incidence rate to describe the epidemiological characteristics of type 1 diabetes. According to the analysis of available data, the incidence of type 1 diabetes varies greatly in different regions of the world, with the highest incidence in Northern European countries and relatively low incidence in Southeast Asian countries. In recent years, the incidence of type 1 diabetes has tended to increase year by year around the world, but the rate of increase is much less than that of type 2 diabetes. The incidence of type 1 diabetes in European countries tends to increase from south to north, and the incidence of type 1 diabetes is consistent with the prevalence of seasonal and viral diseases, suggesting that the onset of type 1 diabetes may be related to viral infections. China has one of the lowest incidence rates of type 1 diabetes in the world, but because of its large population base, the absolute number of patients with type 1 diabetes is not small. According to domestic estimates, the total number of patients with type 1 diabetes is currently between 2 and 3 million. Table 1-1 shows the incidence of type 1 diabetes in some countries in the 1990s.
Table 1-1 Incidence of type 1 diabetes in the 1990s (1 per 100,000)
Population Finland United States Japan China
Incidence rate 35.5 15.8 1.5 0.7
Type 2 diabetes is more insidious in its onset and difficult to diagnose at the first sign, but its prevalence is high. The epidemiological characteristics of type 2 diabetes are generally studied in terms of prevalence. In recent years, the prevalence of type 2 diabetes has increased dramatically in all countries of the world, and the proliferation of type 2 diabetes is the main reason for the dramatic increase in the total number of people with diabetes worldwide. According to the results reported by WHO since the 1980s, the changes in the prevalence of type 2 diabetes in the world have the following common features: 1. The prevalence has increased dramatically, and the trend of dramatic increase in type 2 diabetes in the past 30 to 50 years is still difficult to be alleviated. In 2010, it will be 239 million, and in 2025, it will exceed 300 million. At present, the top 3 countries in the world with the largest number of diabetes patients are India, China and the United States; 2. type 2 diabetes is the main body of the diabetes population. type 2 diabetes accounts for about 90% of diabetes patients, and the proportion of type 2 diabetes in China is also the same; 3. the age of onset is young. In many countries, type 2 diabetes in children has accounted for 50% to 80% of children with diabetes, and the problem of type 2 diabetes in children has attracted great attention; 4. There are a large number of people with elevated blood glucose but who do not meet the diagnostic criteria for diabetes. Their fasting blood glucose, 2-hour postprandial blood glucose or 2-hour post-saccharide blood glucose are between normal blood glucose and diabetes diagnostic criteria. The current trend in the diabetes community is to refer to these individuals as impaired glucose regulation (IGR). The large number of people with impaired glucose regulation is the reserve army of diabetics, and their presence indicates that the trend of an explosive epidemic of diabetes is continuing to develop; 5. The prevalence of type 2 diabetes varies greatly from country to country around the world, from less than 0.1% up to 40%. The highest prevalence rates are found in the Pacific Island nation of Nauru and the Pima Indians of the United States. The fastest increase in prevalence is in developing countries where there is a dramatic shift from poor to rich.
Other specific types of diabetes are those that are neither type 1 nor type 2 diabetes and are not related to pregnancy, including diabetes caused by pancreatic or endocrine disease, diabetes caused by medications, and diabetes associated with genetic disorders. Other specific types of diabetes, although complex in etiology, account for less than 1% of the total number of people with diabetes. Some of these types of diabetes are remittable with the cure of the primary disease.
Gestational diabetes is defined as diabetes that occurs or is detected during pregnancy. Pregnancy is a time of high prevalence of diabetes, and the incidence of gestational diabetes is much higher than has been estimated and poses a threat to the safety of mother and child, so although the regression of gestational diabetes is generally good, sufficient attention should be paid to this type of condition.
Current status and epidemiological trends of diabetes mellitus in China
(I) History of diabetes in China
Written records of the clinical manifestations of diabetes mellitus can be found in China, India, Egypt, Greece, Rome and other ancient civilizations of the world. However, “it cannot be said that the conditions recorded at that time were necessarily diabetes as defined today”. Because of China’s long history of poverty and backwardness, diabetes did not pose a great threat to the health and lives of our people in the past. In the last 20 years or so, the rapid development of China’s national economy and the rapid improvement of people’s living standards have led to significant changes in the disease spectrum in China, and chronic non-communicable diseases, including diabetes, have gradually become an important social health problem. According to the information in 1996, patients with diabetes and impaired glucose tolerance in China accounted for 3.2% and 4.8% of the total population over 20 years old, respectively, which means that the population with abnormal blood glucose is close to 100 million. Table 1-2 shows the results of several large national epidemiological studies of diabetes in adults in China since the 1980s.
Table 1-2 Epidemiological findings of diabetes mellitus in China (% prevalence)
Time (years) Diabetes (%) Impaired glucose tolerance (%)
1980 1.00 –
1989 2.02* 2.95
1994 2.51* 3.20
1996 3.21* 4.81
*All according to WHO 1985 diagnostic criteria.
Diabetes is a huge hazard, not only affecting the quality of life of patients, but also imposing a heavy psychological burden on them. Diabetic complications pose a threat to the health and life of patients and can lead to disability and early death. In 2001, the Chinese Medical Association’s Division of Diabetes organized a retrospective analysis of the status of diabetic complications and related macrovascular diseases in 24,496 diabetic patients hospitalized in endocrinology departments in major cities in China from various provinces and cities, and the results are shown in Table 1-3
Table 1-3 Complications of diabetes mellitus in China (% prevalence)
Type of diabetes mellitus Hypertension Cerebrovascular lesions Cardiovascular lesions Diabetic foot Ocular lesions Nephropathy Neuropathy
T1DM 9.1 1.8 4.0 2.6 20.5 22.5 44.9
T2DM 34.2 12.6 17.1 5.2 35.7 34.7 61.8
Total 31.9 12.2 15.9 5.0 34.3 33.6 60.3
The results of the analysis show that it is quite common for diabetic patients in China to have chronic complications, and the prevalence rate has reached a fairly high level; among them, those with combined hypertension, cardiovascular and cerebrovascular disease, eye and nephropathy all account for about 1/3, and those with neuropathy account for more than half. The prevalence of macrovascular diseases, such as hypertension, cerebrovascular and cardiovascular lesions, has increased significantly compared to the previous. Although the prevalence of cardiovascular complications is lower than in western countries, it has become the chronic complication with the highest rate of disability and death and the most harmful in China. The prevalence of diabetic microvascular complications such as kidney and fundus and diabetic neurological complications are comparable to those in developed countries. Therefore, the prevention and treatment of diabetes and its complications is a major social health problem before us.
Review of diabetes prevention and treatment in the past 30 years
In 1995, the Department of Disease Control of the Ministry of Health organized experts to formulate the National Diabetes Prevention and Control Plan from 1996 to 2000, set up the Diabetes Prevention and Control Expert Advisory Committee of the Ministry of Health, and organized surveys on the prevalence of diabetes in China in 1996 and 2002. This series of initiatives has greatly promoted the prevention and treatment of diabetes in China. In the past 30 years, under the leadership and support of the Ministry of Health, medical workers in China have done a lot of specific work in the prevention and treatment of diabetes. Initially, the prevention and treatment of diabetes was carried out in hospitals, and doctors, nurses and dieticians who were enthusiastic about the prevention and treatment of diabetes spontaneously carried out the education, prevention and treatment of diabetes and achieved certain results. 1985 saw the establishment of the Diabetes Group of the Endocrinology Branch of the Chinese Medical Association. In 1991, the Fourth National Diabetes Conference was held in Shanghai, and the Diabetes Division of the Chinese Medical Association (CDS) was established at this conference. This marked a new stage in the prevention and treatment of diabetes in China.
Since its establishment, the CDS has organized a series of major activities nationwide, including a large number of diabetes education, flow regulation, prevention, treatment and scientific research, and has made great achievements. The Diabetes Branch supported the establishment of Diabetes Branch Patient Associations in all provinces and municipalities nationwide, and now there are 20 Diabetes Chapters or Groups and 8 Patient Associations nationwide. These societies and associations have played an important role in diabetes promotion, education, prevention and treatment. Since 1992, the Diabetes Society has hosted several national and local World Diabetes Day (WDD) events. The Diabetes Division attaches great importance to diabetes education and has held several courses for diabetic physicians and nurses over the past 10 years. At the end of 1993, the Chinese Journal of Diabetes was launched, which was well received by readers for its rich content, high quality papers and beautiful printing. 1999, the famous diabetes scholars in China compiled the In 2001, on the occasion of the 10th anniversary of the establishment of the Diabetes Division, the official website of China Diabetes www.eds.org.cn建立 was launched, marking the entry of a new information era for the prevention and treatment of diabetes in China.
In addition, the Diabetes Division has organized a large number of international exchange activities. Since 1987, the China-Japan Diabetes Symposium has been held in China and Japan alternately every two to three years, and the 5th International Diabetes Federation Western Pacific Region Congress (IDF-WPR Congress), held for the first time in Beijing, China, in May 2002, was a great success and achieved a good social impact both at home and abroad.
(III) The epidemic trend of diabetes in China and the work faced
In the face of the serious status of the diabetes epidemic in China, although we have done a lot of work for the cause of diabetes prevention and treatment, we still face great challenges and daunting tasks in the next two to three decades.
(1) The epidemic of diabetes, especially type 2 diabetes, has just begun in China. Within the next 30 years, the total number of patients will increase dramatically, and chronic complications will pose a serious threat to people’s quality of life and lives, creating enormous pressure on the prevention and treatment of diabetes in China and on the social economy.
(2) The level of awareness of diabetes among the general public in China is not in line with the trend of the diabetes epidemic, and there is an urgent need to carry out extensive, in-depth and sustained diabetes publicity and education work to improve the knowledge and skills of diabetes prevention for the whole population.
(3) The development of diabetes prevention and treatment in China and the deployment of health resources are very uneven. The remote areas and the vast rural areas are at the stage of enlightenment, and these areas may be the potential areas of diabetes epidemic. Therefore, we should strengthen the deployment of health resources and the prevention and treatment of diabetes in these areas.
(4) The role of our nursing community in diabetes prevention and treatment is relatively lagging behind compared to that of western countries and needs to be strengthened so that our nursing staff at large can play a greater role in the cause of diabetes prevention and treatment.
(5) Diabetes nutrition is still almost a gap, and most hospitals do not have diabetic dieticians yet. Professionals in this field need to be cultivated urgently.
2 The danger of diabetes mellitus
Diabetes is a disease that poses a serious threat to human health and has a significant impact on social development, mainly in four aspects.
3. High prevalence
Diabetes is a worldwide epidemic disease, and its prevalence is increasing. According to WHO’s estimation, there are about 175 million people with diabetes worldwide, and it will reach 300 million by 2025. The prevalence of diabetes in China is also increasing dramatically, with a four- to five-fold increase from the 1980s to the mid-1990s, and an estimated 30-40 million people now have diabetes (see Part 1 of this guideline for details).
In the past, diabetes was thought to be a disease of middle age and old age. In recent years, it has been found that, whether in the West or in China, with the increase in childhood and adolescent obesity, the number of children and adolescents with diabetes, especially type 2 diabetes, has also increased rapidly and has become a major health problem early in life.
4. High incidence of complications of diabetes, resulting in tissue and organ destruction, with disability and death, serious harm
(a) Acute complications
1. Diabetic ketoacidosis
This is the most common acute complication of diabetes mellitus, which is common in type 1 diabetes mellitus and occurs in cases of poor metabolic control, concomitant infection, severe stress, interruption of insulin therapy and eating disorders, etc. Type 2 diabetes mellitus can also occur in cases of poor metabolic control and severe stress. Delayed diagnosis or treatment may result in death. Mortality is higher in patients of young or advanced age, coma, or hypotension. The mortality rate is <5% in experienced medical centers in the United States, but can be as high as 10% in our primary care hospitals.
2. Diabetic non-ketotic hyperosmolar syndrome
This syndrome is mostly seen in elderly patients. It leads to coma, shock and multi-organ failure due to severe hyperglycemia and disturbance of water and electrolyte balance. The mortality rate of this syndrome is extremely high, and can be as high as 15% even in high level hospitals.
3. Lactic acidosis
The incidence of diabetes mellitus combined with lactic acidosis is not high, but the morbidity and mortality rate is very high. It mostly occurs in patients with hepatic and renal insufficiency, or with chronic cardiopulmonary insufficiency and other hypoxic diseases, especially those who take phenibut at the same time. It is mainly due to the large accumulation of anaerobic enzymatic glucose metabolites-lactic acid in the body leading to hyperlactatemia and further decrease in body fluid PH, resulting in lactic acidosis.
(II) Chronic complications
1 Vascular complications
Cardiovascular disease is the main cause of disability, death and economic loss in diabetic patients. After the 1980s, due to the understanding of the causes and pathogenesis of coronary arteriosclerosis and the achievements of prevention and treatment trials, the incidence and death rate of coronary arteriosclerosis in the general population of western countries have been declining significantly. This is not the case in the diabetic population, where the prevalence of cardiovascular disease and mortality are increasing. The annual incidence of cardiovascular disease in the diabetic population is two to three times higher than in the non-diabetic population of the same age and sex. The Framingham 7-year primary prevention cohort follow-up study of men aged 51-59 years and the Finnish Coronary Heart Disease Event and Mortality Study (1059 type 2 diabetic and 1373 non-diabetic cases) both showed that the incidence of cardiovascular events and mortality were significantly higher in diabetics than in non-diabetics. The National Cholesterol Education Program Adult Treatment Panel Report 3 (NCEP-ATP III) states that the risk of cardiovascular events within 10 years in diabetic patients without previous myocardial infarction is similar to that in nondiabetic patients with previous myocardial infarction, and therefore diabetes is considered an equal risk for coronary heart disease. type 2 diabetes is an independent risk factor for coronary heart disease.
Diabetic arterial endothelial cell dysfunction, arterial endothelial damage, followed by early onset of response to vascular injury and accelerated atherosclerosis are important causes of increased coronary events and death. Also diabetic cardiomyopathy, left ventricular diastolic dysfunction, predisposition to congestive heart failure and arrhythmias due to cardiac autonomic neuropathy are also important causes of increased cardiovascular mortality. The basis for vascular endothelial dysfunction and injury and atherosclerosis is diabetic insulin resistance and its associated risk factors, such as obesity, hypertension, hyperglycemia, small and dense LDL-C elevation, hypertriglyceridemia, low HDL-C, elevated PAI-1, hyperhomocysteinemia (i.e., metabolic syndrome), and smoking. The metabolic syndrome, which is a multiple risk factor for cardiovascular disease, is present not only during diabetes but also during the pre-diabetes phase, such as the impaired glucose tolerance phase. Therefore, when dealing with diabetes, and effective early interventions to prevent and treat it, to minimize the incidence of cardiovascular disease and mortality.
2 Diabetic cerebrovascular disease
The most common diabetic cerebrovascular disease is ischemic encephalopathy caused by cerebral atherosclerosis, such as transient ischemic attack (TIA), lacunar cerebral infarction, multiple cerebral infarction, cerebral thrombosis and so on. In diabetic vascular disease, cerebral thrombosis mostly occurs in the middle cerebral artery, while lacunar cerebral infarction is mostly seen in the blood supply area of deep penetrating branches in the brain, such as the nucleus accumbens, internal capsule, thalamus and the base of the pons. Because of the high incidence of hypertension in diabetes (20%-60%), hemorrhagic encephalopathy can also occur.
In 2002, cerebrovascular disease was the second leading cause of death in urban areas and the first in rural areas. The incidence of cerebrovascular disease is significantly higher in diabetics than in non-diabetics, especially in women, and the Framingham study found that the incidence of cerebral infarction was 2.5 times higher in men and 3.7 times higher in women aged 45-74 years with diabetes than in non-diabetics. Moreover, the incidence of ischemic stroke was higher in diabetics than in nondiabetics at all ages.
Risk factors for diabetic cerebrovascular disease include hyperglycemia, hypertension, dyslipidemia, abnormal blood rheology, smoking, and chronic inflammatory states. Of these, hypertension is particularly important and is an independent risk factor for diabetic ischemic encephalopathy. In ischemic stroke patients, 77% of blood pressure is uncontrolled, making antihypertensive therapy important to reduce the incidence of stroke. This is also confirmed by UKPDS and other clinical trials of antihypertensive treatment such as HOPE, HOT and LIFE. Myocardial infarction in the elderly is also a risk factor for stroke. In a foreign study of 121,432 patients over 65 years of age hospitalized with acute myocardial infarction, the risk of stroke after discharge was 2.5 times higher than that of patients without myocardial infarction.
3 Diabetic eye disease
Lesions can occur in all parts of the eye in diabetic patients, such as corneal abnormalities, iris neovascularization, and optic neuropathy. The prevalence of glaucoma and cataracts is higher in diabetic patients than in non-diabetic patients of the same age. Diabetic retinopathy is the main cause of blindness in diabetic patients, and the prevalence of retinopathy increases with age and duration of the disease in all types of diabetes. 99% of type 1 diabetes and 60% of type 2 diabetes have retinopathy of varying degrees of duration for more than 20 years, and children under 10 years of age with diabetes rarely develop retinopathy. The risk of diabetic retinopathy increases after puberty.
4 Diabetic nephropathy
Diabetic nephropathy occurs in about 20% to 30% of people with type 1 or type 2 diabetes. Some of these progress to end-stage renal disease. Without specific intervention, approximately 80% of type 1 diabetics with persistent microalbuminuria develop clinical nephropathy within 10 to 15 years, at which time hypertension may develop. Once clinical nephropathy occurs, without effective intervention, the glomerular filtration rate gradually decreases within a few years, and 50% after 10 years and more than 75% after 20 years will develop end-stage renal disease.
After the diagnosis of diabetes mellitus in type 2 diabetic patients, many of them immediately develop microalbuminuria and even overt nephropathy. Without special intervention, 20% to 40% of them progress to clinical nephropathy, and about 20% progress to end-stage nephropathy after 20 years. Because of the large number of type 2 diabetic patients, more than half of the kidney disease patients currently on dialysis in Western countries are diabetic.
The presence of microalbuminuria in patients with type 1 or type 2 diabetes not only marks the presence of early kidney disease, but also greatly increases the prevalence of cardiovascular disease and the risk of death, and should therefore be taken very seriously.
5 Diabetic foot
The diabetic foot is the result of a combination of diabetic lower limb vascular disease, neuropathy and infection, which can lead to foot ulceration and even amputation in severe cases. The average number of amputations due to diabetes in the United States from 1989 to 1992 was 1605 cases per year, and foot ulcers are the main factor of amputation. Forty percent of foot and lower extremity amputations in adults are due to diabetes. A study in the United Kingdom followed 469 diabetic patients without previous foot ulcers and found that 10.2% of patients had foot ulcers for 4 consecutive years. Amputation rates were 10.3 and 13.8 times higher in diabetic men and women than in non-diabetic people of the same sex, respectively. There is a lack of epidemiological data on diabetic foot in China.
6 Diabetic osteoarthropathy
The incidence of diabetic osteoarthropathy is about 0.1% to 0.4%, mainly due to neuropathy, and infection can aggravate the damage. Although the incidence of this disease is not high, it can cause joint dislocation and deformity, seriously affecting joint function and reducing the quality of life of patients.
7 Diabetes and oral diseases
The anti-infection ability of the organism of diabetic patients against bacteria is reduced, and the oral and maxillofacial tissues and the gingival and periodontal tissues in the oral cavity are prone to infection, which can cause pus overflowing from the alveoli, resorption of alveolar bone and loosening of teeth. Infections occurring in the soft tissues of the maxillofacial region have a rapid onset and rapid expansion of inflammation, which can cause sudden deterioration of the general condition at the early stage of the disease and can cause death if not treated in time.
(iii) Associated diseases and infections
1. Hypoglycemia
Diabetic obese people are often accompanied by postprandial hyperinsulinemia, so late postprandial hypoglycemic symptoms can appear, but the degree is light. The most common and more serious hypoglycemia and diabetes drug treatment overdose related. Among them, insulin and sulfonylurea oral hypoglycemic drugs are the most common. The latter, in particular, is glibenclamide (euglycemia). Severe hypoglycemia is particularly dangerous in the elderly and children.
2. Metabolic syndrome
Centripetal obesity, hypertension, dyslipidemia, cholelithiasis, hyperuricemia and polycystic ovary syndrome often occur in clusters with diabetes (i.e. metabolic syndrome), which increases the risk of cardiovascular disease in diabetes.
3. Erectile dysfunction
Very common, about half of type 2 diabetic patients have it, mainly due to diabetic autonomic neuropathy.
4. Acute and chronic infections
Diabetic patients with reduced cellular and humoral immune function are often prone to urinary tract and biliary tract infections, fungal or bacterial skin infections, as well as pneumonia and tuberculosis.
III. Psychological Disorders
As mentioned earlier, diabetes is a lifelong disease with a high incidence of complications. Once complications occur, they are not only disabling and fatal, with a serious prognosis, but also cause a heavy economic burden to society and families. Children and adolescents are worried about further education and employment. As a result, patients and their families are under great mental pressure. Diabetic psychological disorders are mainly manifested as anxiety, obsessive-compulsive disorder, phobias and depression, and the incidence of psychological disorders in diabetic patients can be as high as 30% to 50%. Those with psychological disorders have a significantly lower quality of life, which is only 70% of the ideal level.
Fourth, the heavy socio-economic cost
In 1999, WHO and IDF (International Diabetes Federation) jointly proposed the slogan “The Cost of Diabetes” for World Diabetes Day, aiming to draw the attention of governments and people from all walks of life.
Diabetes has seriously affected the health of people around the world and has placed a heavy economic burden on governments and people. For example, in 1997, the United States spent $98 billion on diabetes, of which $44 billion was direct medical spending and $54 billion was indirect spending. Indirect spending refers to the economic expenditure on disability and death caused by diabetes. The annual per capita medical expenditure for people with diabetes is $10,071, while the annual per capita medical expenditure for people without diabetes is $2,699.
Health care costs for people with diabetes are directly related to their glycemic control. for every 1 percentage point increase in HbA1c greater than 7%, health care costs increase significantly. This increased cost is influenced by co-morbidities, particularly heart disease and hypertension. For example, an increase in HbA1c from 6% to 7% costs an additional $378 per patient in medical costs for those without heart disease or hypertension, and an additional $1,504 in medical costs for those with combined heart disease and hypertension.
The cost of diabetes in China was projected from the results of an 11-city survey in 2002, and the direct medical cost of treating diabetes and complications was RMB 18.82 billion, accounting for 3.95% of total health costs, of which RMB 15.24 billion, or 81%, was spent on direct medical care with complications and RMB 3.58 billion, or 19%, was spent on medical care without complications. In another survey, the total per capita hospitalization cost of diabetic patients in 5 years increased from RMB 2382 in 1995 to RMB 4847 in 1999, and the total cost, drug cost, examination cost and bed care cost increased by 103.4%, 82.3%, 151.7% and 128.4% respectively in 5 years.
Guangdong Provincial Hospital of Traditional Chinese Medicine Cardiac Arrhythmia Treatment Center wishes you good health! http://www.ac.ucbbs.org
Excerpted from the 2010 Chinese Diabetes Prevention and Control Guidelines