2010《新英格兰杂志》中国糖尿病患病情况

original article Th e n e w e ngl a nd j o u r na l o f m e dic i n e n engl j med 362;12 nejm.org march 25, 20101090 Prevalence of Diabetes among Men and Women in China Wenying Yang, M.D., Juming Lu, M.D., Jianping Weng, M.D., Weiping Jia, M.D., Linong Ji, M.D., Jianzhong Xiao, M.D., Ph.D., Zhongyan Shan, M.D., Jie Liu, M.D., Haoming Tian, M.D., Qiuhe Ji, M.D., Dalong Zhu, M.D., Jiapu Ge, M.D., Lixiang Lin, M.D., Li Chen, M.D., Xiaohui Guo, M.D., Zhigang Zhao, M.D., Qiang Li, M.D., Zhiguang Zhou, M.D., Guangliang Shan, M.D., Ph.D., and Jiang He, M.D., Ph.D., for the China National Diabetes and Metabolic Disorders Study Group* From China–Japan Friendship Hospital, Beijing (W.Y., J.X.); Chinese People’s Lib- eration Army General Hospital, Beijing (J. Lu); Sun Yat-sen University Third Hos- pital, Guangzhou (J.W.); Shanghai Jiao- tong University Affiliated Sixth People’s Hospital, Shanghai (W.J.); Peking Univer- sity People’s Hospital, Beijing (L.J.); First Affiliated Hospital, Chinese Medical Uni- versity, Liaoling (Z.S.); Shanxi Province People’s Hospital, Taiyuan, Shaanxi (J. Liu); West China Hospital, Sichuan University, Chengdu, Sichuan (H.T.); Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi (Q.J.); Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu (D.Z.); Xinjiang Uygur Autonomous Region’s Hospital, Urmqi, Xinjiang (J.G.); Fujian Provincial Hospital, Fuzhou, Fujiang (L.L.); Qilu Hos- pital, Qilu Hospital of Shandong Univer- sity, Jinan, Shandong (L.C.); Peking Uni- versity First Hospital, Beijing (X.G.); Henan Province People’s Hospital, Zhengzhou, Henan (Z. Zhao); Second Affiliated Hospi- tal of Harbin Medical University, Harbin, Heilongjiang (Q.L.); Xiangya Second Hos- pital, Changsha, Hunan (Z. Zhou); and Pe- king Union Medical College, Beijing (G.S.) — all in China; and Tulane University School of Public Health and Tropical Medi- cine, New Orleans (J.H.). Address reprint requests to Dr. Yang at the Department of Endocrinology, China–Japan Friendship Hospital, Beijing 100029, China, or at ywy_1010@yahoo.com.cn. *The members of the China National Diabetes and Metabolic Disorders Study group are listed in the Supplementary Appendix, available with the full text of this article at NEJM.org. N Engl J Med 2010;362:1090-101. Copyright © 2010 Massachusetts Medical Society. A BS TR AC T BACKGROUND Because of the rapid change in lifestyle in China, there is concern that diabetes may become epidemic. We conducted a national study from June 2007 through May 2008 to estimate the prevalence of diabetes among Chinese adults. METHODS A nationally representative sample of 46,239 adults, 20 years of age or older, from 14 provinces and municipalities participated in the study. After an overnight fast, participants underwent an oral glucose-tolerance test, and fasting and 2-hour glu- cose levels were measured to identify undiagnosed diabetes and prediabetes (i.e., impaired fasting glucose or impaired glucose tolerance). Previously diagnosed dia- betes was determined on the basis of self-report. RESULTS The age-standardized prevalences of total diabetes (which included both previously diagnosed diabetes and previously undiagnosed diabetes) and prediabetes were 9.7% (10.6% among men and 8.8% among women) and 15.5% (16.1% among men and 14.9% among women), respectively, accounting for 92.4 million adults with diabe- tes (50.2 million men and 42.2 million women) and 148.2 million adults with pre- diabetes (76.1 million men and 72.1 million women). The prevalence of diabetes in- creased with increasing age (3.2%, 11.5%, and 20.4% among persons who were 20 to 39, 40 to 59, and ≥60 years of age, respectively) and with increasing weight (4.5%, 7.6%, 12.8%, and 18.5% among persons with a body-mass index [the weight in ki- lograms divided by the square of the height in meters] of <18.5, 18.5 to 24.9, 25.0 to 29.9, and ≥30.0, respectively). The prevalence of diabetes was higher among urban residents than among rural residents (11.4% vs. 8.2%). The prevalence of isolated impaired glucose tolerance was higher than that of isolated impaired fasting glu- cose (11.0% vs. 3.2% among men and 10.9% vs. 2.2% among women). CONCLUSIONS These results indicate that diabetes has become a major public health problem in China and that strategies aimed at the prevention and treatment of diabetes are needed. Downloaded from www.nejm.org on May 17, 2010 . Copyright © 2010 Massachusetts Medical Society. All rights reserved. Diabetes in China n engl j med 362;12 nejm.org march 25, 2010 1091 Cardiovascular disease has become the leading cause of death in China, a de-velopment that has followed rapid eco- nomic growth, an increase in life expectancy, and changes in lifestyle.1 Diabetes is a major risk fac- tor for cardiovascular disease, and the prevalence of diabetes is high and is increasing in China.2-4 A national survey conducted in 1994, involving 224,251 Chinese residents, 25 to 64 years of age, from 19 provinces, showed that the prevalences of diabetes and impaired glucose tolerance were 2.5% and 3.2%, respectively.2 These estimates were higher by a factor of approximately 3 than those reported in 1980.3 In a cross-sectional study in 2000–2001 involving a nationally representative sample of 15,540 adults, 35 to 74 years of age, the prevalences of diabetes and impaired fasting glu- cose were 5.5% and 7.3%, respectively.4 Although these studies have documented a marked increase in the prevalence of diabetes in China, they can- not be compared directly, owing to methodologic differences in sampling and to differences in the criteria used to define diabetes.2-4 Furthermore, the prevalences of diabetes and prediabetes were probably underestimated in these studies because 2-hour oral glucose-tolerance tests were not per- formed in all participants. It has been suggested that isolated hyperglycemia 2 hours after glucose loading is common among Asian patients with diabetes.5 For example, in the Shanghai Diabetes Study, 48.6% of patients with newly diagnosed diabetes had isolated hyperglycemia 2 hours af- ter glucose loading, and 75.0% of those with pre- diabetes had isolated impaired glucose tolerance.6 The China National Diabetes and Metabolic Disorders Study, conducted from June 2007 through May 2008, was a cross-sectional study designed to provide current and reliable data on the preva- lences of diabetes and associated metabolic risk factors in the adult population in China. Me thods Study Participants We used a multistage, stratified sampling meth- od to select a nationally representative sample of persons 20 years of age or older in the general population. The sampling process was stratified according to geographic region (northeast, north, east, south central, northwest, and southwest China), degree of urbanization (large cities [Bei- jing, Shanghai, and provincial capitals], midsize cities, county seats, and rural townships), and eco- nomic development status (as assessed on the basis of the gross domestic product [GDP] for each province). The first two stages of sampling, in which provinces were selected from geographic regions and cities and counties were selected from provinces, were not random. In the next two stag- es (the stage in which city districts were selected from cities and rural townships from counties and the stage in which street districts were selected from city districts and rural villages from town- ships), the sampling was random (see Fig. 1 in the Supplementary Appendix, available with the full text of this article at NEJM.org). This multi- stage, stratified sampling process resulted in an oversampling of urban residents. In total, 152 ur- ban street districts and 112 rural villages were selected. In the final stage of sampling, the sam- ple was stratified according to the sex and age dis- tribution in China, on the basis of Chinese popu- lation data from 2006.7 Only persons who had lived in their current residence for 5 years or lon- ger were eligible to participate. A total of 54,240 people were selected and in- vited to participate in the study; 47,325 persons (18,976 men and 28,349 women) completed the study. The overall response rate was 87.3%: 81.0% for men and 92.0% for women; 88.1% of those who lived in urban areas and 82.7% of those who lived in rural areas responded. After the exclusion of 538 persons for whom demographic informa- tion was missing and 548 for whom data on fast- ing or 2-hour plasma glucose levels were missing, 46,239 adults were included in the final analysis. The institutional review board or ethics com- mittee at each participating institution approved the study protocol. Written informed consent was obtained from each participant before data col- lection. Data Collection A standard questionnaire was administered by trained staff to obtain information on demograph- ic characteristics, personal and family medical history, and lifestyle risk factors.8 The interview included questions related to the diagnosis and treatment of diabetes, hypertension, dyslipidemia, and cardiovascular events. Cigarette smoking was defined as having smoked at least 100 cigarettes in one’s lifetime. Information was obtained on the amount and type of alcohol that was consumed during the previous year, and alcohol drinking was defined as the consumption of at least 30 g of alcohol per week for 1 year or more. Regular lei- Downloaded from www.nejm.org on May 17, 2010 . Copyright © 2010 Massachusetts Medical Society. All rights reserved. Th e n e w e ngl a nd j o u r na l o f m e dic i n e n engl j med 362;12 nejm.org march 25, 20101092 Ta bl e 1. C ha ra ct er is tic s of S tu dy P ar tic ip an ts A cc or di ng to P la sm a G lu co se C at eg or ie s an d Se x. * C ha ra ct er is tic N or m al G lu co se To le ra nc e Is ol at ed I m pa ir ed Fa st in g G lu co se Is ol at ed I m pa ir ed G lu co se T ol er an ce C om bi ne d Im pa ir ed Fa st in g G lu co se a nd Im pa ir ed G lu co se To le ra nc e Pr ev io us ly U nd ia gn os ed D ia be te s Pr ev io us ly D ia gn os ed D ia be te s M en ( N = 1 8, 41 9) Pa rt ic ip an ts — n o. ( % ) 13 ,4 26 ( 73 .3 ) 68 6 (3 .2 ) 16 91 ( 11 .0 ) 39 5 (1 .9 ) 13 27 ( 6. 5) 89 4 (4 .1 ) M ea n fa st in g pl as m a gl uc os e (9 5% C I) — m g/ dl 87 .3 ( 87 .0 –8 7. 7) 11 4. 9 (1 14 .4 –1 15 .5 ) 93 .1 ( 92 .3 –9 3. 9) 11 6. 2 (1 15 .5 –1 17 .0 ) 13 5. 7 (1 32 .0 –1 39 .4 ) 15 8. 6 (1 51 .8 –1 65 .4 ) M ea n 2- hr p la sm a gl uc os e in o ra l g lu co se -t ol er an ce te st ( 95 % C I) — m g/ dl † 99 .1 ( 98 .4 –9 9. 7) 11 0. 6 (1 07 .9 –1 13 .3 ) 16 0. 9 (1 59 .7 –1 62 .1 ) 16 4. 6 (1 61 .8 –1 67 .4 ) 24 3. 5 (2 36 .4 –2 50 .7 ) 26 5. 9 (2 52 .8 –2 78 .9 ) M ea n ag e (9 5% C I) — y r 42 .5 ( 42 .1 –4 3. 0) 48 .5 ( 46 .4 –5 0. 6) 50 .2 ( 49 .0 –5 1. 5) 50 .2 ( 47 .8 –5 2. 6) 52 .1 ( 50 .8 –5 3. 4) 55 .8 ( 54 .2 –5 7. 4) Fa m ily h is to ry o f d ia be te s (9 5% C I) — % 12 .9 ( 11 .8 –1 4. 1) 12 .8 ( 9. 3– 17 .3 ) 14 .6 ( 12 .0 –1 7. 6) 23 .5 ( 17 .3 –3 1. 0) 23 .3 ( 19 .1 –2 8. 1) 42 .6 ( 36 .6 –4 8. 9) C ol le ge o r hi gh er le ve l o f e du ca tio n (9 5% C I) — % 25 .3 ( 24 .1 –2 6. 5) 19 .2 ( 14 .7 –2 4. 8) 18 .7 ( 16 .1 –2 1. 6) 22 .6 ( 17 .3 –2 8. 9) 16 .8 ( 14 .2 –1 9. 7) 16 .4 ( 13 .0 –2 0. 5) C ig ar et te s m ok in g (9 5% C I) — % ‡ 57 .5 ( 56 .2 –5 9. 1) 56 .8 ( 50 .2 –6 3. 1) 58 .6 ( 54 .6 –6 2. 5) 60 .1 ( 52 .2 –6 7. 5) 59 .4 ( 54 .9 –6 3. 8) 50 .5 ( 44 .6 –5 6. 3) C on su m pt io n of a lc oh ol ( 95 % C I) — % § 44 .3 ( 42 .8 –4 5. 7) 41 .7 ( 35 .6 –4 8. 2) 39 .5 ( 35 .7 –4 3. 3) 51 .6 ( 43 .6 –5 9. 4) 40 .5 ( 36 .3 –4 4. 8) 35 .2 ( 29 .9 –4 0. 8) R eg ul ar le is ur e- tim e ph ys ic al a ct iv ity ( 95 % C I) — % ¶ 33 .3 ( 32 .0 –3 4. 7) 31 .6 ( 25 .5 –3 8. 4) 36 .2 ( 32 .5 –4 0. 0) 39 .2 ( 31 .6 –4 7. 4) 30 .3 ( 26 .5 –3 4. 3) 49 .7 ( 43 .9 –5 5. 5) M ea n bo dy -m as s in de x (9 5% C I) ‖ 23 .6 ( 23 .5 –2 3. 7) 24 .5 ( 24 .1 –2 5. 0) 24 .8 ( 24 .5 –2 5. 2) 26 .6 ( 26 .0 –2 7. 2) 25 .8 ( 25 .4 –2 6. 3) 25 .2 ( 24 .9 –2 5. 6) M ea n w ai st c ir cu m fe re nc e (9 5% C I) — c m 82 .1 ( 81 .8 –8 2. 4) 86 .7 ( 85 .0 –8 8. 3) 85 .5 ( 84 .5 –8 6. 5) 90 .7 ( 89 .2 –9 2. 1) 89 .1 ( 88 .1 –9 0. 0) 88 .7 ( 87 .7 –8 9. 7) M ea n sy st ol ic b lo od p re ss ur e (9 5% C I) — m m H g 12 1. 0 (1 20 .5 –1 21 .5 ) 12 7. 4 (1 24 .8 –1 30 .0 ) 12 9. 2 (1 27 .2 –1 31 .1 ) 13 2. 1 (1 29 .3 –1 35 .0 ) 13 3. 2 (1 31 .4 –1 34 .9 ) 13 2. 0 (1 29 .6 –1 34 .3 ) M ea n he ar t r at e (9 5% C I) — b ea ts /m in 72 .4 ( 72 .1 –7 2. 8) 73 .4 ( 72 .1 –7 4. 6) 74 .2 ( 73 .3 –7 5. 1) 75 .1 ( 73 .2 –7 7. 1) 76 .4 ( 75 .4 –7 7. 5) 76 .6 ( 75 .2 –7 8. 0) M ea n H D L ch ol es te ro l ( 95 % C I) — m g/ dl 48 .5 ( 48 .1 –4 8. 9) 47 .1 ( 45 .3 –4 9. 0) 48 .9 ( 47 .9 –4 9. 9) 45 .6 ( 44 .0 –4 7. 3) 48 .1 ( 46 .9 –4 9. 3) 44 .5 ( 42 .9 –4 6. 0) M ea n LD L ch ol es te ro l ( 95 % C I) — m g/ dl 10 1. 2 (1 00 .2 –1 02 .3 ) 10 8. 5 (1 03 .2 –1 13 .7 ) 10 8. 5 (1 05 .2 –1 11 .9 ) 11 2. 5 (1 06 .4 –1 18 .6 ) 11 2. 1 (1 08 .3 –1 15 .8 ) 10 9. 7 (1 05 .3 –1 14 .0 ) M ea n tr ig ly ce ri de s (9 5% C I) — m g/ dl 14 1. 7 (1 38 .6 –1 44 .7 ) 17 6. 5 (1 60 .9 –1 92 .2 ) 16 9. 5 (1 60 .8 –1 78 .1 ) 20 4. 3 (1 80 .9 –2 27 .7 ) 19 8. 6 (1 86 .0 –2 11 .3 ) 17 2. 4 (1 59 .0 –1 85 .7 ) W om en ( N = 2 7, 82 0) Pa rt ic ip an ts — n o. ( % ) 20 ,8 67 ( 76 .4 ) 78 3 (2 .2 ) 28 80 ( 10 .9 ) 56 2 (1 .7 ) 15 81 ( 5. 2) 11 47 ( 3. 5) M ea n fa st in g pl as m a gl uc os e (9 5% C I) — m g/ dl 86 .9 ( 86 .6 –8 7. 2) 11 4. 7 (1 14 .2 –1 15 .2 ) 93 .7 ( 93 .0 –9 4. 4) 11 5. 5 (1 14 .7 –1 16 .4 ) 13 5. 3 (1 31 .2 –1 39 .4 ) 16 5. 2 (1 47 .1 –1 83 .3 ) M ea n 2- hr p la sm a gl uc os e in o ra l g lu co se -t ol er an ce te st ( 95 % C I) — m g/ dl † 10 2. 1 (1 01 .5 –1 02 .6 ) 11 1. 6 (1 09 .4 –1 13 .7 ) 15 9. 6 (1 58 .5 –1 60 .6 ) 16 5. 8 (1 63 .7 –1 67 .9 ) 25 9. 2 (2 50 .9 –2 67 .6 ) 28 5. 8 (2 63 .5 –3 08 .1 ) M ea n ag e (9 5% C I) — y r 42 .1 ( 41 .6 –4 2. 5) 46 .6 ( 44 .8 –4 8. 4) 51 .9 ( 50 .5 –5 3. 4) 53 .9 ( 51 .8 –5 6. 0) 54 .8 ( 53 .4 –5 6. 2) 59 .3 ( 57 .9 –6 0. 8) Fa m ily h is to ry o f d ia be te s (9 5% C I) — % 13 .9 ( 13 .0 –1 4. 8) 12 .2 ( 9. 2– 16 .1 ) 17 .5 ( 13 .4 –2 2. 7) 15 .3 ( 10 .5 –2 1. 8) 23 .4 ( 19 .0 –2 8. 6) 44 .3 ( 36 .3 –5 2. 6) C ol le ge o r hi gh er le ve l o f e du ca tio n (9 5% C I) — % 20 .3 ( 19 .4 –2 1. 3) 11 .1 ( 8. 4– 14 .5 ) 9. 6 (7 .7 –1 2. 0) 11 .0 ( 8. 0– 14 .8 ) 6. 3 (5 .0 –7 .9 ) 4. 6 (3 .4 –6 .3 ) C ig ar et te s m ok in g (9 5% C I) — % ‡ 3. 0 (2 .7 –3 .5 ) 2. 3 (1 .3 –4 .0 ) 4. 4 (3 .1 –6 .2 ) 3. 7 (1 .6 –8 .7 ) 4. 6 (2 .9 –7 .2 ) 4. 2 (2 .4 –7 .3 ) C on su m pt io n of a lc oh ol ( 95 % C I) — % § 4. 1 (3 .7 –4 .6 ) 4. 3 (2 .4 –7 .4 ) 3. 8 (2 .7 –5 .4 ) 4. 0 (2 .2 –6 .9 ) 4. 7 (3 .0 –7 .2 ) 3. 4 (1 .9 –6 .0 ) R eg ul ar le is ur e- tim e ph ys ic al a ct iv ity ( 95 % C I) — % ¶ 30 .9 ( 29 .8 –3 2. 0) 22 .9 ( 18 .1 –2 8. 6) 34 .6 ( 30 .0 –3 9. 6) 30 .9 ( 24 .9 –3 7. 6) 35 .5 ( 31 .2 –4 0. 1) 49 .2 ( 42 .7 –5 5. 7) M ea n bo dy -m as s in de x (9 5% C I) ‖ 22 .9 ( 22 .8 –2 3. 0) 24 .2 ( 23 .8 –2 4. 7) 25 .8 ( 25 .2 –2 6. 4) 25 .9 ( 25 .5 –2 6. 3) 24 .8 ( 24 .5 –2 5. 1) 24 .6 ( 24 .2 –2 5. 1) M ea n w ai st c ir cu m fe re nc e (9 5% C I) — c m 76 .3 ( 76 .0 –7 6. 6) 80 .8 ( 79 .5 –8 2. 1) 82 .0 ( 81 .2 –8 2. 8) 86 .3 ( 84 .5 –8 8. 0) 85 .6 ( 84 .8 –8 6. 4) 84 .4 ( 83 .3 –8 5. 4) M ea n sy st ol ic b lo od p re ss ur e (9 5% C I) — m m H g 11 6. 4 (1 15 .9 –1 17 .0 ) 12 3. 6 (1 20 .7 –1 26 .4 ) 12 8. 6 (1 27 .0 –1 30 .2 ) 13 4. 2 (1 31 .6 –1 36 .9 ) 13 4. 9 (1 32 .9 –1 37 .0 ) 13 6. 1 (1 33 .5 –1 38 .8 ) Downloaded from www.nejm.org on May 17, 2010 . Copyright © 2010 Massachusetts Medical Society. All rights reserved. Diabetes in China n engl j med 362;12 nejm.org march 25, 2010 1093 sure-time physical activity was defined as par- ticipation in moderate or vigorous activity for 30 minutes or more per day at least 3 days a week. Socioeconomic status, educational level, occupa- tion, and income were also recorded. The econom- ic development of provinces or municipalities was defined on the basis of the GDP per capita in 2006. Blood pressure, body weight, height, and waist circumference were measured with the use of standard methods, as described previously.2 All study investigators and staff members suc- cessfully completed a training program that fa- miliarized them with both the aims of the study and the specific tools and methods used. At the training sessions, interviewers were given detailed instructions concerning the administration of the study questionnaire. Clinical staff members were trained to measure blood pressure and obtain anthropometric measurements and blood speci- mens according to a standard protocol.8 Oral Glucose-Tolerance Test Participants were instructed to maintain their usual physical activity and diet for at least 3 days before the oral glucose-tolerance test. After at least 10 hours of overnight fasting, a venous blood speci- men was collected in a vacuum tube containing sodium fluoride, for the measurement of plasma glucose. Participants with no history of diabetes were given a standard 75-g glucose solution, where- as for safety reasons, participants with a self- reported history of diabetes were given a steamed bun that contained approximately 80 g of com- plex carbohydrates. Blood samples were drawn at 0, 30, and 120 minutes after the glucose or car- bohydrate load to measure glucose concentrations. Plasma glucose was measured with the use of a hexokinase enzymatic method, and serum cho- lesterol and triglyceride levels were assessed en- zymatically with the use of commercially avail- able reagents, at the clinical biochemical labora- tories in each province. All the study laboratories successfully completed a standardization and cer- tification program. Study-outcome Definitions The 1999 World Health Organization diagnostic criteria were used to diagnose diabetes.9 Results of plasma glucose testing were categorized as fol- lows: isolated impaired fasting glucose (fasting glucose level, ≥110 mg per deciliter [6.1 mmol per liter] and <126 mg per deciliter [7.0 mmol per liter), M ea n he ar t r at e (9 5% C I) — b ea ts /m in 74 .3 ( 74 .0 –7 4. 6) 74 .7 ( 73 .6 –7 5. 8) 76 .5 ( 75 .6 –7 7. 4) 78 .5 ( 76 .6 –8 0. 4) 78 .0 ( 77 .2 –7 8. 9)