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
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5
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20
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17
2.
4
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85
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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)
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