Current Status of Metabolic Compliance and Risk of Cardiovascular Disease in Patients with Type 2 Diabetes in the Zhuang Population in China

Introduction This study aimed to investigate the blood glucose, blood pressure, and blood lipid status in Zhuang patients with T2DM and to analyze the correlation between compliance with metabolic monitoring and cardiovascular risk factors. Methods A total of 1975 Zhuang patients with T2DM were evaluated in four Class III Grade A hospitals in three prefecture-level cities in the Guangxi Zhuang Autonomous Region between January and August 2022. Laboratory indicators, lifestyle, and demographic characteristics were collected. Results The compliance rates for blood glucose, blood pressure, and blood lipids were 26.08%, 45.77%, and 30.58%, respectively, and only 5.06% of the patients reached the standard in all three indices. The compliance rates for blood glucose, blood pressure, and blood lipids in the CVD group were 32.92%, 21.74%, and 9.94%, respectively. In the CVD group, the usage rates of hypoglycemic, antihypertensive, and lipid-lowering drugs were 77.54%, 3.17%, and 4.11%, respectively. Binary logistic regression analysis showed that older age (OR = 1.033, 95% CI [1.016, 1.050]), female (OR = 0.402, 95% CI [0.260, 0.621]), smoke (OR = 1.994, 95% CI [1.361, 2.922]), blood pressure noncompliance + use of antihypertensive drugs (OR = 0.348, 95% CI [0.230, 0.527]), and blood lipid noncompliance + use of lipid-lowering drugs (OR = 0.244, 95% CI [0.142, 0.417]) were risk factors for CVDs, and moderate-intensity exercise (OR = 0.439, 95% CI [0.300,0.640]) was protective against CVD. Conclusions Older age, female, smoke, blood lipid levels, and blood pressure noncompliance were risk factors for CVD while moderate-intensity exercise was observed to be protective.


Introduction
China is ranked frst globally in terms of diabetic patients with 141 million cases in 2021, according to data from the International Diabetes Federation (IDF) [1].Diabetes carries a signifcant risk of cardiovascular disease (CVD), and cardiovascular complications are now the primary cause of mortality in diabetic patients.In China, the Zhuang population in the Guangxi Zhuang Autonomous Region difers from the predominant Han population in terms of diabetesrelated genotypes [2], demographic characteristics, economic level, dietary habits, and educational level.Most Zhuang people live in mountainous areas where transportation is difcult.Teir main grain crops are rice and corn, and they like to drink alcohol and plant tobacco.Studies have reported that a high intake of dietary fber can reduce the risk of CVD, T2DM, and some cancers [3].However, smoking, drinking, and other unhealthy habits are associated with an increased incidence of hypertension, dyslipidemia, diabetes, and obesity, which may further increase the morbidity and mortality from CVD in China [4].According to previous studies, the Zhuang population has high incidences of T2DM, hyperlipidemia, hypertension, and other diseases [5].Controlling blood pressure and blood glucose and lipid levels can signifcantly reduce the incidence of CVD.Diabetes, complicated by cardiovascular and cerebrovascular diseases, has amplifed the medical burden on society.It is thus important to control the risk factors of diabetes and CVD.Tis study investigated the risk factors for CVD in Zhuang T2DM patients.Te associations between the status of blood pressure, blood glucose and lipid standards, and cardiovascular risk factors were evaluated in Zhuang T2DM patients in Guangxi to provide a theoretical basis and guidance for the metabolic control and prevention of CVD in this region.

Subjects.
A retrospective analysis was performed on a total of 1975 Zhuang patients with T2DM from four Class III Grade A hospitals in three prefecture-level cities in the Guangxi Zhuang Autonomous Region in 2022.Te inclusion criteria were as follows: (1) the patients were of Zhuang ethnicity, shown by the direct third generation belonging to Zhuang ethnicity; (2) the patients were aged between 22 and 87 years; (3) the patients had been diagnosed with T2DM for ≥3 months before data collection; and (4) the patients had lived in Guangxi for over fve years.Te exclusion criteria were as follows: (1) pregnant and nursing women and (2) patients with mental illness and communication difculties.All patients voluntarily participated in the investigation and signed written informed consent.

Methods.
General information and biochemical indicators such as glycated hemoglobin or hemoglobin A1c (HbA1c), blood pressure, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and total cholesterol (TC), as well as drinking history, family history, smoking history, and disease history, were collected from the electronic medical records.A telephone interview was conducted if there were missing values or incorrect data.Two nursing professionals were chosen from each hospital to collect data.Two individuals were responsible for data entry, and 10% of patients' data were randomly selected for verifcation.

Defnitions and Diagnostic
Criteria.T2DM was diagnosed according to the 2022 diagnostic criteria of the American Diabetes Association (ADA) [6].Te 10-year risk of ischemic CVD (ICVD) was calculated using a 10-year risk assessment table recommended by the Chinese Guidelines for the Prevention of Cardiovascular Diseases, which included information on age, systolic blood pressure (SBP), TC, body mass index (BMI), diabetes, and smoking history, leading to a determination of the absolute risk level of ICVD within 20 years, with an absolute risk score <5% representing low risk, ≥5% and <10% indicating medium risk, and ≥10% high risk [7].Smokers were defned as those who smoked at least one cigarette per day, and those who had not smoked within the last year were counted as nonsmokers.Alcohol consumption was defned as drinking more than 30 g of alcohol per day and drinking for more than one year.
Cycling, jogging, playing sports, skiing, swimming, and other activities with a metabolic equivalent (MET) expenditure of >3.0 were considered moderate-intensity exercise.Te following criteria were used to diagnose CVD [8]: congestive heart failure; stroke; and coronary artery disease (CAD), including typical angina pectoris and myocardial infarction.Blood lipids, blood pressure, and blood sugar compliance standards were in accordance with the ADA's 2021 diagnostic criteria [9].Te blood glucose criteria included HbA1c < 7%, the blood pressure criteria were BP < 140/90 mmHg, and the blood lipid criteria were LDL-C < 2.6 mmol/L in the absence of a clear diagnosis of CVD, while blood glucose of HbA1c < 7%, blood pressure of BP < 130/80 mmHg, and blood lipid levels of LDL-C < 1.8 mmol/L were used when CVD was diagnosed.Abnormal blood glucose was defned as HbA1c < 7% and in those taking hypoglycemic drugs as HbA1c ≥ 7%.Te definitions of abnormal blood pressure were as follows: with a clear diagnosis of CVD, BP ≥ 130/80 mmHg or BP < 130/ 80 mmHg with the use of antihypertensive drugs; in the absence of a clear CVD diagnosis, BP ≥ 140/90 mmHg or BP < 140/90 mmHg when taking antihypertensive drugs.Te defnitions of dyslipidemia are as follows: with a clear diagnosis of CVD, LDL-C ≥ 1.8 mmol/L or LDL-C < 1.8 mmol/L when using lipid-lowering drugs; in the absence of a clear CVD diagnosis, LDL-C ≥ 2.6 mmol/L or LDL-C < 2.6 mmol/L when using lipid-lowering drugs.

Statistical
Methods.SPSS 27.0 was used for data sorting and analysis.Enumeration data were expressed as a constituent ratio (%), and comparisons between and within groups were performed by χ 2 tests; measurement data were expressed as mean ± standard deviation and compared by independent sample t-tests.A binary logistic regression model using CVD as the dependent variable and the non-CVD patient group serving as the control group was used to evaluate the factors infuencing CVD.Sex, age, smoke ICVD 10-year absolute risk, family history of diabetes, moderateintensity exercise, blood pressure compliance, and blood lipid compliance were taken as independent variables.Te forward selection method was used to select independent variables.Te probability of including a variable in the model was α ≤ 0.05, and that for excluding was α > 0.1.P < 0.05 was considered statistically signifcant.

General Information about the Subjects. A total of 2013
Zhuang patients with T2DM were initially included in the study.Of these, 38 patients with incomplete data were excluded, resulting in the inclusion of 1975 patients in the fnal analysis.Te average age was 58.89 ± 11.24 years, the average duration of diabetes was 6.01 ± 4.93 years, and the average age at diagnosis of diabetes was 53.99 ± 11.38 years.Tere were 1328 males (67.24) in total.Te CVD group contained 161 cases (8.15%), and the non-CVD group included 1814 cases (91.85%).Among the patients with CVD events, 131 patients (81.37%) had had a stroke, 15 patients (9.32%) had 2 International Journal of Endocrinology experienced an acute myocardial infarction, and 15 patients (9.32%) had coronary heart disease.Tere were signifcant diferences in age, sex, SBP, the 10-year absolute risk of ICVD, family history of diabetes, moderate-intensity exercise, smoking, blood pressure, and blood lipids between the two groups (P < 0.05).Among the 1975 patients, 1136 (57.52%) had moderate or above 10-year absolute risk of ICVD, of which 125 patients (77.64%) were in the CVD group and 1011 (55.74%) were in the non-CVD group, Te compliance rates of blood pressure (21.74% vs. 47.91%) and LDL-C (9.94% vs. 32.41%) in the CVD group were lower than those in the non-CVD group, Among the 1975 patients, the compliance rates of blood glucose, blood pressure, and blood lipid were 26.08%, 45.77%, and 30.58%, respectively.Only 100 patients (5.06%) complied with all three items of blood pressure, blood glucose, and lipids, as shown in Table 1.

Discussion
In daily life, diabetes and cardiovascular diseases not only signifcantly afect patients' quality of life but also bring a severe burden to society and families.Poor metabolic control increases the risk of diabetic complications, while reasonable metabolic control helps stabilize the patient's condition.Te results of this study showed that the blood glucose, blood pressure, and blood lipids compliance rates of Zhuang patients were 26.08%, 45.77%, and 30.58%, respectively.Te compliance rates of blood lipids and blood glucose from our study are higher than those in Tibetan T2DM patients in Yan Mao's survey, which reported the compliance rates of blood lipids and blood glucose at 8.0% and 11.0%, respectively [10].Te reason may be the short Course of diabetes mellitus used (6 years vs 10 years) and the inclusion of moderate-intensity exercise.It may also be due to the higher educational level of the patients.Te blood glucose compliance rate was lower than that of Chinese outpatients with T2DM (32.6%) [11], and the blood pressure and blood lipid compliance rates were much lower than the results of community T2DM patients (compliance rates of blood pressure and blood lipids were of 31.4% and 39.4%, respectively) in Nanjing in Liu Jie's survey [12].Poor dietary adherence, a lack of self-management, the state of the economy, and failure to take medication may all be factors infuencing compliance rates.Only 5.06% of Guangxi Zhuang T2DM patients met the standards for blood pressure, blood lipids, and glucose simultaneously, suggesting that the level of comprehensive management needs to be raised.Tese results are lower than those reported in Liu Lin's survey on Chinese patients with T2DM in 2010 (5.4%) [13].Possible explanations include the location of the selected research site in Guangxi, western China, where the economic level is relatively low and knowledge of diabetes prevention and treatment is relatively poor.Terefore, patients will typically present at hospitals only when the disease has progressed considerably.Despite signifcant improvements over the past decade, the overall control rate of blood glucose, blood pressure, and blood lipids in patients with diabetes in the Zhuang population remains unsatisfactory.Hence, there is substantial room for further improvement in diabetic metabolic control to reduce the morbidity and mortality of diabetes-related CVDs.
Te results of this study showed that the compliance rates of blood glucose, blood pressure, and blood lipids in the CVD group were 32.92%, 21.74%, and 9.94%, respectively.Te usage rates of hypoglycemic, antihypertensive, and lipid-lowering drugs were 77.54%, 3.17%%, and 4.11%%, respectively.Studies have indicated that normal high blood pressure can increase the risk of coronary atherosclerotic heart disease, myocardial infarction, stroke and other diseases [14].Diabetes mellitus patients can control blood glucose-related indicators within the normal range to prevent or delay the occurrence and development of complications through efective management and nursing intervention, such as medication, dietary management, blood glucose monitoring, physical activity, and treatment of complications.Tis study shows that the current blood glucose control and the clinical medication situation in Zhuang T2DM patients are unsatisfactory.Terefore, it is suggested that strengthening diabetes education and management are important strategies for treating T2DM patients in the Guangxi Zhuang population.
Tis study confrmed earlier fndings by demonstrating that the risk of CVD increased with age in Zhuang T2DM patients [15].Te analysis of epidemiological data shows that the proportion of CVD patients among women, especially elderly women, has increased, but the standardized International Journal of Endocrinology International Journal of Endocrinology diagnosis and treatment and the improvement of prognosis are poor.Among diabetic patients, compared with men, the risk of coronary heart disease in women is 58% higher and the risk of death is also increased by 13% [16].Studies have reported that lack of physical activity, smoking, and excessive drinking are the main risk factors for the sharp rise in cardiovascular and metabolic diseases [17].Increasing physical activity signifcantly protects against the main risk factors for CVD and is also conducive to weight control [18].A Chinese cohort study showed that maintaining moderate physical activity ≥150 minutes per week or high-intensity physical activity ≥75 minutes per week in adults can reduce the incidence of CVD [19].A recent study in the UK showed that the risk of cardiovascular death was reduced by 29% when the physical activity level was gradually increased to a combination of moderate and high-intensity physical activity ≥150 minutes per week over fve years [20].Poor blood pressure control is a risk factor for CVD, consistent with previous fndings [21], and continuous blood pressure compliance can reduce the risk of CVDs.Damage to the vascular endothelium produced by continuous highpressure blood fow can be reduced, and atherosclerotic plaque formation can also be reduced when the blood pressure of hypertensive individuals is managed below 140/ 90 mmHg [22], thereby reducing the incidence of ischemic stroke [23] and acute myocardial infarction [24].Tis shows that the treatment of hypertension should not only emphasize the initial targets but should also address continuous long-term blood pressure targets.Dyslipidemia is a signifcant risk factor for CVD.Several studies and guidelines have pointed out that LDL-C is a key pathogenic factor for atherosclerotic CVD, and dyslipidemia has been estimated to lead to an increase of 9.2 million cardiovascular events.In contrast, reducing blood lipid levels can signifcantly reduce the morbidity and mortality associated with CVD [25].
Te present study showed that 58.94% of the patients had a moderate or high 10-year absolute risk of ICVD and 90.23% of the patients were treated with hypoglycemic drugs.Hypoglycemic drug therapy appears to be underused in terms of its potential benefts in reducing cardiovascular risk [26].Diabetic patients are often complicated with hypertension, dyslipidemia, obesity, and other cardiovascular risk factors.Only improving blood sugar control cannot efectively delay the progress of diabetic macrovascular complications.Studies have shown that active intervention in CVD risk factors such as hypertension and dyslipidemia can reduce the risk of cardiovascular events in patients with T2DM.ACCORD researchers published the results of post-event epidemiological analysis of the research data [27], which showed that the increase of HbAlc was closely related to the increase of death risk.Every 1% increase of HbA1c on average would increase the all-cause International Journal of Endocrinology mortality by 20%.Te analysis results show that the mortality of people with HbA1c<7% is reduced among patients receiving intensive hypoglycemic therapy.After further analysis of the results of the ACCORD trial, the researchers mentioned that the increase in mortality only occurred in people whose blood sugar control was still unsatisfactory after intensive treatment, and most of these people were relatively old, with a long course of diabetes and high-risk groups with cardiovascular and cerebrovascular complications.
While ICVD is considered a signifcant predictor of 10year cardiovascular risk in the overall Chinese population, it was not necessarily appropriate for the present study on the Zhuang population as this study is a cross-sectional survey rather than a 10-year study.Despite being a cross-sectional study, we found that the risk score was not related to the occurrence of CVD.Tis may suggest that the ICVD10-year absolute risk score does not apply to the Zhuang population.Terefore, further investigation is required into a suitable assessment scale for predicting cardiovascular risk in the Zhuang population.
Tere are limitations to this study.As the study subjects were not randomly sampled, there may be some selection bias.Diabetic retinopathy (DR), an important diabetic microangiopathy, was not included.Follow-up studies should be supplemented with DR screening.Furthermore, this study was cross-sectional.Future studies should address the integrated management of diabetes in hospitals and communities, and the metabolic management status of patients belonging to ethnic minorities in community hospitals should be addressed.Tese measures can promote patient self-management, increase comprehensive standards, and lessen the occurrence and progression of cardiovascular diseases while strengthening diabetes education for all patients.
In conclusion, the compliance levels of blood glucose, blood lipids, and blood pressure in the Zhuang population are abysmal, as is medication compliance.Hence, achieving comprehensive control of blood glucose, blood pressure, and blood lipids in Zhuang T2DM patients should be a direction for future research.Te results of this study may serve as a warning to improve the clinical management of diabetic patients in the public health system in ethnic minority areas and thus also lower the economic burden of chronic diseases in China, given the observed increasing prevalence of T2DM.

Table 3 .
Blood Pressure, Blood Lipids, and Blood Glucose.Te compliance rates of blood glucose, blood pressure, and blood lipids in the CVD group were 14.29%, 21.74%, and 9.32%, respectively.Te rates of usage of hypoglycemic, antihypertensive, and lipid-lowering drugs were 77.54%, 3.17%, and 4.11%, respectively.Te usage rates of hypoglycemic drugs (77.54% vs. 79.47%) in blood glucose noncompliant cases, antihypertensive drugs (3.17% vs. 4.74%) in blood pressure non-compliant cases, and lipidlowering drugs (4.11% vs. 4.74%) in blood lipids noncompliant cases in the CVD group were lower than those in the non-CVD group, and the usage of angiotensinconverting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) was also lower than that in the non-CVD group (0.08% vs. 0.32%).As shown in Table2, less than 10% of the patients took lipid-lowering medications, and statins were the medication of choice for all 65 patients who did take lipid-lowering medications.3.3.Binary Logistic Regression Analysis of CVD Risk Factors.According to the results, age (OR � 1.033, 95% CI[1.

Table 2 :
Analysis of current drug treatment of patients with abnormal metabolic indicators (blood glucose, blood pressure, and blood lipid).

Table 3 :
Binary logistic regression analysis of CVD infuencing factors.