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

Xu, Danqing; Dai, Xia; Yang, Qiong; Li, Xueying; Xiao, Ying; Huang, Qiuhong; Qingqing Lou, undefined

doi:https://doi.org/10.1155/2023/1057121

International Journal of Endocrinology

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Abstract Introduction Methods Results Discussion Data Availability Additional Points Ethical Approval Consent Disclosure Conflicts of Interest Acknowledgments References Copyright Related Articles

Research Article | Open Access

Volume 2023 | Article ID 1057121 | https://doi.org/10.1155/2023/1057121

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

Danqing Xu,¹Xia Dai,¹Qiong Yang,¹Xueying Li,¹Ying Xiao,¹Qiuhong Huang,²and Qingqing Lou³

Academic Editor: Aman Rajpal

Received02 Nov 2022

Revised25 Apr 2023

Accepted25 Nov 2023

Published22 Dec 2023

Abstract

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.

1. Introduction

China is ranked first 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 significant 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 differs from the predominant Han population in terms of diabetes-related genotypes [2], demographic characteristics, economic level, dietary habits, and educational level. Most Zhuang people live in mountainous areas where transportation is difficult. Their 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 fiber 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 significantly reduce the incidence of CVD. Diabetes, complicated by cardiovascular and cerebrovascular diseases, has amplified the medical burden on society. It is thus important to control the risk factors of diabetes and CVD. This study investigated the risk factors for CVD in Zhuang T2DM patients. The 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.

2. Subjects and Methods

2.1. 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. The 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 five years. The exclusion criteria were as follows: (1) pregnant and nursing women and (2) patients with mental illness and communication difficulties. All patients voluntarily participated in the investigation and signed written informed consent.

2.2. 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 verification.

2.3. Definitions and Diagnostic Criteria

T2DM was diagnosed according to the 2022 diagnostic criteria of the American Diabetes Association (ADA) [6]. The 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 defined 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 defined 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. The 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]. The 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 defined as HbA1c < 7% and in those taking hypoglycemic drugs as HbA1c ≥ 7%. The 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. The definitions 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.

2.4. 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 χ² 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 influencing CVD. Sex, age, smoke ICVD 10-year absolute risk, family history of diabetes, moderate-intensity exercise, blood pressure compliance, and blood lipid compliance were taken as independent variables. The forward selection method was used to select independent variables. The 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 significant.

3. Results

3.1. 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 final analysis. The 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. There were 1328 males (67.24) in total. The 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 experienced an acute myocardial infarction, and 15 patients (9.32%) had coronary heart disease. There were significant differences 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 . 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, The 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.

3.2. Status of Abnormal Blood Pressure, Blood Lipids, and Blood Glucose

The compliance rates of blood glucose, blood pressure, and blood lipids in the CVD group were 14.29%, 21.74%, and 9.32%, respectively. The rates of usage of hypoglycemic, antihypertensive, and lipid-lowering drugs were 77.54%, 3.17%, and 4.11%, respectively. The 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 lipid-lowering 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 angiotensin-converting 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 Table 2, 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 [1.016, 1.050]), gender (OR = 0.402, 95% CI [0.260, 0.621]), moderate-intensity exercise (OR = 0.439, 95% CI [0.300, 0.640]), smoke (OR = 1.994, 95% CI [1.361, 2.922]), use of antihypertensive drugs + blood pressure noncompliance (OR = 0.348, 95% CI [0.230, 0.527]), and use of lipid-lowering drugs + blood lipids non-compliance (OR = 0.244, 95% CI [0.142, 0.417]) were associated with CVD, as shown in Table 3.

4. Discussion

In daily life, diabetes and cardiovascular diseases not only significantly affect 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. The 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. The 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]. The 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. The 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 influencing 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. These 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. Therefore, patients will typically present at hospitals only when the disease has progressed considerably. Despite significant 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.

The 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. The 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 effective management and nursing intervention, such as medication, dietary management, blood glucose monitoring, physical activity, and treatment of complications. This study shows that the current blood glucose control and the clinical medication situation in Zhuang T2DM patients are unsatisfactory. Therefore, it is suggested that strengthening diabetes education and management are important strategies for treating T2DM patients in the Guangxi Zhuang population.

This study confirmed earlier findings by demonstrating that the risk of CVD increased with age in Zhuang T2DM patients [15]. The analysis of epidemiological data shows that the proportion of CVD patients among women, especially elderly women, has increased, but the standardized 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 significantly 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 five years [20]. Poor blood pressure control is a risk factor for CVD, consistent with previous findings [21], and continuous blood pressure compliance can reduce the risk of CVDs. Damage to the vascular endothelium produced by continuous high-pressure blood flow 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]. This 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 significant 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 significantly reduce the morbidity and mortality associated with CVD [25].

The 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 benefits 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 effectively 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 mortality by 20%. The 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 significant predictor of 10-year 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. This may suggest that the ICVD10-year absolute risk score does not apply to the Zhuang population. Therefore, further investigation is required into a suitable assessment scale for predicting cardiovascular risk in the Zhuang population.

There 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. These 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. The 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.

Data Availability

Data used to support this study are available on request.

Additional Points

Summary. There are differences in dietary habits and diabetes-related gene phenotypes between Han and Zhuang nationalities in China. Zhuang people live in mountainous areas and like to grow tobacco and drink alcohol, and their blood sugar, blood pressure, and blood lipid are low, and their medication compliance is low.

Ethical Approval

The study was carried out in accordance with the Helsinki Declaration and was approved by the medical ethics committees of four hospitals.

Written informed consent was obtained from each patient.

Disclosure

Danqing Xu and Xia Dai are first coauthors.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Acknowledgments

The authors acknowledge Climbing Plan for Nursing Clinical Research of the First Affiliated Hospital of Guangxi Medical University (YYZS2020028).

References

International Diabetes Federation, “IDF diabetes atlas,” 2021, https://diabetesatlas.org/atlas/tenth-edition/.
View at: Google Scholar
J. Chen, C. Wu, Y. Lan, H. Luo, and W. Yesheng, “Distribution of polymorphism of CD40L gene at rs3092921G/A and rs3092933G/A in Guangxi Zhuang and Han populations,” Modern Preventive Medicine, vol. 42, no. 19, pp. 3551–3554, 2015.
View at: Google Scholar
D. Belardo, E. D. Michos, R. Blankstein et al., “Practical, evidence-based approaches to nutritional modifications to reduce atherosclerotic cardiovascular disease: an American society for preventive cardiology clinical practice statement,” American Journal of Preventive Cardiology, vol. 10, Article ID 100323, 2022.
View at: Publisher Site | Google Scholar
J. Liu, “Summary of China cardiovascular health and disease report 2020,” China Journal of Circulation, vol. 36, no. 6, pp. 521–545, 2021.
View at: Google Scholar
Q. Zhang, H. Mountain, X. Zhong, V. Huang, M. Cui, and D. Xia, “Analysis on the prevalence and aggregation of cardiovascular risk factors among Zhuang adults in Nanning, Guangxi,” Modern Preventive Medicine, vol. 47, no. 07, pp. 1167–1170, 2020.
View at: Google Scholar
American Diabetes Association Professional Practice Committee, “2. Classification and diagnosis of diabetes: standards of medical care in diabetes-2022,” Diabetes Care, vol. 45, no. 1, pp. S17–S38, 2022.
View at: Publisher Site | Google Scholar
Cardiovascular Branch of Chinese Medical Association, “Editorial committee of Chinese journal of cardiology. China guidelines for cardiovascular disease prevention,” Chinese Journal of Cardiology, vol. 39, no. 1, pp. 3–22, 2011.
View at: Google Scholar
Y. Wu, D. Liang, J. Li, Y. Zhou, and Z. Liu, “Prevalence and risk factors of cardiovascular disease in patients with IgA nephropathy and diabetic nephropathy,” Journal of Kidney Disease and Dialysis Kidney Transplantation, vol. 21, no. 3, pp. 210–216, 2012.
View at: Google Scholar
American Diabetes Association, “2. Classification and diagnosis of diabetes: standards of medical care in diabetes-2021,” Diabetes Care, vol. 44, no. 1, pp. S15–S33, 2021.
View at: Publisher Site | Google Scholar
Y. Mao, L. Yuan, X. Xu, and Z. Xiong, “Investigation on blood sugar control and self-management ability of Tibetan patients with type 2 diabetes in a hospital in Ganzi Prefecture,” Nursing Research, vol. 31, no. 27, pp. 3426–3429, 2017.
View at: Google Scholar
D. Zou, L. Ji, L. Chen et al., “Glycemic control rate of T2DM outpatients in China: a multi-center survey,” Medical Science Monitor, vol. 21, pp. 1440–1446, 2015.
View at: Publisher Site | Google Scholar
J. Liu, T. Gu, P. Li, R. Meng, B. Yan, and D. Zhu, “Current metabolic control status and microvascular complications and their influencing factors among type 2 diabetes mellitus in Nanjing communities,” Chinese Journal of Diabetes, vol. 28, no. 1, pp. 23–28, 2020.
View at: Google Scholar
L. Liu, Q. Lou, X. Guo et al., “Management status and its predictive factors in patients with type 2 diabetes in China: a nationwide multicenter study: a nationwide multicenter study,” Diabetes, vol. 31, no. 8, pp. 811–816, 2015.
View at: Publisher Site | Google Scholar
Y. G. Kim, S. Y. Roh, K. D. Han et al., “Hypertension and diabetes including their earlier stage are associated with increased risk of sudden cardiac arrest,” Scientific Reports, vol. 12, no. 1, Article ID 12307, 2022.
View at: Publisher Site | Google Scholar
Y. Cha, Y. Deng, M. Zuo et al., “Main risk factors and clustering of cardiovascular diseases in Sichuan Province based on a multilevel model,” Chinese Journal of Disease Control and Prevention, vol. 26, no. 3, pp. 331–336, 2022.
View at: Publisher Site | Google Scholar
Y. Wang, A. O'Neil, Y. Jiao et al., “Sex differences in the association between diabetes and risk of cardiovascular disease, cancer, and all-cause and cause-specific mortality: a systematic review and meta-analysis of 5,162,654 participants,” Bone Marrow Concentrate Medicine, vol. 17, no. 1, p. 136, 2019.
View at: Publisher Site | Google Scholar
National Center for Cardiovascular Diseases, Annual Report on Cardiovascular Health and Diseases in China, Peking Union Medical College Press, Beijing, China, 2023.
J. M. Jakicic, K. E. Powell, W. W. Campbell et al., “Physical activity and the prevention of weight gain in adults: a systematic review,” Medicine & Science in Sports and Exercise, vol. 51, no. 6, pp. 1262–1269, 2018.
View at: Publisher Site | Google Scholar
Q. Liu, F. C. Liu, K. Y. Huang et al., “Beneficial effects of moderate to vigorous physical activity on cardiovascular disease among Chinese adults,” Journal of Geriatric Cardiology, vol. 17, no. 2, pp. 85–95, 2020.
View at: Publisher Site | Google Scholar
A. Mok, K. T. Khaw, R. Luben, N. Wareham, and S. Brage, “Physical activity trajectories and mortality: population based cohort study,” British Medical Association, vol. 365, p. l2323, 2019.
View at: Publisher Site | Google Scholar
Y. Ma, X. Li, L. I. U. Qian et al., “Times of attaining the target blood pressure level and cardio-cerebrovascular disease incidence in hypertensive patients,” Chinese General Practice, vol. 23, no. 28, pp. 3608–3614, 2020.
View at: Google Scholar
G. Mancia, R. Kreutz, M. Brunström et al., “ESH guidelines for the management of arterial hypertension the task force for the management of arterial hypertension of the European society of hypertension: endorsed by the international society of hypertension (ISH) and the European renal association (ERA),” Journal of Hypertension, vol. 41, no. 12, pp. 1874–2071, 2023.
View at: Publisher Site | Google Scholar
K. Rahimi, Z. Bidel, M. Nazarzadeh et al., “Pharmacological blood pressure lowering for primary and secondary prevention of cardiovascular disease across different levels of blood pressure: an individual participant-level data meta-analysis,” The Lancet, vol. 397, no. 10285, pp. 1625–1636, 2021.
View at: Publisher Site | Google Scholar
W. Zhang, S. Zhang, Y. Deng et al., “Trial of intensive blood-pressure control in older patients with hypertension,” New England Journal of Medicine, vol. 385, no. 14, pp. 1268–1279, 2021.
View at: Publisher Site | Google Scholar
H. H. Wang, D. K. Lee, M. Liu, P. Portincasa, and D. Q. Wang, “Novel insights into the pathogenesis and management of the metabolic syndrome,” Pediatr Gastroenterol Hepatol Nutr, vol. 23, no. 3, pp. 189–230, 2020.
View at: Publisher Site | Google Scholar
B. Pintaudi, A. Scatena, G. Piscitelli et al., “Clinical profiles and quality of care of subjects with type 2 diabetes according to their cardiovascular risk: an observational, retrospective study,” Cardiovascular Diabetology, vol. 20, no. 1, p. 59, 2021.
View at: Publisher Site | Google Scholar
S. Wang and B. Su, “Is it safer to control glycosylated hemoglobin below 7%,” Medicine and Philosophy: Clinical Decision Forum Edition, vol. 32, no. 5, pp. 10–13, 2011.
View at: Google Scholar

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Copyright © 2023 Danqing Xu et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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