Glucose, Lipid, and Blood PressureControl in Australian Adults With Type 2DiabetesThe 19992000 AusDiab

THOMAS M. KEMP, FRCP1

ELIZABETH L.M. BARR, MPH2

PAUL Z. ZIMMET, AO, MD, PHD2

ADRIAN J. CAMERON, MPH2

TIMOTHY A. WELBORN, AO, PHD3

STEPHEN COLAGIURI, MD4

PATRICK PHILLIPS, MD5

JONATHAN E. SHAW, MD2

ON BEHALF OF THE AUSDIAB STEERINGCOMMITTEE

T he risk of diabetes complicationscan be reduced by tight control ofblood glucose (1), serum lipids (2),and blood pressure (3,4). However, evi-dence from a limited number of studies(59) indicates that many people withtype 2 diabetes do not achieve recom-mended targets for these factors. We ex-amined levels of glucose, lipid, and bloodpressure control in participants with type2 diabetes taking part in the national pop-ulation-based Australian Diabetes, Obe-sity, and Lifestyle Study (AusDiab) (10)conducted during 19992000.

RESEARCH DESIGN ANDMETHODS AusDiab was a nationalpopulation-based survey of the generalpopulation and has been described in de-tail earlier (10). Diagnosis of diabetes wasbased on self-reported physician diagno-sis of diabetes confirmed either by self-reported use of hypoglycemic drugs orresults from a 75-g oral glucose tolerance

test (11). Participants who started insulintreatment within 2 years of diagnosis wereclassified as having type 1 diabetes (if di-abetes onset was at age 40 years; BMIalso had to be27 kg/m2). All other caseswere classified as type 2 diabetes.

Fasting (9 h) serum total choles-terol, LDL and HDL cholesterol, and trig-lycerides were measured (OlympusAU600 analyzer; Olympus Optical, To-kyo, Japan). Total glycated hemoglobinanalysis used high-performance liquidchromatography (Bio-Rad Variant Hemo-globin Testing System; Bio-Rad, Her-cules, CA) with standardized conversionto HbA1c values (normal range 4.26.3%). Blood pressure measurementswere performed in a seated position afterrest for 5 min (12). Interviewer-administered questionnaires ascertainedmedication use.

Data were weighted to match the ageand sex distribution of the 1998 residen-tial population of Australia aged 25

years. The percentages of participants fail-ing to achieve the accepted national clin-ical targets recommended for diabetesmanagement in place at the time of thesurvey (HbA1c levels 7.0%, LDL 3.5mmol/l, HDL 1.0 mmol/l, triglycerides2.0 mmol/l, total cholesterol 5.5mmol/l [13,14], blood pressure140/90mmHg [15,16], and more recent Ameri-can Diabetes Association [ADA] targets[1719]) were determined. The study wasapproved by the local ethics committee.Participants gave written consent.

RESULTS Of 11,247 participants,439 had previously diagnosed type 2 di-abetes. The means SD and median(25th75th percentile) HbA1c levels were7.3 1.8% and 6.8% (6.18.0), respec-tively. The percentage of individuals notmeeting glucose, total cholesterol, andblood pressure targets differed signifi-cantly by treatment category (Table 1).The combination of the good controltargets was achieved by 13% (n 60) ofparticipants. ADA targets for LDL (2.6mmol/l) and blood pressure (130/80mmHg) were not met by 80 and 81% ofparticipants, respectively. All three ADAtargets were achieved by 2% (n 11).

CONCLUSIONS Only half thepopulation met the individual glycemic,lipid, and blood pressure targets recom-mended at the time of the survey, andapproximately one in seven met all threetargets. Achievement of more stringentlevels recommended by the ADA for lip-ids and blood pressure was considerablyworse, and there was evidence, especiallyfor lipids and blood pressure, of underuseof drug therapy. By comparison, U.S. datashow that 44% in NHANES III (NationalHealth and Nutrition Examination SurveyIII) and 37% in NHANES 19992000had HbA1c 7.0% (noting that the nor-mal range for the HbA1c assays used inAusDiab was very similar to the normalrange reported in the U.S. surveys) (6).

From the 1Department of Medicine, Dewsbury & District Hospital, Dewsbury, West Yorkshire, U.K.; the2International Diabetes Institute, Caulfield, Victoria, Australia; the 3Department of Medicine, University ofWestern Australia, Nedlands, Western Australia, Australia; the 4Department of Endocrinology, Diabetes andMetabolism, The Prince of Wales Hospital, Randwick, New South Wales, Australia; and the 5EndocrinologyUnit, North Western Adelaide Health Service, Queen Elizabeth Hospital, Woodville, South Australia, Aus-tralia.

Address correspondence and reprint requests to Elizabeth L.M. Barr, International Diabetes Institute, 250Kooyong Rd., Caulfield, Victoria 3162, Australia. E-mail: lbarr@idi.org.au.

Received for publication 14 January 2005 and accepted 17 January 2005.T.M.K. and E.L.M.B. contributed equally to this report.T.A.W. has been on an advisory panel of and has received honoraria/consulting fees and grant research

support from Abbott International, Bayer, Aventis (Sanofi Synthelabo), Eli Lilly, Pfizer, Roche, and ServierLaboratories.

Abbreviations:ADA, American Diabetes Association; AusDiab, Australian Diabetes, Obesity, and LifstyleStudy.

A table elsewhere in this issue shows conventional and Syste`me International (SI) units and conversionfactors for many substances.

2005 by the American Diabetes Association.The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby

marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.

E p i d e m i o l o g y / H e a l t h S e r v i c e s / P s y c h o s o c i a l R e s e a r c hB R I E F R E P O R T

1490 DIABETES CARE, VOLUME 28, NUMBER 6, JUNE 2005

Beaton et al. (8) identified 7,114 adultswith diabetes through a U.S. managedcare organization and found that few at-tained ADA goals for HbA1c, LDL choles-terol, and systolic blood pressure. ADanish study (7) reported that 60% ofpeople with type 2 diabetes had HbA1cvalues 6.3%.

The progressive nature of diabetes (1)usually requires escalating therapy. Poorglycemic control in the AusDiab type 2diabetic population was twice as preva-lent among those on oral hypoglycemicagents (without insulin) as in those usingdietary regimes alone. This suggests thatin the face of poor glycemic control, thereis greater delay in adding insulin to oralhypoglycemic agents than in adding oralhypoglycemic agents to dietary regime.However, achieving tight glycemic con-trol can be difficult, and even in clinicaltrials such as the UKPDS (U.K. Prospec-tive Diabetes Study), a large proportion ofparticipants receiving intensive therapyremained above target (1). Moreover, thegoal of an HbA1c 7.0% may be imprac-tical in long-duration type 2 diabetes, asattempts to achieve it are often compli-cated by hypoglycemia (1).

Aggressive management of choles-terol (2) and blood pressure (4) are effec-tive in preventing macrovascular diseasein type 2 diabetes. The observations re-ported here, however, suggest that oppor-tunities for cardiovascular disease risk

reduction are being missed, as a signifi-cant proportion of individuals (includingthose on medication) were not meetingtargets for both cholesterol and bloodpressure.

In conclusion, this population-basedstudy found that in 400 people withtype 2 diabetes, there was evidence of un-der-use of medication leading to subopti-mal achievement of glucose, lipid, andblood pressure national therapeutic tar-gets, with only one in seven peopleachieving all three targets. In addition tobehavioral modifications such as diet andexercise, increased use of insulin, multi-ple antihypertensive therapy, and lipid-lowering drugs are likely to be required.

Acknowledgments We are most grateful tothe following for their support of the study:Associate Prof. Damien Jolley, School ofHealth and Social Development, Deakin Uni-versity, Victoria, Australia, for his statisticaladvice; The Commonwealth Department ofHealth and Aged Care; Abbott Australasia; Al-phapharm; Aventis Pharmaceuticals; Astra-Zeneca; Bristol-Myers Squibb; Eli Lilly (Aust);GlaxoSmithKline; Janssen-Cilag (Aust); MerckLipha; Merck Sharp & Dohme (Aust); Novar-tis Pharmaceuticals (Aust); Novo Nordisk;Pharmacia and Upjohn; Pfizer; Roche Diag-nostics; Sanofi Synthelabo (Aust); Servier Lab-oratories (Aust); Bio-Rad Laboratories;HITECH Pathology; the Australian KidneyFoundation; Diabetes Australia; Diabetes Aus-

tralia (Northern Territory); QueenslandHealth; South Australian Department of Hu-man Services; Tasmanian Department ofHealth and Human Services; Territory HealthServices; Victorian Department of Human Ser-vices; and the Health Department of WesternAustralia.

Also, for their contribution to the field ac-tivities of AusDiab, we are grateful to AnnieAllman, Marita Dalton, David Dunstan, AdamMeehan, Claire Reid, Alison Stewart, RobynTapp, and Fay Wilson.

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Table 1Proportions not meeting HbA1c, total cholesterol, and blood pressure targets ac-cording to treatment category

Percentage in eachtreatment category

Percentage notachieving target* P value

HbA1cDiet regime only 32.4 (130) 21.5 (27) 0.0001Oral hypoglycemic agents 58.0 (259) 49.5 (126)Insulin 9.6 (49) 76.1 (33)Total 100 (438) 43.0 (186)

Total cholesterolLipid-lowering treatment 35.9 (154) 29.0 (47) 0.0001No lipid-lowering treatment 64.1 (279) 57.1 (157)Total 100 (433) 47.2 (204)

Blood pressureBlood pressure treatment 42.5 (211) 67.8 (136) 0.0001No blood pressuretreatment

57.5 (224) 45.3 (98)

Total 100 (435) 54.7 (234)

Data are weighted % (actual n). *The % (n) of people above target for HbA1c (7%), total cholesterol (5.5mmol/l), and blood pressure (140/90 mmHg) according to treatment category. P value for difference inproportions not achieving target between treatment groups. Included people taking either insulin alone(n 35) or insulin and oral hypoglycemic agents (n 14).

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