Comparisons of clinical outcomes between newly diagnosed early- and late-onset T2DM: a real-world study from the Shanghai Hospital Link Database

in Endocrine Connections
Authors:
Xinge Tao Department of Endocrinology and Diabetes, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China

Search for other papers by Xinge Tao in
Current site
Google Scholar
PubMed
Close
https://orcid.org/0009-0006-8548-6733
,
Yanbin Xue Computer Net Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China

Search for other papers by Yanbin Xue in
Current site
Google Scholar
PubMed
Close
,
Rui Niu Department of Endocrinology and Diabetes, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China

Search for other papers by Rui Niu in
Current site
Google Scholar
PubMed
Close
,
Wenjing Lu Department of Endocrinology and Diabetes, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China

Search for other papers by Wenjing Lu in
Current site
Google Scholar
PubMed
Close
,
Huayan Yao Computer Net Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China

Search for other papers by Huayan Yao in
Current site
Google Scholar
PubMed
Close
,
Chunmei He Department of Endocrinology and Diabetes, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China

Search for other papers by Chunmei He in
Current site
Google Scholar
PubMed
Close
,
Bin Cui Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China

Search for other papers by Bin Cui in
Current site
Google Scholar
PubMed
Close
https://orcid.org/0000-0002-7293-5740
, and
Changqin Liu Department of Endocrinology and Diabetes, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
Xiamen Key Laboratory for Clinical Efficacy and Evidence-Based Research of Traditional Chinese Medicine, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
Fujian Province Key Laboratory of Diabetes Translational Medicine, The First Affiliated Hospital of Xiamen University, School of medicine, Xiamen University, Xiamen, China

Search for other papers by Changqin Liu in
Current site
Google Scholar
PubMed
Close
https://orcid.org/0000-0001-8063-7906

Correspondence should be addressed to B Cui or C Liu: cb11302@rjh.com.cn or liuchangqin@xmu.edu.cn

*(X Tao, Y Xue and R Niu contributed equally to this work)

Open access

Sign up for journal news

Objective

The aim of this study was to compare the differences in incident population, comorbidities, and glucose-lowering drug prescriptions between newly diagnosed patients with early-onset type 2 diabetes mellitus (T2DM) and those with late-onset T2DM to provide real-world evidence for clinical practice.

Methods

This study was based on the Shanghai Hospital Link Database (SHLD). Anonymized electronic medical record (EHR) data from 2013 to 2021 were included in this study. Newly diagnosed patients with T2DM were defined as those without related diagnostic records or glucose-lowering medicine prescriptions in the past 3 years. Early-onset T2DM was defined as patients who were aged 18–40 years old at the first visit for T2DM to represent those who were born after the 1980s. And late-onset T2DM was defined as those aged 65–80 years old to represent those who were born in a relatively undeveloped period. Descriptive statistical analyses were performed to describe their incidence number, glucose-lowering drug prescriptions, and comorbidities at the first visit to the hospital between two T2DM groups.

Results

There were a total of 35,457 newly diagnosed patients with early-onset T2DM and 149,108 newly diagnosed patients with late-onset T2DM included in this study. Patients with late-onset T2DM constituted the majority and their number increased by 2.5% on average by years, while the number of patients with early-onset T2DM remained stable each year. Compared with late-onset T2DM patients, more early-onset T2DM patients had dyslipidemia at the first visit to hospitals (9.5% vs 7.7%, P < 0.01) despite their significant age differences. Patients with early-onset T2DM were more likely to use metformin (74.8% vs 46.5, P < 0.01), dipeptidyl peptidase-4 inhibitors (DDP-4i) (16.7% vs 11.2%, P < 0.01), thiazolidinediones (TZD) (14.9% vs 8.4%, P < 0.01), sodium glucose cotransporter 2 inhibitors (SGLT2-i) (0.8% vs 0.3%, P < 0.01), and glucagon-like peptide 1 receptor agonists (GLP-1 RA) (3.7% vs 0.5%, P < 0.01) at their first visit to the hospital.

Conclusions

Different characteristics were observed between patients with early-onset T2DM and those with late-onset T2DM. Compared with patients with late-onset T2DM, those with early-onset T2DM were more prone to dyslipidemia and had novel organ-protective drugs prescribed.

Abstract

Objective

The aim of this study was to compare the differences in incident population, comorbidities, and glucose-lowering drug prescriptions between newly diagnosed patients with early-onset type 2 diabetes mellitus (T2DM) and those with late-onset T2DM to provide real-world evidence for clinical practice.

Methods

This study was based on the Shanghai Hospital Link Database (SHLD). Anonymized electronic medical record (EHR) data from 2013 to 2021 were included in this study. Newly diagnosed patients with T2DM were defined as those without related diagnostic records or glucose-lowering medicine prescriptions in the past 3 years. Early-onset T2DM was defined as patients who were aged 18–40 years old at the first visit for T2DM to represent those who were born after the 1980s. And late-onset T2DM was defined as those aged 65–80 years old to represent those who were born in a relatively undeveloped period. Descriptive statistical analyses were performed to describe their incidence number, glucose-lowering drug prescriptions, and comorbidities at the first visit to the hospital between two T2DM groups.

Results

There were a total of 35,457 newly diagnosed patients with early-onset T2DM and 149,108 newly diagnosed patients with late-onset T2DM included in this study. Patients with late-onset T2DM constituted the majority and their number increased by 2.5% on average by years, while the number of patients with early-onset T2DM remained stable each year. Compared with late-onset T2DM patients, more early-onset T2DM patients had dyslipidemia at the first visit to hospitals (9.5% vs 7.7%, P < 0.01) despite their significant age differences. Patients with early-onset T2DM were more likely to use metformin (74.8% vs 46.5, P < 0.01), dipeptidyl peptidase-4 inhibitors (DDP-4i) (16.7% vs 11.2%, P < 0.01), thiazolidinediones (TZD) (14.9% vs 8.4%, P < 0.01), sodium glucose cotransporter 2 inhibitors (SGLT2-i) (0.8% vs 0.3%, P < 0.01), and glucagon-like peptide 1 receptor agonists (GLP-1 RA) (3.7% vs 0.5%, P < 0.01) at their first visit to the hospital.

Conclusions

Different characteristics were observed between patients with early-onset T2DM and those with late-onset T2DM. Compared with patients with late-onset T2DM, those with early-onset T2DM were more prone to dyslipidemia and had novel organ-protective drugs prescribed.

Introduction

Type 2 diabetes mellitus (T2DM) has become one of the most serious health-care challenges in the 21st century owing to its increasing incidence worldwide. Prevention and care for T2DM and its related complications has imposed a substantial health burden, especially on developing countries. According to the diabetes atlas of the International Diabetes Federation in 2022, China had the largest number of patients with T2DM and spent the second highest amount on diabetes (1). The prevalence of T2DM in China increased from 0.67% in the 1980s to almost 12.4% in 2018 (2). Unhealthy lifestyles that were associated with the fast-developing society have been suggested to be responsible for the escalating prevalence of T2DM in China, especially among the young group (3).

Early-onset T2DM, which often refers to those aged 18–40 years, has gained particular attention given its longer hyperglycemia exposure and more aggressive disease progression (4, 5). Currently, in China, most of early-onset T2DM patients were born after the 1980s and enjoyed a superior modernized life mode. On the contrary, most of those with late-onset T2DM lived a traditional agricultural lifestyle in their early lives (6, 7). Therefore, we select those 65+-year-old people as the representative group of late-onset T2DM to compare them with those with early-onset T2DM.

To enable patients with T2DM to have easier access to medical therapy and management, China implemented a health-care reform in 2013 and launched an integrated hospital-community health-care system for the hierarchical diagnosis and treatment of T2DM (8, 9). As a result, people had access to diagnosis and treatment for T2DM and its relevant complications at comprehensive tertiary hospitals and then to long-term follow-up at primary or secondary hospitals in the community. In Shanghai, we built a corresponding database based on the Shanghai Hospital Link Project to get the real-world knowledge of T2DM patients and provide better health-care service for them. This database has 1.45 million electronic health records of diabetes from 35 municipal hospitals in Shanghai from 2013 to 2020. To our knowledge, it is the most comprehensive medical and health information exchange system in China to date (10).

In this study, we aimed to explore the incidence number, glucose-lowering medicine prescriptions, and relevant comorbidities of newly diagnosed T2DM patients at their first visit to the hospital by the Shanghai Hospital Link Database (SHLD) to provide new real-world evidence for the management and therapy of T2DM.

Methods

Data source

Data in this study were extracted from SHLD, which included electronic health records (EHRs) for patients from 37 tertiary hospitals in Shanghai (11). SHLD was established by Shanghai Hospital Development Center and covered most of Shanghai’s inhabitants because Shanghai has achieved universal health coverage with a medical insurance participation rate of over 90% (https://tjj.sh.gov.cn/). It has achieved information sharing for all residents in Shanghai since 2013 and all patients could be identified by their unique Hospital Link identification cards, which corresponded to the existing social security cards and were near-universally covered. A keyword dictionary, which widely covered diagnosis and related explanation, was established to map the clinical data to the specific form. Diagnoses of diseases were drawn from case reports or the diseases identified according to the International Classification of Diseases, Tenth Revision, and relevant diagnostic criteria.

Definition of variables

Patients with clinically reported T2DM (ICD-10-CM: E11 or relevant diagnosis) and their related clinical information were identified from 2013 to 2021. Other medical data including demographic data, diagnosis records, and drug prescriptions were available through link files. Multiple processes for data security were applied to protect the patients’ privacy, including desensitizing the key fields about personally identifiable information and building up the special platform for the study and research. No informed consent was obtained for our study because any personally identifiable information was scrambled to protect privacy and the researchers were blinded to patient identities. This study was approved by the ethics committee of SHLD and Ruijin Hospital (No.2020-226Y).

Study population

Patients with T2DM diagnostic record or glucose-lowering medicine prescriptions for the first time in past continuous 3 years were defined as newly diagnosed T2DM patients. Their information, including ID, age, date of visit, medical diagnosis, and glucose-lowering medicine prescriptions at the first visit to hospitals, was extracted to achieve the aim of this study. Patients who got the diagnosis of T2DM at the age of 18–40 were defined as early-onset T2DM and those at the age of 65–85 years old were defined as late-onset T2DM according to their different social–economic–environmental experiences in early life.

There were 1.85 million patients with diabetes identified from 2013 to 2021. Among them, 675 thousand patients were excluded for their abnormal or missing data and 163 thousand patients with type 1 diabetes, gestational diabetes, and other type of diabetes were excluded. Data from 2020 to 2021 were also excluded for the influence of coronavirus disease 2019 (COVID-19) on the behaviors of patients. Finally, 35,457 patients who suffered from newly diagnosed early-onset T2DM and 149,108 patients who suffered from newly diagnosed late-onset T2DM were included in this study.

Statistical analysis

Descriptive statistical analyses were performed to describe the population, glucose-lowering drug prescription, and comorbidity of patients with T2DM at the first visit to the hospital. Patients with T2DM were stratified by age (18–40, 65–85) and sex (male and female). Population of patients were presented as numbers and proportions. Prescriptions of glucose-lowering medicine and comorbidities of patients with T2DM at their first visit to the hospitals were presented as proportions. Chi-squared test was applied for comparing proportions between study groups and P < 0.05 was considered meaningful. All the aforementioned analyses were carried out using R, version 3.4.1.

Results

In the end, there were total 390 thousand patients from 2016 to 2019 included in this study. Among them, there were totally 35,457 patients with incident early-onset T2DM and 149108 patients with incident late-onset T2DM. Males made up 67.7% of patients with early-onset T2DM and 49.9% of those with late-onset T2DM.

Increasing population of patients with T2DM

The number of newly diagnosed patients with early-onset T2DM or late-onset T2DM in each year is shown in Table 1. There were 8521, 9642, 8718, and 8576 newly diagnosed patients with early-onset T2DM and 36,050, 36,993, 37,300, and 38,765 newly diagnosed patients with late-onset T2DM identified for the first time in each year from 2016 to 2019, respectively. Among newly diagnosed T2DM patients, the late-onset group constituted the majority and they were nearly four times more than those with early-onset T2DM. There was a slight upward fluctuation for the number of patients with late-onset T2DM by years, while the population of newly diagnosed early-onset diabetes remained stable. Furhtermore, a significant gender difference was observed between the two groups (P < 0.001). A higher proportion of male patients was in the early-onset T2DM group, and this disproportion became larger by years consistently. This sex-specific difference was not found in the late-onset group.

Table 1

Sex-specific difference in glucose-lowering medicine prescription.

Year Early-onset T2DM Late-onset T2DM P
Male Female Total Male Female Total
2016 5556 2965 8521 18458 17592 36050 <0.001
2017 6422 3220 9642 18644 18349 36993 <0.001
2018 5989 2729 8718 18501 18799 37300 <0.001
2019 6020 2556 8576 18801 19964 38765 <0.001
Total 23987 11470 35457 74404 74704 149108 <0.001

Population of incident patients with early-onset T2DM and those with late-onset T2DM in each year was presented as numbers. Chi-square test was performed to identify the gender difference between two groups and P < 0.05 was considered significant.

Differences in glucose-lowering drug prescriptions at the first visit to hospitals

Differences in glucose-lowering drug prescriptions between the early-onset T2DM group and the late-onset T2DM group at their first visit to hospitals are shown in Figs 1 and 2. Metformin was the most common choice of oral glucose-lowering medicine both in the early-onset T2DM group and the late-onset T2DM group. A total of 74.8% of patients with early-onset T2DM were treated with metformin at their first visit to the hospital, while only 46.5% of patients with late-onset T2DM were treated with metformin at their first visit to the hospital. Insulin was prescribed for 46.9% of patients with the late-onset T2DM and for 37.3% of patients with early-onset T2DM as the second common glucose-lowering medicine. Other types of glucose-lowering medicines were ranked by the proportions of prescriptions: α-glucosidase-inhibitors, sulfonylureas, dipeptidyl peptidase-4 inhibitors (DPP-4i), thiazolidinediones (TZDs), glinides, glucagon-like peptide 1 receptor agonists (GLP-1 RAs), sodium glucose cotransporter 2 inhibitors (SGLT2-i).

Figure 1
Figure 1

Sex-specific difference in glucose-lowering medicine prescription. Glucose-lowering drug prescriptions of patients with T2DM at their first visit to the hospital are presented as percent (%).

Citation: Endocrine Connections 13, 2; 10.1530/EC-23-0474

Figure 2
Figure 2

Difference in glucose-lowering medicine prescription. Glucose-lowering drug prescriptions of patients with T2DM at their first visit to the hospital are presented as percent (%).

Citation: Endocrine Connections 13, 2; 10.1530/EC-23-0474

Compared to late-onset T2DM patients, more patients with early-onset T2DM had novel organ-protective glucose-lowering drug prescriptions: DPP-4i (16.7% vs 11.2%, P < 0.01), SGLT2-i (0.8% vs 0.3%, P < 0.01), and GLP-1 RAs (3.7% vs 0.5%, P < 0.01), while less of them had prescription of insulin (37.3% vs 46.9%, P < 0.01), α-glucosidase inhibitors (23.4% vs 30.6%, P < 0.01), and sulfonylureas (20.8% vs 28.9%, P < 0.01). Larger sex differences were found in the drug prescription in the early-onset group. More male newly diagnosed early-onset T2DM patients had glucose-lowering drug prescription at their first visit to the hospital. Males late-onset T2DM patients had more insulin prescription (40.2% vs 31.4%, P < 0.01).

Differences in comorbidities of patients with T2DM at the first visit to the hospital

Comorbidities of patients with T2DM at their first visit to the hospital are presented in Tables 2 and 3. Late-onset T2DM patients had higher prevalence for most kinds of comorbidities at the onset than those with early-onset T2DM except for dyslipidemia (9.48% vs 7.68%, P < 0.01). Hypertension was the most common comorbidity in both groups, 13.33% in the early-onset group and 43.45% in the late-onset group. The prevalence of diabetic nephropathy, diabetic retinopathy, diabetic neuropathy, cerebrovascular disease, peripheral vascular disease, and heart failure was 1.36%, 2.29%, 0.96%, 1.91%, 0.23%, and 0.69% for patients with early-onset T2DM and 2.36%, 3.16%, 2.25%, 17.86%, 2.42%, and 4.67% for patients with late-onset T2DM, respectively. As for their sex-specific differences, male patients with early-onset T2DM had a higher prevalence of hypertension (15.16% vs 9.52%, P < 0.01), dyslipidemia (11.32% vs 5.63%, P < 0.01), diabetic nephropathy (1.58% vs 0.89%, P < 0.01), heart failure (0.83% vs 0.41%, P < 0.01), and cerebrovascular disease (2.18% vs 1.33%, P < 0.01) than female patients, and this sex-specific difference was quite smaller in the late-onset group. (43.79% vs 43.11%, P < 0.01 for hypertension; 2.76% vs 1.97%, P < 0.01 for diabetic nephropathy; 5.06% vs 4.27%, P < 0.01 for heart failure; and 19.17% vs 16.55, P < 0.01 for cerebrovascular disease). More female patients with late-onset T2DM suffered from dyslipidemia than males (6.58% vs 8.78%, P < 0.01).

Table 2

Sex-dependent differences in comorbidities between patients with early-onset T2DM and those with late-onset T2DM at their first visit to hospitals.

Early-onset T2DM Late-onset T2DM
Male Female P Male Female P
Hypertension (%) 15.16 9.52 <0.001 43.79 43.11 0.008
Dyslipidemia (%) 11.32 5.63 <0.001 6.58 8.78 <0.001
Ischemic heart disease (%) 2.75 1.47 <0.001 19.25 17.62 <0.001
Cerebrovascular disease (%) 2.18 1.33 <0.001 19.17 16.55 <0.001
Heart failure (%) 0.83 0.41 <0.001 5.06 4.27 <0.001
Peripheral vascular disease (%) 0.24 0.21 0.557 3.05 1.78 <0.001
Chronic kidney disease (%) 0.83 0.59 0.017 2.74 1.81 <0.001
Cancer (%) 0.08 0.11 0.697 1.03 0.52 <0.001
Diabetic complications (%) 6.67 4.98 <0.001 10.79 9.39 <0.001
Diabetic nephropathy (%) 1.58 0.89 <0.001 2.76 1.97 <0.001
Diabetic retinopathy (%) 2.35 2.16 0.256 3.12 3.21 0.318
Diabetic neuropathy (%) 1.05 0.78 0.014 2.46 2.04 <0.001

Comorbidities of patients with T2DM at their first visit to the hospital are presented as percent (%). Chi-square test was performed to identify the age-dependent difference between two groups and P < 0.05 was considered significant.

Table 3

Age-dependent differences in comorbidities between patients with early-onset T2DM and those with late-onset T2DM at their first visit to hospitals.

Male Female
18–40 65–85 P 18–40 65–85 P
Hypertension (%) 3.70 33.11 <0.001 1.27 37.37 <0.001
Dyslipidemia (%) 2.76 4.98 <0.001 0.75 7.61 <0.001
Ischemic heart disease 0.67 14.56 <0.001 0.20 15.27 <0.001
Cerebrovascular disease (%) 0.53 14.50 <0.001 0.18 14.35 <0.001
Heart failure (%) 0.20 3.83 <0.001 0.05 3.70 <0.001
Peripheral vascular disease (%) 0.06 2.31 <0.001 0.03 1.54 <0.001
Chronic kidney disease (%) 0.20 2.07 <0.001 0.08 1.57 <0.001
Cancer (%) 0.02 0.78 <0.001 0.01 0.45 <0.001
Diabetic complications (%) 1.63 8.16 <0.001 0.66 8.14 <0.001
Diabetic nephropathy (%) 0.39 2.09 <0.001 0.12 1.71 <0.001
Diabetic retinopathy (%) 0.57 2.36 <0.001 0.29 2.78 <0.001
Diabetic neuropathy (%) 0.26 1.86 <0.001 0.10 1.77 <0.001

Comorbidities of patients with T2DM at their first visit to the hospital are presented as percent (%). Chi-square test was performed to identify the age-dependent difference between two groups and P < 0.05 was considered significant.

Discussion

In this study, we described the real-world differences of newly diagnosed patients with T2DM in the incident population, with regard to comorbidities and glucose-lowering drug prescriptions at their first visit to the hospitals. We classified these newly diagnosed patients with T2DM into early-onset T2DM group and late-onset T2DM group according to their age and different experiences in early life. We found group-specific and sex-specific differences, which might provide real-world evidence for clinical practice.

A previous study reported that the prevalence of T2DM in Shanghai was <1% in 1980 and rose ten-fold in some areas over the next 20 years (12). By analyzing EHR data from SHLD, we also found an overall upward trend in the population of newly diagnosed patients with late-onset T2DM but not in patients with early onset T2DM. This rapid increase could be attributed to China experiencing a drastic social transition in the past 60 years. For example, Chinese dietary patterns changed from a traditional Asian dietary pattern to a modern Western dietary pattern. This energy-dense dietary structure as well as insufficient physical activities induced the prevalence of obesity among the young group (13, 14). Other unhealthy lifestyle changes, such as long-term high-intensity work and imbalance of rhythm, that are associated with rapid modernization after the 1980s have also been reported to be responsible for the rapid rise in T2DM nowadays (15). Therefore, early-onset T2DM patients were defined as patients who aged 18–40 years old at their first visit for T2DM to represent those who were born in a relatively developed period in this study. On the other hand, a previous study indicated that exposure to malnutrition during fetal or early life increased the risk of adulthood diabetes (16, 17). People who were born in a relatively undeveloped period and experienced the transformation from a traditional lifestyle pattern to a modern pattern in their middle lives constituted majority of patients with late-onset T2DM in China nowadays (6). And we chose 65–80-year-old T2DM patients as late-onset group to represent those were born in a relatively undeveloped period.

As one of the most common chronic diseases, T2DM was related to many comorbidities and posed a huge threat to people health and medical care system in China. These comorbidities at the onset of T2DM revealed the health status of patients and may pose more interactive harm (18). In this study, we found that more newly diagnosed late-onset T2DM patients had comorbidities, where 43.5% of them suffered from hypertension and nearly 18% of them suffered from ischemic heart disease or cerebrovascular disease. As for their prescription of glucose-lowering drugs, insulin and metformin were the most common choice and were prescribed for 46.9% and 46.5% of them. Insulin was prescribed more for men, which may indicate their worse glycemic status. Former studies have indicated that TZD was effective in preventing elderly people from many adverse outcomes, but it was found to be prescribed in a limited number of cases (19). High proportions of insulin and sulfonylureas prescriptions were found among late-onset T2DM patients, which might indicate their worse glucose control level (20). Clinicians should emphasize the worse glycemic status and complexity of health status of patients with late-onset T2DM in the clinical practice. Given their higher baseline blood glucose level, periodic follow-up examination and regular blood glucose monitor were recommended to get the knowledge of the progression of T2DM in time (21). Contrary to the late-onset T2DM group, more male patients were found in this group and they consisted nearly 70% of the incident early-onset T2DM patients. China has the largest population of patients with early-onset diabetes around the world and it has become a health-care crisis given its rapid progression (22). Former studies have pointed out that early-onset T2DM patients were at higher risk of vascular complications in the same duration (5). And we found that more of them were under dyslipidemia, especially for males. Besides, hypertension was the most common comorbidity and more prevalent among male patients with early-onset T2DM. Then, more precautionary measures for cardiovascular diseases should be taken for male patients with early-onset T2DM. Similar sex-specific differences were also observed in other comorbidities such as nephropathy, retinopathy, neuropathy, and peripheral vascular and ischemic heart disease. As for their prescription of glucose-lowering medicine, metformin and insulin were the most frequent choice in the early-onset T2DM group. And more novel organ-protective drugs, such as SGLT2-i and GLP-1, were prescribed for them, which are recommended for patients with high BMI by the specialist guideline for T2DM in China (23). Therefore, young males should be paid more attention for the prevention of T2DM and its vascular complications since higher prevalence of hypertension and dyslipidemia were found among them. Although former study has confirmed that SGLT2-i and GLP-1 has vascular and weight-control benefit and recommended them for patients with high risk of ASCVD for prevention, a little of prescriptions was found in this real-world data base (24). And given the fact that the majority of early-onset T2DM stayed asymptomatic for a long period, screening for early-onset T2DM was imminent for young adults with obesity, family history of diabetes, or markers of insulin resistance (25). Furthermore, early education and more interventions are necessary to care for patients with early-onset T2DM given their low awareness on their health status (26).

There were some strengths of this study. First, the largest and well-designed diabetes database enabled us to explore the real-world knowledge of patients with T2DM from multiple perspectives. Second, we classified newly diagnosed patients with T2DM into two presentative groups by their different experiences in the early life at their first visit to the hospitals to provide real-world reference for the precise management of patients with T2DM.

However, our study also has some limitations. First, this study was of cross-sectional design and the casual relationship needs to be investigated in further studies. Second, real-world data from electronic health record may be affected by many complex confounders, although we have tried to minimize them at the stage of database design and establishment. Therefore, the result of this study needs to be interpreted cautiously and confirmed in further studies to guide clinical practices. Third, SHLD database only included data from tertiary hospitals. But it had wide geographical coverage and a huge quantity of data. And considering the Chinese health-seeking behavior and the special hierarchical health-care system in China, we believed the database was representative enough. Fourth, although this database has a wide coverage of residents and is well designed to get robust real-world information, it fails to combine clinical parameters, such as patients’ laboratory examination results, which was an obstacle for us to explore deeper.

Conclusion

In conclusion, this study showed the characteristics of newly diagnosed patients with T2DM and provided new real-world evidence for the management and therapy of diabetes. These findings suggest different profiles between patients with early-onset T2DM and those with late-onset T2DM. Therefore, more customized strategies were appropriate for management of different patients with T2DM. And given the limitation of the cross-sectional design of the current study, a new cohort study has been launched to get more data.

Declaration of interest

The authors declare there is no potential conflict of interest.

Funding

CL was funded by High-Quality Development Funds of The First Affiliated Hospital of Xiamen University (No. YN81870611) and Natural Science Foundation of China (No. 82270928).

Data availability statement

The data underlying this article will be available from the corresponding author upon reasonable request.

Author contribution statement

The study concept and design were framed by BC and CL. YX and XT conducted the statistical data analysis and drafted the manuscript. WL, RN, and CH contributed to discussion. BC and CL contributed to discussion and revision. All authors read and approved the final version of the manuscript.

Acknowledgements

We are grateful to all the subjects for their participation in the study.

References

  • 1

    International Diabetes Federation. IDF Diabetes Atlas, 11th ed. Brussels, Belgium: International Diabetes Federation, 2022.

  • 2

    Wang L, Peng W, Zhao Z, Zhang M, Shi Z, Song Z, Zhang X, Li C, Huang Z, Sun X, et al.Prevalence and treatment of diabetes in China, 2013–2018. JAMA 2021 326 24982506. (https://doi.org/10.1001/jama.2021.22208)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Li Y, Wang DD, Ley SH, Vasanti M, Howard AG, He Y, & Hu FB. Time trends of dietary and lifestyle factors and their potential impact on diabetes burden in China. Diabetes Care 2017 40 16851694. (https://doi.org/10.2337/dc17-0571)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Lascar N, Brown J, Pattison H, Barnett AH, Bailey CJ, & Bellary S. Type 2 diabetes in adolescents and young adults. Lancet Diabetes and Endocrinology 2018 6 6980. (https://doi.org/10.1016/S2213-8587(1730186-9)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Magliano DJ, Sacre JW, Harding JL, Gregg EW, Zimmet PZ, & Shaw JE. Young-onset type 2 diabetes mellitus - implications for morbidity and mortality. Nature Reviews. Endocrinology 2020 16 321331. (https://doi.org/10.1038/s41574-020-0334-z)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Bloomgarden Z, & Ning G. Diabe tes and aging. Journal of Diabetes 2013 5 369371. (https://doi.org/10.1111/1753-0407.12086)

  • 7

    Liu D, Yu DM, Zhao LY, Fang HY, Zhang J, Wang JZ, Yang ZY, & Zhao WH. Exposure to famine during early life and abdominal obesity in adulthood: findings from the Great Chinese famine during 1959–1961. Nutrients 2019 11 903. (https://doi.org/10.3390/nu11040903)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Xu Y, Wang L, He J, Bi Y, Li M, Wang T, Wang L, Jiang Y, Dai M, Lu J, et al.Prevalence and control of diabetes in Chinese adults. JAMA 2013 310 948959. (https://doi.org/10.1001/jama.2013.168118)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Jia W, & Tong N. Diabetes prevention and continuing health-care reform in China. Lancet Diabetes and Endocrinology 2015 3 840842. (https://doi.org/10.1016/S2213-8587(1500382-4)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Yu G, Cui W, Zhou L, Bates DW, Gu Jianlei, & Lu H. Implementation of a city-wide Health Information Exchange solution in the largest metropolitan region in China. 2016 I EEE International Conference on Bioinformatics and Biomedicine (BIBM), Shenzhen, 2016, pp. 795798. (https://doi.org/10.1109/BIBM.2016.7822626)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Qi J, He P, Yao H, Xue Y, Sun W, Lu P, Qi X, Zhang Z, Jing R, Cui B, et al.Developing a prediction model for all-cause mortality risk among patients with type 2 diabetes mellitus in Shanghai, China. Journal of Diabetes 2023 15 2735. (https://doi.org/10.1111/1753-0407.13343)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Shanghai Diabetes Research Cooperative Group. Diabetes mellitus survey in Shanghai. Chinese Medical Journal 1980 93 663672.

  • 13

    Li R, Lu W, Jiang QW, Li YY, Zhao GM, Shi L, Yang QD, Ruan Y, Jiang J, Zhang SN, et al.Increasing prevalence of type 2 diabetes in Chinese adults in Shanghai. Diabetes Care 2012 35 10281030. (https://doi.org/10.2337/dc11-1212)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Wang Y, Zhao L, Gao L, Pan A, & Xue H. Health policy and public health implications of obesity in China. Lancet Diabetes and Endocrinology 2021 9 446461. (https://doi.org/10.1016/S2213-8587(2100118-2)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Petroni ML, Brodosi L, Marchignoli F, Sasdelli AS, Caraceni P, Marchesini G, & Ravaioli F. Nutrition in patients with Type 2 diabetes: present knowledge and remaining challenges. Nutrients 2021 13 2748. (https://doi.org/10.3390/nu13082748)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Lu J, Li M, Xu Y, Bi Y, Qin Y, Li Q, Wang T, Hu R, Shi L, Su Q, et al.Early life famine exposure, ideal cardiovascular health metrics, and risk of incident diabetes: findings from the 4C study. Diabetes Care 2020 43 19021909. (https://doi.org/10.2337/dc19-2325)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Keating ST, Plutzky J, & El-Osta A. Epigenetic changes in diabetes and cardiovascular risk. Circulation Research 2016 118 17061722. (https://doi.org/10.1161/CIRCRESAHA.116.306819)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Reyes-García R, Moreno-Pérez Ó, Tejera-Pérez C, Fernández-García D, Bellido-Castañeda V, de la Torre Casares ML, Rozas-Moreno P, Fernández-García JC, Marco Martínez A, Escalada-San Martín J, et al.Document on a comprehensive approach to type 2 diabetes mellitus. Endocrinology, Diabetes and Nutrition 2019 66 443458. (https://doi.org/10.1016/j.endinu.2018.10.010)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    DREAM (Diabetes REduction Assessment with ramipril and rosiglitazone Medication) Trial Investigators, Gerstein HC, Yusuf S, Bosch J, Pogue J, Sheridan P, Dinccag N, Hanefeld M, Hoogwerf B, Laakso M, et al.Effect of rosiglitazone on the frequency of diabetes in patients with impaired glucose tolerance or impaired fasting glucose: a randomised controlled trial. Lancet 2006 368 10961 1 05. (https://doi.org/10.1016/S0140-6736(0669420-8)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, et al.13. Older Adults: Standards of Care in Diabetes-2023. Diabetes Care 2023 46(Suppl ement 1) S216S229. (https://doi.org/10.2337/dc23-S013)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Qi J, Su Y, Song Q, Ding Z, Cao M, Cui B, & Qi Y. Reconsidering the HbA1c cutoff for diabetes diagnosis based on a Large Chinese cohort. Experimental and Clinical Endocrinology and Diabetes 2021 129 8692. (https://doi.org/10.1055/a-0833-8119)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Zhang Y, & Ning G. Diabetes: young-onset type 2 diabetes mellitus-a challenge for Asia. Nature Reviews. Endocrinology 2014 10 703704. (https://doi.org/10.1038/nrendo.2014.162)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Chinese Elderly Type 2 Diabetes Prevention and Treatment of Clinical Guidelines Writing Group, Geriatric Endocrinology and Metabolism Branch of Chinese Geriatric Society, Geriatric Endocrinology and Metabolism Branch of Chinese Geriatric Health Care Society, Geriatric Professional Committee of Beijing Medical Award Foundation & National Clinical Medical Research Center for Geriatric Diseases (PLA General Hospital). Clinical guidelines for prevention and treatment of type 2 diabetes mellitus in the elderly in China (2022 edition). Zhonghua Nei Ke Za Zhi 2022 61 1250. (https://doi.org/10.3760/cma.j.cn112138-20211027-00751)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Diallo A, Carlos-Bolumbu M, & Galtier F. Age, sex, race, BMI, and duration of diabetes differences in cardiovascular outcomes with glucose lowering drugs in type 2 diabetes: A systematic review and meta-analysis. EClinicalmedicine 2022 54 101697. (https://doi.org/10.1016/j.eclinm.2022.101697)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Pan J, & Jia W. Early-onset diabetes: an epidemic in China. Frontiers of Medicine 2018 12 624633. (https://doi.org/10.1007/s11684-018-0669-1)

  • 26

    Canadian Diabetes Association Clinical Practice Guidelines Expert Committee, Meneilly GS, Knip A, & Tessier D. Diabetes in the elderly. Canadian Journal of Diabetes 2013 37(Supplement 1) S184S190. (https://doi.org/10.1016/j.jcjd.2013.01.045)

    • PubMed
    • Search Google Scholar
    • Export Citation

 

  • Collapse
  • Expand
  • Figure 1

    Sex-specific difference in glucose-lowering medicine prescription. Glucose-lowering drug prescriptions of patients with T2DM at their first visit to the hospital are presented as percent (%).

  • Figure 2

    Difference in glucose-lowering medicine prescription. Glucose-lowering drug prescriptions of patients with T2DM at their first visit to the hospital are presented as percent (%).

  • 1

    International Diabetes Federation. IDF Diabetes Atlas, 11th ed. Brussels, Belgium: International Diabetes Federation, 2022.

  • 2

    Wang L, Peng W, Zhao Z, Zhang M, Shi Z, Song Z, Zhang X, Li C, Huang Z, Sun X, et al.Prevalence and treatment of diabetes in China, 2013–2018. JAMA 2021 326 24982506. (https://doi.org/10.1001/jama.2021.22208)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Li Y, Wang DD, Ley SH, Vasanti M, Howard AG, He Y, & Hu FB. Time trends of dietary and lifestyle factors and their potential impact on diabetes burden in China. Diabetes Care 2017 40 16851694. (https://doi.org/10.2337/dc17-0571)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Lascar N, Brown J, Pattison H, Barnett AH, Bailey CJ, & Bellary S. Type 2 diabetes in adolescents and young adults. Lancet Diabetes and Endocrinology 2018 6 6980. (https://doi.org/10.1016/S2213-8587(1730186-9)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Magliano DJ, Sacre JW, Harding JL, Gregg EW, Zimmet PZ, & Shaw JE. Young-onset type 2 diabetes mellitus - implications for morbidity and mortality. Nature Reviews. Endocrinology 2020 16 321331. (https://doi.org/10.1038/s41574-020-0334-z)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Bloomgarden Z, & Ning G. Diabe tes and aging. Journal of Diabetes 2013 5 369371. (https://doi.org/10.1111/1753-0407.12086)

  • 7

    Liu D, Yu DM, Zhao LY, Fang HY, Zhang J, Wang JZ, Yang ZY, & Zhao WH. Exposure to famine during early life and abdominal obesity in adulthood: findings from the Great Chinese famine during 1959–1961. Nutrients 2019 11 903. (https://doi.org/10.3390/nu11040903)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Xu Y, Wang L, He J, Bi Y, Li M, Wang T, Wang L, Jiang Y, Dai M, Lu J, et al.Prevalence and control of diabetes in Chinese adults. JAMA 2013 310 948959. (https://doi.org/10.1001/jama.2013.168118)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Jia W, & Tong N. Diabetes prevention and continuing health-care reform in China. Lancet Diabetes and Endocrinology 2015 3 840842. (https://doi.org/10.1016/S2213-8587(1500382-4)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Yu G, Cui W, Zhou L, Bates DW, Gu Jianlei, & Lu H. Implementation of a city-wide Health Information Exchange solution in the largest metropolitan region in China. 2016 I EEE International Conference on Bioinformatics and Biomedicine (BIBM), Shenzhen, 2016, pp. 795798. (https://doi.org/10.1109/BIBM.2016.7822626)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Qi J, He P, Yao H, Xue Y, Sun W, Lu P, Qi X, Zhang Z, Jing R, Cui B, et al.Developing a prediction model for all-cause mortality risk among patients with type 2 diabetes mellitus in Shanghai, China. Journal of Diabetes 2023 15 2735. (https://doi.org/10.1111/1753-0407.13343)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Shanghai Diabetes Research Cooperative Group. Diabetes mellitus survey in Shanghai. Chinese Medical Journal 1980 93 663672.

  • 13

    Li R, Lu W, Jiang QW, Li YY, Zhao GM, Shi L, Yang QD, Ruan Y, Jiang J, Zhang SN, et al.Increasing prevalence of type 2 diabetes in Chinese adults in Shanghai. Diabetes Care 2012 35 10281030. (https://doi.org/10.2337/dc11-1212)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Wang Y, Zhao L, Gao L, Pan A, & Xue H. Health policy and public health implications of obesity in China. Lancet Diabetes and Endocrinology 2021 9 446461. (https://doi.org/10.1016/S2213-8587(2100118-2)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Petroni ML, Brodosi L, Marchignoli F, Sasdelli AS, Caraceni P, Marchesini G, & Ravaioli F. Nutrition in patients with Type 2 diabetes: present knowledge and remaining challenges. Nutrients 2021 13 2748. (https://doi.org/10.3390/nu13082748)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Lu J, Li M, Xu Y, Bi Y, Qin Y, Li Q, Wang T, Hu R, Shi L, Su Q, et al.Early life famine exposure, ideal cardiovascular health metrics, and risk of incident diabetes: findings from the 4C study. Diabetes Care 2020 43 19021909. (https://doi.org/10.2337/dc19-2325)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Keating ST, Plutzky J, & El-Osta A. Epigenetic changes in diabetes and cardiovascular risk. Circulation Research 2016 118 17061722. (https://doi.org/10.1161/CIRCRESAHA.116.306819)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Reyes-García R, Moreno-Pérez Ó, Tejera-Pérez C, Fernández-García D, Bellido-Castañeda V, de la Torre Casares ML, Rozas-Moreno P, Fernández-García JC, Marco Martínez A, Escalada-San Martín J, et al.Document on a comprehensive approach to type 2 diabetes mellitus. Endocrinology, Diabetes and Nutrition 2019 66 443458. (https://doi.org/10.1016/j.endinu.2018.10.010)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    DREAM (Diabetes REduction Assessment with ramipril and rosiglitazone Medication) Trial Investigators, Gerstein HC, Yusuf S, Bosch J, Pogue J, Sheridan P, Dinccag N, Hanefeld M, Hoogwerf B, Laakso M, et al.Effect of rosiglitazone on the frequency of diabetes in patients with impaired glucose tolerance or impaired fasting glucose: a randomised controlled trial. Lancet 2006 368 10961 1 05. (https://doi.org/10.1016/S0140-6736(0669420-8)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, et al.13. Older Adults: Standards of Care in Diabetes-2023. Diabetes Care 2023 46(Suppl ement 1) S216S229. (https://doi.org/10.2337/dc23-S013)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Qi J, Su Y, Song Q, Ding Z, Cao M, Cui B, & Qi Y. Reconsidering the HbA1c cutoff for diabetes diagnosis based on a Large Chinese cohort. Experimental and Clinical Endocrinology and Diabetes 2021 129 8692. (https://doi.org/10.1055/a-0833-8119)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Zhang Y, & Ning G. Diabetes: young-onset type 2 diabetes mellitus-a challenge for Asia. Nature Reviews. Endocrinology 2014 10 703704. (https://doi.org/10.1038/nrendo.2014.162)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Chinese Elderly Type 2 Diabetes Prevention and Treatment of Clinical Guidelines Writing Group, Geriatric Endocrinology and Metabolism Branch of Chinese Geriatric Society, Geriatric Endocrinology and Metabolism Branch of Chinese Geriatric Health Care Society, Geriatric Professional Committee of Beijing Medical Award Foundation & National Clinical Medical Research Center for Geriatric Diseases (PLA General Hospital). Clinical guidelines for prevention and treatment of type 2 diabetes mellitus in the elderly in China (2022 edition). Zhonghua Nei Ke Za Zhi 2022 61 1250. (https://doi.org/10.3760/cma.j.cn112138-20211027-00751)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Diallo A, Carlos-Bolumbu M, & Galtier F. Age, sex, race, BMI, and duration of diabetes differences in cardiovascular outcomes with glucose lowering drugs in type 2 diabetes: A systematic review and meta-analysis. EClinicalmedicine 2022 54 101697. (https://doi.org/10.1016/j.eclinm.2022.101697)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Pan J, & Jia W. Early-onset diabetes: an epidemic in China. Frontiers of Medicine 2018 12 624633. (https://doi.org/10.1007/s11684-018-0669-1)

  • 26

    Canadian Diabetes Association Clinical Practice Guidelines Expert Committee, Meneilly GS, Knip A, & Tessier D. Diabetes in the elderly. Canadian Journal of Diabetes 2013 37(Supplement 1) S184S190. (https://doi.org/10.1016/j.jcjd.2013.01.045)

    • PubMed
    • Search Google Scholar
    • Export Citation