Treatment and control of modifiable cardiovascular risk factors among patients with diabetes mellitus and hypertension in Inner Mongolia: A cross‐sectional study

Abstract The authors assessed treatment and control of blood glucose, blood pressure (BP), and blood lipids among patients from Inner Mongolia with diabetes mellitus (DM) and hypertension (HTN) and identified the modifiable factors associated with treatment and achievement of blood glucose, BP, and blood lipid targets. The authors used a multistage stratified cluster sampling method according to geographical location and level of economic development in Inner Mongolia. Among patients with DM and HTN, the crude rates of fasting plasma glucose (FPG) treatment and control was 30.76% and 4.73%, respectively. Crude rates of BP treatment and control were 50.81% and 8.70%, respectively. The authors found that treatment rates of HTN and DM and control rates of BP and FPG showed a gradually increasing trend with increased age. Among patients with DM and HTN, the likelihood of treatment for HTN and DM was significantly increased among participants who were older, non‐Mongolian, male, obese, smokers, and those with previous cardiovascular disease. The authors found that control of BP, FPG, and low‐density lipoprotein cholesterol was far from optimal among study participants. Medical and health departments in Inner Mongolia should take appropriate measures to reduce the burden of DM and HTN in the population, such as by promoting and improving the quality of HTN and DM treatment to achieve control goals and reduce the risk of cardiovascular disease.


INTRODUCTION
Type 2 diabetes mellitus (DM) and hypertension (HTN) are established risk factors for cardiovascular disease (CVD). [1][2][3][4] Moreover, patients with DM and HTN have an increased risk of cardiovascular mortality compared with patients who have either condition alone. 5,6 Patients with HTN and DM have a higher risk of heart disease or stroke. 3,4,7 Further, DM and HTN are common conditions that frequently present together. One study reported that up to 75% of adults with DM also have HTN, and patients with HTN alone often show evidence of insulin resistance. 8 HTN and DM are common, intertwined conditions with considerable overlap with respect to underlying risk factors. 9 The current epidemic of DM and HTN has become a serious pub- to explore those factors associated with treatment and achievement of blood glucose, BP, and blood lipid target goals. We also provide an effective scientific basis for the prevention and control of CVD and death in high-risk groups.

Study design and participants
The data in this study were from the China Patient-Centered Evalu-  Among patients with dyslipidemia, those without CVD who had LDL-C < 2.6 mmol/L and those with prior CVD who had LDL-C < 1.8 mmol/L were considered to have reached the treatment target of LDL-C.

Statistical analysis
Continuous variables are presented as mean and standard deviation (SD) or median and compared using the chi-square test. Categorical variables are shown as number and percentage. We calculated the rates of both treatment and control of BP, FPG, and LDL-C according to the different subgroups, as well as 95% confidence intervals (CIs).
Age-and sex-standardized rates of treatment and control for diabetes and HTN at national level were calculated using a direct method of standardization 13

RESULTS
A total of 9617 patients with DM and HTN were included in this study; the study flow chart is shown in Figure S1. Overall, 13.66% (9617/70380) of participants had DM and HTN. Characteristics of the study population are shown in Table 1.

Treatment and control of FPG, BP, and LDL-C
The treatment and control of FPG, BP, and LDL-C by different groups are displayed in Tables 2 and 3. The standardized treatment rate and control rate of DM, HTN, and dyslipidemia were slightly lower than the crude rate (Tables 2 and 3).
We found that treatment rates for HTN and DM were higher in older patients (p trend < .05). Similarly, the control rates of BP and FPG also increased with age (p trend < .05). Ethnic Mongolian participants had lower rates of treatment and control for DM, HTN, and hyperlipidemia.
The control rates of BP, blood glucose, and LDL-C in married patients were significantly higher than those in unmarried patients (p < .05).
Participants living in urban areas had higher rates of diabetes treatment and control. Furthermore, higher control rates of FPG, BP, and LDL-C were found in the group with higher education levels. Compared with patients who did not have CVD, those with prior CVD had much higher rates of treatment and control for DM as well as HTN (p < .05).

Distance to treatment targets
Differences in optimal treatment targets for FPG, BP, and LDL-C were calculated in uncontrolled patients (Figure 1). We found that the difference in FPG and SBP optimal treatment targets was greater in treated than in untreated patients. The differences in optimal treatment target values of LDL-C were smaller in treated patients with dyslipidemia.
The optimal treatment target distance to SBP was calculated as the

Factors influencing treatment and control of BP, FPG, and LDL-C
Using a binary logistic model, we identified several independent influencing factors related to the treatment and control of patients with DM and HTN (Figures 2-4). Patients with prior CVD and those who were married, Han ethnicity, obese, female, or older had higher treatment levels. Patients without hyperlipidemia and those with higher education levels, female sex, and older age were more likely to achieve BP control goals (  Table 1. Abbreviations: BP, blood pressure; CVD, cardiovascular disease; FPG, fasting blood glucose; LDL-C, low-density lipoprotein cholesterol. a The value is presented in percent (95% confidence interval). b Age-and sex-standardized rates at national level.

DISCUSSION
This study was the largest cross-sectional investigation related to CVD,

DM, and HTN in the Inner Mongolia Autonomous Region in recent
years. This study, which included a large study population from multiple regions and comprising different minority ethnic groups, provides an up-to-date assessment of the treatment and control of FPG, BP, and LDL-C among patients with DM and HTN in Inner Mongolia and identifies predictive factors for poor FPG, BP, and LDL-C control. We are confident that the results of our research will help improve public health policies and effectively improve the level of public health in the region.
International clinical guidelines strongly recommend that optimal control levels of FPG, BP, and LDL-C are important to prevent the risk of developing CVD in patients with DM combined with HTN. 14,15 However, we found that control levels of FPG (5.13%), BP (8.7%), and LDL-C (56.44%) in our study population were far from ideal. We also found that high treatment rates do not mean that these risk factors are well prevented and controlled. Therefore, the health care sector should adopt relevant strategies to improve the quality and effectiveness of treatment to achieve control goals.
Whereas previous reports have shown that the prevalence of HTN among individuals in China is slightly lower, on average, than that in Western countries, this study showed that the prevalence of HTN in China is now comparable to that in the West. 16 However, the level of diagnosis, treatment, and control of HTN in China is much lower than that in many high-income countries. 17 and LDL-C. 26 Similarly, unsatisfactory composite control of risk factors has been reported in other developed countries. 20 Therefore, it is an enormous challenge for China as well as other developed countries to achieve treatment targets for key indicators.
According to age group, we found that treatment and control of BP were lower in patients with HTN in the young and middle-aged groups.
The same trend was observed in patients treated with DM, which was consistent with the results of other studies. 27 HTN, and dyslipidemia were slightly lower than the crude estimates.
Moreover, owing to sampling bias, we expect that the treatment rate and control rate were overestimated in our study because potential participants were more likely to yield positive results owing to greater concern about their health. This study was based on 2010 guidelines.
In comparison with current, more stringent guidelines, the control rates based on 2020 guidelines were overestimated. Finally, only crosssectional estimates of BP, FPG, and LDL-C control were counted and changes in these indicators could not be tracked.

CONCLUSIONS
In this study, we investigated prevalence, treatment, and control rates in a representative sample of middle-aged and older Chinese patients with DM and HTN and found sex-specific and age-specific patterns. We found that control of BP and blood glucose was far from optimal in our sample. We also observed that high treatment rates do not mean that these risk factors are well controlled. Therefore, the health sector should adopt a variety of strategies to achieve control objectives, including promotion and improvement of the quality of treatment for DM and HTN.