Epidemiology/Health Services/Psychosocial Research

B R I E F

R E P O R T

Glucose, Lipid, and Blood Pressure

Control in Australian Adults With Type 2
Diabetes
The 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 STEERING
COMMITTEE

test (11). Participants who started insulin

treatment within 2 years of diagnosis were
classified as having type 1 diabetes (if diabetes onset was at age 40 years; BMI
also had to be 27 kg/m2). All other cases
were classified as type 2 diabetes.
Fasting (9 h) serum total cholesterol, LDL and HDL cholesterol, and triglycerides were measured (Olympus
AU600 analyzer; Olympus Optical, Tokyo, Japan). Total glycated hemoglobin
analysis used high-performance liquid
chromatography (Bio-Rad Variant Hemoglobin Testing System; Bio-Rad, Hercules, CA) with standardized conversion
to HbA 1c values (normal range 4.2
6.3%). Blood pressure measurements
were performed in a seated position after
rest for 5 min (12). Intervieweradministered questionnaires ascertained
medication use.
Data were weighted to match the age
and sex distribution of the 1998 residential population of Australia aged 25

he risk of diabetes complications

can be reduced by tight control of
blood glucose (1), serum lipids (2),
and blood pressure (3,4). However, evidence from a limited number of studies
(59) indicates that many people with
type 2 diabetes do not achieve recommended targets for these factors. We examined levels of glucose, lipid, and blood
pressure control in participants with type
2 diabetes taking part in the national population-based Australian Diabetes, Obesity, and Lifestyle Study (AusDiab) (10)
conducted during 1999 2000.
RESEARCH DESIGN AND
METHODS AusDiab was a national
population-based survey of the general
population and has been described in detail earlier (10). Diagnosis of diabetes was
based on self-reported physician diagnosis of diabetes confirmed either by selfreported use of hypoglycemic drugs or
results from a 75-g oral glucose tolerance

From the 1Department of Medicine, Dewsbury & District Hospital, Dewsbury, West Yorkshire, U.K.; the
2
International Diabetes Institute, Caulfield, Victoria, Australia; the 3Department of Medicine, University of
Western Australia, Nedlands, Western Australia, Australia; the 4Department of Endocrinology, Diabetes and
Metabolism, The Prince of Wales Hospital, Randwick, New South Wales, Australia; and the 5Endocrinology
Unit, North Western Adelaide Health Service, Queen Elizabeth Hospital, Woodville, South Australia, Australia.
Address correspondence and reprint requests to Elizabeth L.M. Barr, International Diabetes Institute, 250
Kooyong 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 Servier
Laboratories.
Abbreviations: ADA, American Diabetes Association; AusDiab, Australian Diabetes, Obesity, and Lifstyle
Study.
A table elsewhere in this issue shows conventional and Syste`me International (SI) units and conversion
factors 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.

1490

years. The percentages of participants failing to achieve the accepted national clinical targets recommended for diabetes
management in place at the time of the
survey (HbA1c levels 7.0%, LDL 3.5
mmol/l, HDL 1.0 mmol/l, triglycerides
2.0 mmol/l, total cholesterol 5.5
mmol/l [13,14], blood pressure 140/90
mmHg [15,16], and more recent American Diabetes Association [ADA] targets
[1719]) were determined. The study was
approved by the local ethics committee.
Participants gave written consent.
RESULTS Of 11,247 participants,
439 had previously diagnosed type 2 diabetes. The means SD and median
(25th75th percentile) HbA1c levels were
7.3 1.8% and 6.8% (6.1 8.0), respectively. The percentage of individuals not
meeting glucose, total cholesterol, and
blood pressure targets differed significantly by treatment category (Table 1).
The combination of the good control
targets was achieved by 13% (n 60) of
participants. ADA targets for LDL (2.6
mmol/l) and blood pressure (130/80
mmHg) were not met by 80 and 81% of
participants, respectively. All three ADA
targets were achieved by 2% (n 11).
CONCLUSIONS Only half the
population met the individual glycemic,
lipid, and blood pressure targets recommended at the time of the survey, and
approximately one in seven met all three
targets. Achievement of more stringent
levels recommended by the ADA for lipids and blood pressure was considerably
worse, and there was evidence, especially
for lipids and blood pressure, of underuse
of drug therapy. By comparison, U.S. data
show that 44% in NHANES III (National
Health and Nutrition Examination Survey
III) and 37% in NHANES 1999 2000
had HbA1c 7.0% (noting that the normal range for the HbA1c assays used in
AusDiab was very similar to the normal
range reported in the U.S. surveys) (6).
DIABETES CARE, VOLUME 28, NUMBER 6, JUNE 2005

Kemp and Associates

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

HbA1c
Diet regime only
Oral hypoglycemic agents
Insulin
Total
Total cholesterol
Lipid-lowering treatment
No lipid-lowering treatment
Total
Blood pressure
Blood pressure treatment
No blood pressure
treatment
Total

Percentage in each
treatment category

Percentage not
achieving target*

32.4 (130)
58.0 (259)
9.6 (49)
100 (438)

21.5 (27)
49.5 (126)
76.1 (33)
43.0 (186)

0.0001

35.9 (154)
64.1 (279)
100 (433)

29.0 (47)
57.1 (157)
47.2 (204)

0.0001

42.5 (211)
57.5 (224)

67.8 (136)
45.3 (98)

0.0001

100 (435)

54.7 (234)

P value

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

Beaton et al. (8) identified 7,114 adults

with diabetes through a U.S. managed
care organization and found that few attained ADA goals for HbA1c, LDL cholesterol, and systolic blood pressure. A
Danish study (7) reported that 60% of
people with type 2 diabetes had HbA1c
values 6.3%.
The progressive nature of diabetes (1)
usually requires escalating therapy. Poor
glycemic control in the AusDiab type 2
diabetic population was twice as prevalent among those on oral hypoglycemic
agents (without insulin) as in those using
dietary regimes alone. This suggests that
in the face of poor glycemic control, there
is greater delay in adding insulin to oral
hypoglycemic agents than in adding oral
hypoglycemic agents to dietary regime.
However, achieving tight glycemic control can be difficult, and even in clinical
trials such as the UKPDS (U.K. Prospective Diabetes Study), a large proportion of
participants receiving intensive therapy
remained above target (1). Moreover, the
goal of an HbA1c 7.0% may be impractical in long-duration type 2 diabetes, as
attempts to achieve it are often complicated by hypoglycemia (1).
Aggressive management of cholesterol (2) and blood pressure (4) are effective in preventing macrovascular disease
in type 2 diabetes. The observations reported here, however, suggest that opportunities for cardiovascular disease risk
DIABETES CARE, VOLUME 28, NUMBER 6, JUNE 2005

reduction are being missed, as a significant proportion of individuals (including

those on medication) were not meeting
targets for both cholesterol and blood
pressure.
In conclusion, this population-based
study found that in 400 people with
type 2 diabetes, there was evidence of under-use of medication leading to suboptimal achievement of glucose, lipid, and
blood pressure national therapeutic targets, with only one in seven people
achieving all three targets. In addition to
behavioral modifications such as diet and
exercise, increased use of insulin, multiple antihypertensive therapy, and lipidlowering drugs are likely to be required.

Acknowledgments We are most grateful to

the following for their support of the study:
Associate Prof. Damien Jolley, School of
Health and Social Development, Deakin University, Victoria, Australia, for his statistical
advice; The Commonwealth Department of
Health and Aged Care; Abbott Australasia; Alphapharm; Aventis Pharmaceuticals; AstraZeneca; Bristol-Myers Squibb; Eli Lilly (Aust);
GlaxoSmithKline; Janssen-Cilag (Aust); Merck
Lipha; Merck Sharp & Dohme (Aust); Novartis Pharmaceuticals (Aust); Novo Nordisk;
Pharmacia and Upjohn; Pfizer; Roche Diagnostics; Sanofi Synthelabo (Aust); Servier Laboratories (Aust); Bio-Rad Laboratories;
HITECH Pathology; the Australian Kidney
Foundation; Diabetes Australia; Diabetes Aus-

tralia (Northern Territory); Queensland

Health; South Australian Department of Human Services; Tasmanian Department of
Health and Human Services; Territory Health
Services; Victorian Department of Human Services; and the Health Department of Western
Australia.
Also, for their contribution to the field activities of AusDiab, we are grateful to Annie
Allman, Marita Dalton, David Dunstan, Adam
Meehan, Claire Reid, Alison Stewart, Robyn
Tapp, and Fay Wilson.
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