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Multilevel Examination of Diabetes in Modernising China: What Elements of Urbanisation Are Most Associated with Diabetes?


Attard, Samantha M.; Herring, Amy H.; Mayer-Davis, Elizabeth J.; Popkin, Barry M.; Meigs, James B.; & Gordon-Larsen, Penny (2012). Multilevel Examination of Diabetes in Modernising China: What Elements of Urbanisation Are Most Associated with Diabetes?. Diabetologia, 55(12), 3182-3192. PMCID: PMC3483108


Aims/hypothesis: The purpose of this study was to examine the association between urbanisation-related factors and diabetes prevalence in China.
Methods: Anthropometry, fasting blood glucose (FBG) and community-level data were collected for 7,741 adults (18–90 years) across 217 communities and nine provinces in the 2009 China Health and Nutrition Survey to examine diabetes (FBG ≥7.0 mmol/l or doctor diagnosis). Sex-stratified multilevel models, clustered at the community and province levels and controlling for individual-level age and household income were used to examine the association between diabetes and: (1) a multicomponent urbanisation measure reflecting overall modernisation and (2) 12 separate components of urbanisation (e.g., population density, employment, markets, infrastructure and social factors).
Results: Prevalent diabetes was higher in more-urbanised (men 12%; women 9%) vs less-urbanised (men 6%; women 5%) areas. In sex-stratified multilevel models adjusting for residential community and province, age and household income, there was a twofold higher diabetes prevalence in urban vs rural areas (men OR 2.02, 95% CI 1.47, 2.78; women, OR 1.94, 95% CI 1.35, 2.79). All urbanisation components were positively associated with diabetes, with variation across components (e.g. men, economic and income diversity, OR 1.42, 95% CI 1.20, 1.66; women, transportation infrastructure, OR 1.18, 95% CI 1.06, 1.32). Community-level variation in diabetes was comparatively greater for women (intraclass correlation [ICC] 0.03–0.05) vs men (ICC ≤0.01); province-level variation was greater for men (men 0.03–0.04; women 0.02).
Conclusions/interpretation: Diabetes prevention and treatment efforts are needed particularly in urbanised areas of China. Community economic factors, modern markets, communications and transportation infrastructure might present opportunities for such efforts.


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Attard, Samantha M.
Herring, Amy H.
Mayer-Davis, Elizabeth J.
Popkin, Barry M.
Meigs, James B.
Gordon-Larsen, Penny