Journal of Diabetes and Its Complications 26 (2012) 102–106

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Journal of Diabetes and Its Complications

j o u r n a l h o m e p a g e : W W W. J D C J O U R N A L . C O M

Diabetes and cardiovascular risk factor controls in Thai type 2 diabetes with no
history of cardiovascular complications; situation and compliance to diabetes
management guideline in Thailand
Patcharaporn Sudchada a,⁎, Chayada Khom-ar-wut a, Anuchit Eaimsongchram a, Saksipong Katemut a,
Piwadee Kunmaturos b, Rawisut Deoisares c
a
Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Pharmaceutical Care Research Unit, Naresuan University, Phitsanulok, Thailand
b
Department of Pharmacy, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
c
Department of General Medicine, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand

a r t i c l e i n f o a b s t r a c t

Article history: Background: Cardiovascular complication is one of the most important issues causing morbidity and death in
Received 1 March 2011 diabetic patients. Primary prevention is a key to prevent this complication.
Received in revised form 23 February 2012 Aims: The objective was to study the situations of diabetes and cardiovascular risk factor controls in Thai type
Accepted 25 February 2012 2 diabetic patients who had no history of cardiovascular complication at a university hospital in Thailand after
Available online 2 April 2012
the Thai diabetes management guideline was recently launched.
Methods: The study was a cross-sectional survey in type 2 diabetes patients with no history of cardiovascular
Keywords:
Diabetes
disease. Seven hundred and fourteen patients were enrolled in the study and 54.3% were females. The data
Cardiovascular were collected retrospectively from out-patient medical records and an electronic data base for the patients
Risk factors who were followed up at the hospital during January–December 2010. The most recent laboratory values
Thai were utilized in the analysis.
Results: 70%–90% of all patients were checked for HbA1c and lipid profiles (LDL-C, total cholesterol,
triglycerides) at least once a year. It was observed that only 28% of the patients had HbA1c b 6.5%.
Furthermore, the percentages of the patients who had blood pressure b 130/80 mmHg, and who had
LDL-C b 100 mg/dL were 28% and 41%, respectively.
Conclusion: Even though the practice guideline has been launched since 2008, diabetes, hypertension and
dyslipidemia were still poorly controlled. Further study is recommended to identify factors influencing these
outcomes as well as the policy of diabetic care in Thailand is needed to be seriously implemented.
© 2012 Elsevier Inc. All rights reserved.

1. Introduction diabetes patients do not know that they are having diabetes
(Aekplakorn et al., 2003; Bureau of Policy and strategy of Ministry
Diabetes is a chronic disease that affects quality of life and is a of Public Health, 2005).
main cause of morbidity and mortality of population worldwide Cardiovascular complication is one of the most frequent causes of
(Amos et al., 1997; International Diabetes Federation, 2003; Wild death and morbidity in type 2 diabetes patients (Centers for Disease
et al., 2004). World Health Organization (WHO) has predicted that Control and Prevention. National Diabetes Fact Sheet, 2007). A study
there will be patients with diabetes approximately 366 million in reported that more than 75% of diabetic patients died from
2030 (Wild et al., 2004). It is a challenge for health care professionals cardiovascular diseases (Davis et al., 1997). It has been known that
around the world to control the disease and its complications in 21st diabetes is an independent risk factor for cardiovascular disease and
century. In Thailand, there are about 20,000 diabetes patients who die hypertension and dyslipidemia are also modified risk factors for
each year. In addition, there are approximately 9.6 Thai people with prevention of cardiovascular disease. Therefore, glycemic, blood
age of more than 35 years old having diabetes and about 50% of pressure and lipid controls may help in reducing cardiovascular
complications in type 2 diabetes individuals (American Diabetes
Association, 2010; NCEP Expert Panel on Detection (ATP III), 2002).
⁎ Corresponding author. Pharmaceutical Care Research Unit, Department of The quality of diabetes care is not only able to control blood sugar
Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsa-
nulok 65000, Thailand. Tel: +66 55 961 830; fax: +66 55 963 731.
levels but it is also involved in comprehension of risk factor
E-mail addresses: patcharaporns2000@yahoo.com, psudchada@gmail.com management. Subsequently, it will help to prevent both macro-
(P. Sudchada). vascular and micro-vascular complications, decrease mortality as well

1056-8727/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.jdiacomp.2012.02.006
 P. Sudchada et al. / Journal of Diabetes and Its Complications 26 (2012) 102–106 103

as improve quality of life in these patients (American Diabetes diseases other than hypertension and dyslipidemia. Therefore, a total of
Association, 2006; Jappesen & Bek, 2004; The Diabetes Control and 714 individuals were included in the study analysis.
Complications Trial Research Group, 1993). The data were collected from out patient medical records and an
Asian countries including Thailand have faced issues of inadequate electronic hospital database. Patient demographics including age,
metabolic and hypertension controls in diabetic care that are needed gender, weight, medical history and medication used were collected.
to be urgently addressed (Nitiyanant et al., 2002). Emerging of type 2 However, the information of height was not available since it was not
diabetes is, therefore, a crucial problem in Thailand and causes recorded in the out patient medical records, therefore, the body mass
enormous economic burden to the country for the managements of index could not be calculated. Clinical related information was
the disease and its complications. A recent economic burden study divided into 2 category including process and outcome measures.
revealed the enormous economic burden from diabetes and compli- Process measures composed of the frequency of glycosylated
cation managements suggesting that serious and effective interven- hemoglobin (HbA1c), fasting blood sugar (FBS), low density lipopro-
tions are needed to prevent the disease or to slow progression as well tein-cholesterol (LDL-C), total cholesterol (TC), high density lipopro-
as to prevent the complications (Chatterjee et al., 2011). A previous tein-cholesterol (HDL-C), and triglycerides (TG) measurements for
study in Thai population in 2009 showed that about 70% of the each individual. Outcome measures included levels of HbA1c, FBS,
patients received yearly assessment for HbA1c and lipid profiles. LDL-C, HDL-C, TC, and TG at the last visit of each individual.
However, the outcomes showed that diabetes cardiovascular risk
factors were poorly managed. Of all the patients, only about 25% and 2.1. Statistical analysis
30% had the most recent HbA1c and LDL-cholesterol on target levels
(Kanchanaphibool et al., 2009). The statistical package for Social Science version 17.0 (SPSS Inc,
Over the past several years, there has been a concerted effort by Chicago, IL, USA) was utilized for the analysis. Data are presented as
professional organizations to establish the Thai diabetes management mean and standard deviation (SD), range, or percentage. The χ 2 test
guideline to help in improving diabetic care. Therefore, the current was used to compare the distributions of between groups. Student
Thai diabetes management guideline was launched in 2008 which t test and analysis of variance (ANOVA) were used to compare means
was established by a cooperation of Diabetes Association of Thailand, of values among groups.
the Endocrine Society of Thailand and National Health Security of
Thailand. As the evidenced based guideline supports that the effective
3. Results
strategy to reduce cardiovascular complications is by primary
prevention through controlling cardiovascular risk factors such as
3.1. Subject characteristics
hypertension, diabetes mellitus and hyperlipidemia which should be
the primary focus. In addition, it has been known that the differences
Of all 714 Thai type 2 diabetes patients with no history of
between what is recommended and what is actually practiced still
cardiovascular complication, 54% were females. The subject charac-
exist. Moreover, limited data are available for the situation and
teristics are summarized in Table 1. Of these, some patients were
compliance to the Thai guideline for diabetes and cardiovascular risk
excluded from the analysis for each clinical characteristic due to
factor controls as a primary prevention in Thai type 2 diabetes.
missing data on each specific value. Therefore, the number of patients
for each characteristic of individuals was not equal. Some patients did
2. Patients and methods not receive checks for some values or no data were recorded in the
outpatient medical records. The mean age of males and females was
This study was a retrospective cross-sectional survey study. The 58.4 ± 10.6 and 60.0 ± 11.0 (p = 0.048) years, respectively. Females
study was approved by the Ethics Committee of Naresuan University. Of had lower mean total body weight, serum creatinine, and hemoglobin
1876 Thai type 2 diabetes patients who were followed up at a university but higher HDL-C, compared to males (p b 0.001).
hospital during 2010, the patients were excluded if they were having
long-term follow-up at other hospitals, only coming for emergency 3.2. Medications
treatments or health checking visits, receiving insulin therapy, being
diagnosed of micro- and macro-vascular complications as reported in Subjects' medications used are illustrated in Table 2. Most of the
the electronic hospital data base, having cancer or other serious chronic subjects were on metformin and/or sulfonylureas for diabetes which

Table 1
Subject characteristics.

Patient characteristics Mean ± SD ⁎p-value Mean ± SD

(all patients)
Males Females

N N

Age (years) 326 58.4 ± 10.6 388 60.0 ± 11.0 0.048 59.3 ± 10.8
Weight (kg) 305 71.9 ± 13.0 354 64.6 ± 13.6 0.000 67.9 ± 13.8
SBP(mmHg) 309 136.0 ± 18.0 367 138.0 ± 20.0 N 0.050 137.0 ± 19.0
DBP (mmHg) 309 76.0 ± 11.0 367 76.0 ± 11.0 N 0.050 76.0 ± 11.0
LDL-C (mg/dl) 293 109.0 ± 37.0 337 107.0 ± 36.0 N 0.050 108.0 ± 37.0
HDL-C (mg/dl)) 293 44.0 ± 11.0 337 48.0 ± 12.0 0.000 46.0 ± 12.0
TG (mg/dl) 295 166.0 ± 85.0 338 155.0 ± 76.0 N 0.050 161.0 ± 84.0
TC (mg/dl) 295 184.0 ± 36.0 337 186.0 ± 39.0 N 0.050 185.0 ± 38.0
Non HDL-C (mg/dl) 292 140.0 ± 37.0 336 138.0 ± 39.0 N 0.050 139.0 ± 38.0
% HbA1C 269 7.1 ± 1.2 293 7.2 ± 1.4 N 0.050 7.2 ± 1.3
FBS (mg/dl) 313 136.0 ± 43.0 365 140.0 ± 47.0 N 0.050 138.0 ± 45.0

N, number of patients included in the analysis; SBP, systolic blood pressure; DBP, diastolic blood pressure; LDL-C, low density lipoprotein-cholesterol; HDL-C, high density
lipoprotein-cholesterol; TG, triglycerides; TC, total cholesterol; Non-HDL-C, non-high density lipoprotein-cholesterol; HbA1C, glycosylated hemoglobin; FBS, fasting blood sugar.
⁎ p value of independent Student t test between males and females.
104 P. Sudchada et al. / Journal of Diabetes and Its Complications 26 (2012) 102–106

Table 2 Table 4
Medications. Blood pressure control.

Medications Number of patients (%) Blood pressure All patients Number of patients (%)
(%) (N = 677)
All patients Males Females Males Females
(N = 714) (N = 325) (N = 388) (N = 309) (N = 367)

Diabetic medications SBP and DBP b 130/80 mmHg 192 (28.4) 98 (31.7) 94 (25.6)
1. Metformin 486 (68.1) 262 (67.5) SBP b 130 mmHg or DBP b 80 mmHg 272 (40.2) 117 (37.9) 155 (42.2)
2. Sulfonylureas 336 (47.1) 159 (48.9) 176 (45.4) SBP and DBP ≥ 130/80 mmHg 213 (31.5) 94 (30.4) 118 (32.2)
3. Pioglitazone 88 (12.3) 38 (11.7) 50 (12.9)
For abbreviations, see legend to Table 1.
4. Acarbose 17 (2.4) 8 (2.5) 9 (2.3)
5. Gliptins 2 (0.3) 1 (0.3) 1 (0.3)
Antihypertensives 156 (21.8) 69 (21.2) 86 (22.2) of blood pressure on the out-patient medical records. Therefore, a
1. Beta blockers total of 677 individuals were included in the analysis. Of these, it was
2. ACEIs or ARBs 353 (50.0) 158 (48.6) 194 (50.0)
3. Diuretics 158 (22.1) 66 (20.3) 92 (23.7)
observed that only 28% had blood pressures on target levels (BP b 130/
4. Calcium channel 165 (23.1) 74 (22.8) 91 (23.5) 80 mmHg), according to the Thai diabetes management guideline.
blockers When we considered systolic and diastolic blood pressure separately,
Antihyperlipidemia the number of subjects who had diastolic blood pressure at target
1 Statins 396 (55.5) 178 (54.8) 218 (56.2)
levels is more than that of systolic blood pressure. In addition, when
2. Fibrates 105 (14.7) 59 (18.2) 45 (11.6)
Antiplatelets classified by HbA1c levels, means of systolic and diastolic blood
1. Aspirin 294 (41.2) 134 (41.2) 160 (41.2) pressures among groups were not different (Table 5).
Angiotensin-converting enzyme inhibitors, (ACEI). Angiotensin receptor blockers, ARB.
For all of 436 patients with hypertension diagnosed, mean SBP and
DBP were 139 ± 18 and 76 ± 11 mmHg, respectively. Only 24.5% had
blood pressure on target levels (130/80 mmHg). For all of 241 patients
is a standard treatment recommended in the Thai Diabetes Manage-
with no hypertension diagnosed, mean SBP and DBP were 133 ± 20
ment Guideline. Angiotensin converting enzyme inhibitors (ACEIs) or
and 75 ± 11 mmHg, respectively. Of these patients, only 36.5% had
angiotensin II receptor antagonist (ARBs) was used in 81% of 436
blood pressure on target levels. Besides, the means of SBP and DBP
patients who had hypertension diagnosed. Statins and fibrates were
between the patients who were diagnosed with hypertension and
used in 84.6% and 22.4%, respectively, of 468 patients who had
who were not diagnosed with hypertension were not different (data
dyslipidemia diagnosed (data not shown).
not shown).

3.3. Outcome measures

3.3.3. Lipid controls
3.3.1. Glycemic controls
Table 6 shows lipid controls in these subjects. Of approximately
Table 3 shows the number of patients who had HbA1C and FBS
600 patients who had lipid profile checked, about 60% had LDL-C
falling into each category according to the Thai diabetes management
(N100 mg/dL), HDL-C (b40 mg/dL for males, b50 mg/dL for females)
guideline (Diabetes Association of Thailand et al., 2008) which
and non-HDL-C (N130 mg/dL) not on target levels. Majority of these
recommended target goals of glycemic controls of b6.5% for HbA1c
subjects (50%) had LDL-C level range of 100–159 mg/dL. For
and b120 mg/dL for FBS. HbA1c measurements were available for 563
triglyceride level, more than 45% had the levels N150 mg/dL. Of 241
subjects (78.9%). Of these, mean HbA1c was 7.2% ± 1.3 (Table 1) and
patients with no dyslipidemia diagnosed, 172 individuals were
only 28% had HbA1c on target levels (Table 3). In addition, fasting
assessed for LDL-C. Of these patients, 69.7% (120 patients) had
blood sugar (FBS) measurements were available for 675 subjects
LDL-C levels N 100 mg/dL (data not shown).
(94.5%). Of these, mean FBS was 138 ± 45 mg/dL (Table 1) and only
When classified by HbA1c levels, ANOVA analysis revealed that
about 37% had FBS level b 120 mg/dL (Table 3).
levels of triglycerides (p = 0.014), HDL-C (p = 0.027) and non-HDL-C
When we classified groups of patients by co-morbidities of
(p = 0.015) were different among groups (Table 7). In addition, pos-
hypertension and/or dyslipidemia, means of HbA1c and FBS were
hoc analysis showed that the group of HbA1c b 6.5% had significantly
not different among these groups (data not shown).
lower LDL-C (p = 0.012), non-HDL-C (p = 0.015) and higher HDL-C
(p = 0.047), compared to the group of HbA1C N 8% (Table 7).
3.3.2. Blood pressure controls
Blood pressure controls in the patients are given in Table 4. Of all
714 subjects, 37 were excluded from the analysis due to missing data 3.4. Process measures

Table 3 Table 8 shows the frequency of patients who were checked for
Glycemic controls.
process indicators, according to the Thai Diabetes Management
Laboratory All Number of patients (%) guideline. Of 714 patients, 73.4% were checked for HbA1c at least
values patients 2 times/year. More than 80% were checked for lipid profiles and
Males Females
serum creatinine at least once a year.
N N

HbA1C (%) (N = 562) Table 5

b6.5 159 (28.2) 269 79 (29.4) 293 80 (27.3) Blood pressure control in patients with different HbA1c levels.
6.5-7.9 298 (52.9) 140 (52.0) 157 (53.6)
≥8 106 (18.8) 50 (18.6) 56 (19.1) % HbA1c Numbers Mean ± SD
FBS (mg/dl) (N = 675) of patients
SBP DBP
b110 140 (20.7) 312 63 (20.2) 363 77 (21.2)
110-120 114 (16.9) 58 (18.6) 56 (15.4) b 6.5 154 136 ± 21 75 ± 11
121-160 308 (45.7) 146 (46.8) 162 (44.6) 6.5–7.9 275 138 ± 18 76 ± 10
161-200 61 (9.0) 24 (7.7) 37 (10.2) ≥8 102 136 ± 18 77 ± 12
N200 52 (7.7) 21 (6.7) 31 (8.5) All patients 531 137 ± 19 76 ± 11

For abbreviations, see legend to Table 1. For abbreviations, see legend to Table 1.
 P. Sudchada et al. / Journal of Diabetes and Its Complications 26 (2012) 102–106 105

Table 6 Table 8
Lipid control. Process measures.

Laboratory values Number of patients (%) Process indicators Number of patients

N = 714 (%)
All Males Females
subjects 1. Patients were checked for HbA1c at least 2 times a year 524 (73.4)
N N
2. Patient were checked for Total cholesterol at least once 610 (85.4)
TC (mg/dl) (N = 633) a year
b 200 441 (69.7) 295 214 (72.5) 337 227 (67.4) 3. Patient were checked for HDL-cholesterol at least once 608 (85.2)
200–239 142 (22.4) 63 (21.4) 79 (23.4) a year
≥ 240 50 (7.9) 18 (6.1) 31 (9.2) 4. Patient were checked for triglyceride at least once a year 608 (85.2)
TG (mg/dl) (N = 634)
For abbreviations, see legend to Table 1.
b 150 349 (55.0) 295 150 (50.8) 338 199 (58.9)
150–199 139 (21.9) 72 (24.4) 67 (19.8)
≥ 200 146 (23.0) 73 (24.7) 72 (21.3) target goals. Besides, no one had all of HbA1c, blood pressure and lipid
HDL-C (mg/dl) (N = 631)
profiles on target levels.
N 40 for males or 282 (44.7) 293 170 (58.0) 337 112 (33.2)
N 50 for females For antiplatelet therapy, the current Thai guideline recommends
LDL-C (mg/dl) (N = 611) prescribing aspirin to diabetic patients who have age of more than 40
b 100 252 (41.2) 286 111 (38.8) 324 140 (43.2) years old and/or have other cardiovascular risk factors (Diabetes
100–129 221 (36.2) 112 (39.2) 109 (33.6) Association of Thailand et al., 2008). A recent review has discussed on
130–159 91 (14.9) 44 (15.4) 47 (14.5)
≥ 160 47 (7.7) 19 (6.6) 28 (8.6)
uncertain balance of aspirin therapy as primary prevention for
Non HDL-C (mg/dl) (N = 629) cardiovascular diseases (Pignone et al., 2010). The authors discussed
b 130 268 (42.6) 292 115 (39.4) 336 153 (45.5) about the risk and benefit balance of using aspirin as a primary
130–159 202 (32.1) 104 (35.6) 98 (29.2) prevention for cardiovascular disease. The review provided the
160–189 105 (16.7) 52 (17.8) 53 (15.8)
opinion that aspirin may have no effect on either total or
≥ 190 54 (8.6) 21 (7.2) 32 (9.5)
cardiovascular mortality. Even though aspirin may have some
For abbreviations, see legend to Table 1.
benefits in reducing stroke and myocardial infarction in some
populations, the risk of bleeding is increased, especially in the elderly.
4. Discussion Therefore, aspirin therapy should not be warranted as a primary
prevention for all diabetes patients and before starting the treatment,
Since the Thai diabetes management guideline was launched in the risks and benefits should be weighed for each individual.
2008, no study has investigated the impact of the guideline on However, in this study, we did not look into the reason for each
diabetes and cardiovascular risk factor control, in particular, as a patient being or not being on aspirin as a primary prevention for
primary prevention. In the present study, therefore, we aimed to cardiovascular diseases. In addition, the latest review (Pignone et al.,
study the situations of diabetes and cardiovascular risk factor controls 2010) suggests that our diabetes management guideline needs to be
and compliance to the guideline in type 2 diabetic patients who had reviewed for the role of antiplatelet therapy as a primary prevention
no cardiovascular complication. for cardiovascular diseases in type 2 diabetes patients.
Diabetes outcomes on controls in type 2 diabetes individuals were For antihypertensive drugs, it was observed that approximately 50%
studied across Asian regions in 1998 including Thailand. The results of all the patients or 80% of the patients who were diagnosed of having
revealed that poor HbA1c and FBS controls were noted (Nitiyanant hypertension were on ACEIs or ARBs. In our guideline, ACEI or ARBs are
et al., 2002). Besides, the study by Ngarmukos et al. 2006 reported that suggested to be the first line drugs in the treatment of hypertension in
of these patients, only 18% had blood pressure less than 130/80 mmHg diabetic patient (Diabetes Association of Thailand et al., 2008) since
and 25% had HbA1c b 7% (Ngarmukos et al., 2006). Although, the Thai their benefit in slowing progression of renal impairment in these
guideline for diabetes management was established and more than patients has been proven (American Diabetes Association. Standards of
70% of theses patients were checked for HbA1c, a similar trend was medical care in diabetes et al., 2010; Chobanian et al., 2003). There were
noted for our study in which less than 30% had HbA1c and blood only about 30% of these patients who could achieve the goal of blood
pressure on target levels. In terms of lipid management, the results of pressure (130/80 mmHg). Similar findings were found in hypertension
Thailand registry project (Pratipanawatr et al., 2006) determined the therapy, 50% of the patients were treated with statins, however, only
prevalence of dyslipidemia in adult Thai type 2 diabetes in university about 40% achieved goal of LDL-C (b100 mg/dL). These evidences
and tertiary care hospitals. Of all 9419 diabetes individuals, more than suggest that more aggressive interventions are urgently needed to be
80% had dyslipidemia and only 40% who were on lipid-lowering adopted in order to minimize cardiovascular risks in these patients.
medications reached the target LDL-C (Pratipanawatr et al., 2006). In A number of factors have been recognized affecting diabetes and
this present study, although most of the patients were monitored for complication controls such as education levels, compliances, care
lipid profile annually, less than 50% had LDL-C, HDL-C, non HDL-C on receive, number of tablets and frequency burden as well as family and
social supports. In the present study, we did not look into the real
reasons why most of the patients had poor controls on these
Table 7 outcomes. In the past, the accessibility of Thai health care system
Lipid controls in patients with different HbA1c levels. may be the important issue. However, with the Universal Coverage
% HbA1c Mean ± SD (Numbers of patients)
policy since 2002, the accessibility has improved enormously. From
our perspectives and practice experience, issues of patient adherence
TC TG HDL-C LDL-C Non-HDL-C
on their life-style management and taking medication are still crucial.
(mg/dL) (mg/dL) (mg/dL) (mg/dL) (mg/dL)
Moreover, we have still been facing insufficiency of health care
b 6.5⁎ (N = 155) 179 ± 34 145 ± 60 48 ± 14 104 ± 34 132 ± 34
professionals including physicians, pharmacist, and nurses. Since
6.5–7.9 (N = 281) 184 ± 37 161 ± 84 45 ± 11 109 ± 38 139 ± 37
≥ 8⁎ (N = 102) 191 ± 44 172 ± 80 44 ± 11 112 ± 39 146 ± 45
overloaded numbers of patients visit the hospital, individual care
All subjects (N = 538) 184 ± 37 157 ± 72 46 ± 12 108 ± 37 108 ± 37 could not be given effectively. Therefore, they may have poor
For abbreviations, see legend to Table 1.
understanding about the disease and its complications. These
⁎ Post hoc analysis showed that TC (p = 0.038), TG (p = 0.020), Non-HDL-C problems have been in our country for decades and have not yet
(p = 0.006) between group of HbA1C b 6% and group of HbA1C ≥ 8% are different. been corrected properly. Moreover, the counseling criteria for the
106 P. Sudchada et al. / Journal of Diabetes and Its Complications 26 (2012) 102–106

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