title: Multilevel examination of diabetes in modernising China: what elements of urbanisation are most associated with diabetes?
abstract: OBJECTIVE
  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
  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.
authors.affiliation: Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 123 West Franklin Street, Chapel Hill, NC 27516-3997, USA.
authors.forename: S M
authors.initials: SM
authors.lastname: Attard
authors.forename: A H
authors.initials: AH
authors.lastname: Herring
authors.forename: E J
authors.initials: EJ
authors.lastname: Mayer-Davis
authors.forename: B M
authors.initials: BM
authors.lastname: Popkin
authors.forename: J B
authors.initials: JB
authors.lastname: Meigs
authors.forename: P
authors.initials: P
authors.lastname: Gordon-Larsen
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001786:Blood Glucose / Q000378:metabolism*; D015992:Body Mass Index; D002681:China / Q000453:epidemiology; D003924:Diabetes Mellitus, Type 2 / Q000097:blood* / Q000453:epidemiology* / Q000517:prevention & control; D004522:Educational Status; D005260:Female; D006442:Glycated Hemoglobin / Q000378:metabolism*; D006306:Health Surveys; D006801:Humans; D008297:Male; D008875:Middle Aged; D009752:Nutritional Status; D015995:Prevalence; D011634:Public Health; D017678:Sex Distribution; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D014505:Urban Population / Q000706:statistics & numerical data*; D014507:Urbanization
chemical_list: D001786:Blood Glucose; D006442:Glycated Hemoglobin; C517652:hemoglobin A1c protein, human