关键词: 糖尿病, 慢性病共病, 非医疗处方, 血糖控制, 中介效应

Abstract: Background Against the backdrop of rapid population aging and the rising prevalence of diabetes, middle aged and older adults with diabetes face a substantial burden of comorbidities. However, systematic evidence on the long-term effects and mechanisms of non-medical prescriptions in delaying the progression of diabetes-related comorbidities remains limited. Objective To examine changes in the issuance of non-medical prescriptions and glycemic control among middle-aged and older adults with diabetes comorbidities, and to evaluate the role of non-medical prescriptions in delaying comorbidity progression and its mediating mechanism. Methods Data were drawn from four waves of the China Health and Retirement Longitudinal Study (CHARLS) conducted in 2011, 2013, 2015, and 2018. A total of 1, 731 adults aged ≥ 45 years with diabetes comorbidities were included to construct a dynamic cohort. Changes in comorbidity burden and patterns, issuance of non-medical prescriptions, and glycemic control were descriptively analyzed. Logistic regression models were used to assess the effect of physician-issued non medical prescriptions on the increase in comorbidities at the subsequent follow-up. Generalized Structural Equation Modeling (GSEM) was applied to examine the mediating effect of glycemic control. Results Among the 1 731 participants, the mean age was (60.4±9.0) years, with 42.9% aged 55-64 years. Most participants had an education level of junior high school or below (85.3%), and 46.6% were rural residents. During follow-up, the prevalence of comorbidities increased from 87.1% at baseline to 96.7% at the final wave, while the median number of comorbidities (including diabetes) rose from 3.3(2.0,4.0)to 4.9 (3.0,6.0). The issuance rate of non-medical prescriptions remained high ( ≥ 90.0%) across all waves and increased from 92.7% at F0 to 100.0% at F3. Dietary prescriptions (66.0%) and exercise prescriptions (57.4%) were the most frequently issued, while foot care prescriptions showed a marked increase (from 12.3% to 26.7%). Meanwhile, the glycemic control rate declined from 76.3% to 66.0%. Logistic regression and GSEM analyses indicated that physician-issued non-medical prescriptions were significantly associated with a lower risk of increased comorbidities at the subsequent follow-up (overall comorbidities: OR=0.666; traditional concordant comorbidities [TCC]: OR= 0.507). Mediation analyses further showed that non-medical prescriptions reduced the probability of overall comorbidity progression (β=-0.850, 95%CI=-1.583 to -0.116) and TCC progression (β=-2.901, 95%CI=-5.262 to-0.549) partly through improvements in glycemic control. Conclusion The comorbidity burden among middle-aged and older adults with diabetes increases with disease duration, comorbidity patterns become more complex, and glycemic control generally deteriorates, particularly among individuals with multiple comorbidities. As an essential component of comprehensive diabetes management, non-medical prescriptions may partially offset the adverse effects of comorbidity accumulation by improving glycemic control, thereby delaying the development and progression of diabetes-related comorbidities.

Key words: Diabetes mellitus, Multiple chronic conditions, Non-medical prescribing, Glycemic control, Mediation effect