A Framework for T2D Management & Knowledge Discovery of

Complications in the Context of Chinese Culture: From Triggers to

Causalities

Mujiexin Liu

, Jianqiang Xiao

1,*

, Dazheng Zhang

and Zhidong Jia

Ineye Hospital of Chengdu University of TCM, Jinniu District, 610084, Chengdu, Sichuan, China

Chengdu University of Traditional Chinese Medicine, 610075, Chengdu, Sichuan, China

Chengdu Neusoft University, Qingchengshan, 611844, Sichuan, China

Keywords: Type II Diabetes Management, Symptoms, Patterns, Complications, Correlations, Knowledge Discovery.

Abstract: Background: With the ever-increasing number of Type-2 Diabetes (T2D) patients and its mortality rate in

China, the medical care system is under huge pressure with all other related complications in the world's

largest population. Failing to afford the needed resources on T2D management after patients leaving the

hospital, the burden and challenges of diabatic complications have become more acute than ever. In the

context of the Chinese culture, especially the habits and priority of eating in the daily life makes it even harder

for T2D patients to control and manage. Limited knowledge of complications and their causalities are the

biggest challenges faced by doctors all around the world. Only with the knowledge on the progression and

evolution of T2D and its complications can doctors have the opportunity to find solutions. To tackle this

daunting challenge, a system is in urgent need that can collect the real-time, patient-generated data which will

unveil the patterns about the triggers and causalities for better decision-making and, in the long run, provide

an overarching understanding of the progression and evolution of T2D and its complications.

Methods: To systematically place the data in the hands of patients, knowledge discovery based on data mining

for the proposed framework can be of very high feasibility and accuracy. The triggers, anomalies in patients'

daily life, remind patients to provide the related data input for the analysis of the risk factors, patterns, and

causalities of complications in the progression of T2D. Behind the triggers, the related known symptoms

correlated with the internal organs, are classified by their severity and locations in bodies. Distant-aid like first

responders will be arranged if very high-risk factors occur. Auto responses of suggestions will be given to

patients if the condition is not urgent. The discovered patterns and causalities will be stored in the knowledge

pool for future research and medicine development.

Results:

1. The associations between and among the internal organs brought about by the patterns behind the triggers

under urgent and non-urgent situations will give us answers to the current puzzles of the end-stage

complications.

2. Supported by the updates of patient-provided data on the anomalies going on in their bodies, the data mining

output of the correlation between internal organs and different complications can be of high accuracy with the

"1 to 1", "1 to n" and "n to 1" relationships between symptoms and organs, organs and organs.

3. The collected symptoms correlating to the pathological changes of each individual internal organ can reshape

our understanding about the functions of their own and as a part of the whole system of the human body.

4. The patterns of the known and newly discovered complications and their causalities will help doctors gain

an overarching understanding of the progression and evolution of T2D and its complications.

5. The discovered knowledge will help doctors anticipate the upcoming progressions of diseases at an expert

level with the level of comprehension well beyond the individual physician’s practice experience.

Conclusions: With the application of this framework to the management of T2D and other chronic diseases for

different groups of users, its knowledge pool will be continually enriched and enlarged. Its scalability on

diseases and causalities will probably change many current definitions and enlarge the boundary of medical

science.

554

Liu, M., Xiao, J., Zhang, D. and Jia, Z.

A Framework for T2D Management Knowledge Discovery of Complications in the Context of Chinese Culture: From Triggers to Causalities.

DOI: 10.5220/0011374200003438

In Proceedings of the 1st International Conference on Health Big Data and Intelligent Healthcare (ICHIH 2022), pages 554-564

ISBN: 978-989-758-596-8

1 INTRODUCTION

Type-2 Diabetes (T2D) and its ineffective

management have been challenging the health of a

very large population in China. By the figures given

in the IDF Diabetes Atlas Ninth edition 2019,

approximately 463 million adults (20-79 years) had

been living with diabetes; by 2045 this will rise to 700

million. According to the most recent study of the

prevalence of T2D in mainland China, by the standard

of HbA1c ≥6.5%, the average percentage of

diagnosed and premature T2D has reached 12.8%,

which means almost half of the adult population

suffer from the dysfunction of the glucoregulatory

system with a fast-growing tendency after age 50. (Li,

et al., 2020) The total number of people with T2D has

reached about 1.164 million in China, the largest in

the world. The percentage of diabetes among people

above 60 has reached more than 20% by 2016. (Yang,

Lu, Weng, et al. 2010) With the obesity rate for adults

over 18 already at 11.9% in 2015, the harm of

hyperglycemia goes on before the premature stage till

the occurrence of all kinds of end-stage complications

related to cardiovascular diseases, microangiopathy,

cancer, stroke, Alzheimer's disease, and depression.

(Report on nutrition and chronic diseases of the

Chinese population 2015, Chinese Medical

Association, Diabetes Branch 2018) Proportion of

microalbuminuriax, macroalbuminuria, and renal

failure in patients with T2D nephropathy has reached

25.26%, 4.34%, and 7.03% respectively. 14.9% of the

patients suffer from retinopathy while 24.05% have

diabetic peripheral neuropathy. (ADA 2019) 10.56%

of all patients who went through peripheral artery

disease tests (PAD tests) such as Ankle-Brachial

Index (ABI), angiograms, ultrasound, or MRI got

diagnosed with peripheral artery disease. (ADA

2019) Out of 33.9% of patients with cardiovascular

disease, 94.9% put up with atherosclerotic

cardiovascular disease (ASCVD). (Hong, Mosenzon,

Alguwaihes, Arenas Leon, et al. 2020) All these

problems pose a huge burden to the health system and

great risks to the wellbeing of T2D patients.

T2D management is the crucial part of the whole

course of prevention, intervention and treatment of

complications rather than just screening for the end-

stage ones. At present, insulin administration is the

main treatment for T2D patients, when

hyperglycemia cannot be controlled through diet,

exercise, and oral medication. (Kavakiotis, Ioannis,

Tsave, Olga, Salifoglou, Athanasios, Maglaveras,

Nicos, Vlahavas, Ioannis, Chouvarda, Ioanna 2017)

But according to Research Report on Burden of

Injection and Administration of Diabetic Patients,

90% of patients around the world who administer

daily injections think this therapy is impacting their

normal way of life; 72% think the inconvenience of

injection has a negative effect on following doctor's

orders; 32%

Figure 1: Prevalence of diabetes in China and around the

world from 1990 to 2017. Credit: Xiaoxue L, Chuanhua Y,

et.al. Trends in the Incidence and Mortality of Diabetes in

China from 1990 to 2017: A Joinpoint and Age-Period-

Cohort Analysis. CMR: crude mortality rate; ASMR: age-

standardized mortality rate.

gave up injection therapy because of the

inconvenience. (IQVIAA Study of the Burden of

Administration Modalities in Patients with Injectable

Hypoglycemia.) Similar problems exist among T2D

patients in China. According to a one-year cohort

study by He, et.al., the mean medicine preservation

rate (MPR) of T2D patients only reached 0.499 with

14.1% and 29% of discontinuations in the first month

and the first three months respectively. Only 53% of

the patients remain persistent, where the average time

to non-persistence in the study was 230.3 days. (Zhao,

et al. 2019) Apart from that, data from a survey by

Liu Xiaoxue, et.al. show that 39.1% of the

respondents reported experiencing at least one insulin

injection-related needle-stick injuries (NSIs) and

3.2% reported HBV infections while 0.9% had HCV

infection as a result of NSIs. (Liu, et al. 2020) As a

result, the prevalence of complications and mortality

have always been on the rise in China as shown in

figure 2 and 3. (Nam, et al. 2011, Ma, Ronald 2018,

Lee, Keen, Bennett, Fuller, Lu 2001))

Studies on the complications caused by T2D have

been few and information on their causalities is very

limited. This is mostly due to the absence of

symptom-based triggers or alarms for both patients

and doctors to get actively involved in generating data

and

feedback.

(Chaki,

Jyotismita,

al.

2020)

Even

A Framework for T2D Management Knowledge Discovery of Complications in the Context of Chinese Culture: From Triggers to

Causalities

555

Figure 2: The mortality rate of diabetes classified by sex

groups from 1990 to 2017. Credit: Xiaoxue L, Chuanhua Y,

et.al. Trends in the Incidence and Mortality of Diabetes in

China from 1990 to 2017: A Joinpoint and Age-Period-

Cohort Analysis. CMR: crude mortality rate; ASMR: age-

standardized mortality rate.

with machine learning and artificial intelligence

applied in various products, most of them have not led

to practical solutions for real-world problems. (Yao,

Grace, et al. 2002) Without data to trace down the

correlation between T2D and internal organ's

deterioration and dysfunction going on in the course

of diabatic progression and evolution, it is hard for

doctors to make decisions or provide the needed

intervention and treatment in time. Individualized

plans and services are for sure out of the question.

Therefore, this paper aims to propose a conceptual

framework using the anomalies in patients' daily life

in correlation with the internal organs as triggers to

collect the patient-generated data in order to discover

patterns in the progression and the evolution of T2D

and its complications and form an overarching

understanding of the causalities in the context of the

Chinese culture.

2 THE CULTURAL CONTEXT OF

T2D MANAGEMENT IN CHINA

In western countries, over 75% of individuals

diagnosed with T2D receive exclusive care from

primary care providers. Yet, only about one-third of

patients correctly follow the health care provider's

directions for T2D management. (Gao, et al. 2017) In

China, doctors do a very good job educating patients

for glucose monitoring and control, food intake, and

the need for regular exercises while they are in the

hospital for deciding their dose of insulin injections

or hypoglycemic agents. It all depends on the patients

to manage and take care of themselves once they

leave the hospital. When it comes to complications,

doctors have little clue about what has caused them or

how they have developed. What's more, in the current

health care system in China with the increasing

numbers of patients and types of diseases,

overstretched doctors can spare at most 5 to 10-min

for each office visit. For patients, it is a headache just

think

about

the

large

crowds,

long

lines,

and

Figure 3: Cause-specific mortality rate associated with diabetes complications in China. Figure credit: Ronald C, W. Ma,

Epidemiology of diabetes and diabetic complications in China. Diabetologia 61.6 (2018): 1249-1260. Data credit: Lee ET,

Keen H, Bennett PH, Fuller JH, Lu M (2001) Follow-up of the WHO Multinational Study of Vascular Disease in Diabetes:

general description and morbidity. Diabetologia 44(Suppl 2): S3–S13.

ICHIH 2022 - International Conference on Health Big Data and Intelligent Healthcare

556

prescription. It is also expensive to stay in the hospital

for the needed adjustments or the change of

medications. For convenience, patients tend to be

easily convinced by the salespersons in pharmacies

for the promoted OTC medicines. The huge market

potential has brought about the fierce competition for

users among T2D management applications and

platforms implemented with machine learning and

AI. Unfortunately, most of the products have been

unsuccessful and costly for the mere responses on the

collected data of the glucose, blood pressure, daily

exercises rather than the real-time conditions that

T2D patients suffer from in their daily life.

(Wasserman, Jason Adam, and Brian Philip Hinote

2011).

T2D and its complications, being endemic, have

other cultural factors to be considered in the

management, which include food and dietary

preference, lifestyles, and beliefs about general

health. (Shumaker, Schron, Ockene, McBee 2004,

Diabetes Reduces the Rate of Sputum Culture

Conversion in Patients with Newly Diagnosed

Multidrug-Resistant Tuberculosis) In Chinese

culture, the freedom to enjoy food plays a critical role

in one's quality of life. (Nam, et al. 2011) Thus, the

food culture in China creates all kinds of barriers and

numerous problems for T2D patients, making it

unbelievably hard for them to handle their

management. Together with the general belief about

health in the Chinese society that patients with

chronic medical problems gradually become experts

themselves, T2D management in China is a tough war

against the limited healthcare resources, the natural

instinct, social pressure, eating habits and preference,

and the confusing information in this age of self-

media.

When we look into the food structure in China,

though the proportion of protein and vegetables has

been growing, the intake of carbohydrates has stayed

inordinate. People throughout the country start their

day with dumplings, deep-fried dough sticks,

noodles, porridge, and pancakes. Lunch is always

built upon rice or noodles. And dinner consists of

steamed bread, dumplings or pancake with porridge

and a few dishes of vegetables or pickles. What's

more, most people feel that they are never full without

a bowl of rice or noodles no matter how many dishes

they have eaten at a meal. The increasing number of

dishes on the Chinese dining tables means a

significant increase in the total amount of vegetable

oil, animal fat, sugar, and salt. Though the awareness

of a healthy life has been increasing among the whole

population, the busy life leaves little time for regular

physical exercises, which is another reason for the

increasing numbers of hyperlipidemia,

hyperglycemia, hypertension, and obesity in this

country.

Eating in China is forever the highest priority in

everyday life. Eating well is considered as the most

basic enjoyment, freedom, and the meaning of life.

Varieties on the daily menu are a must for every

family, and feasts at weekends and festivals have

been a routine. Meals for social purposes are hard to

turn down. The normality on these occasions is to

include as many good dishes as possible and the

hosts/hostesses will try their best to push people to try

everything on the table to show their hospitality.

Wine and liquor are proposed and taken as signs of

respect and gratitude to others. More will be poured

if one takes up and finishes the glass even if the

person is not good at drinking or has stated the

medical or other reasons. T2D patients have to face,

involve and interact with others on such occasions,

where it is socially unacceptable to refuse and

impossible for them to resist the good food or to

follow the strict limitations on food intake. And the

thought of just trying a little of each dish often results

in the intake of food out of the right order with

carbohydrates and energy considerably exceeding the

right amount for T2D patients.

Also, the confusing and misleading information

from the internet and peer experience make T2D

management even harder. With the general belief of

health in China, it is not hard to assume how much

more T2D patients fail to correctly follow the health

care provider's directions than the two-thirds out of

75% of patients in western countries. (Jason Fung)

Many patients tend to trust their perception when they

change their medications with over-the-counter

medicines without asking doctors for their advice

until they encounter serious troubles. To manage T2D

at the national level, the guidelines in the Treatment

and Prevention Guide for Type 2 Diabetes in China

(version 2017) on the homepage of China CDC give

clear directions: 1) collecting data about the patients'

condition, knowledge, behaviors, and psychology; 2)

pinning down the problems; 3) making plans for

management and treatment; 4) providing the planned

individual service; 5) giving feedback for adjusting

the plan. To put these jobs down to earth, we need to

pin down the triggers, find patterns supported with

valid data about the causalities and evolutions of all

diabetic complications.

A Framework for T2D Management Knowledge Discovery of Complications in the Context of Chinese Culture: From Triggers to

Causalities

557

3 TRIGGER ANALYSIS FOR T2D

MANAGEMENT

In the context of this culture, it is obvious that most

of the diseases and anomalies are the consequences of

the unregulated food structure and intake. There are

too many variables to consider if we require patients

to provide the details of their daily meals. And it is

really hard to give the right directions on what and

how much exercise to take without the information of

patients' current physical conditions. In the course of

insulin injection treatment and T2D management,

patients tend to be numb about the physical anomalies

as long as they see that their glucose level is under

check. It is exactly these physical discomforts and

anomalies that build up the complications. Just like

other diseases, only when people feel the physical

discomfort, pain or anomalies, can they be alarmed to

ponder about the reasons or whether they should go

to the hospital. Thus, to collect such patient-generated

data on their daily problems for the knowledge

discovery about the evolution of the T2D

complications, the symptoms that can alarm the

patients and push them to turn for help should also be

recorded and used as triggers apart from the most

recent records of the glucose level and blood pressure.

Thirst

Diabetic thirst, or diabetes polydipsia, is caused

by hyperglycemia which exhausts the kidneys in

producing an excessive amount of urine and

dehydrates the patients. The odds ratio of having the

symptom of abnormal thirst is 1.37 times higher (1.17

to the power of 2) for someone with an FPG=11

mmol/L than for someone with an FPG=9 mmol/L

(all other covariates being the same). (Drivsholm, de

Fine Olivarius, Nielsen, & Siersma, 2005) Long-term

polyuria can cause nausea, dizziness, headaches,

fainting, and eventually uremia.

Urine problems

As the consequences of food, water, and drinks,

urine problems are directly related to the

functionalities of the bladder and kidneys. Patients

with T2D, often suffer from pain and burning before,

during, and after urination; passing only a small

amount of urine after strong urges; trouble starting,

and a weak stream of urine. Apart from these

uncomfortable feelings, their urine is often with

bubbles and a strong stench. For female patients, T2D

independently increases the risk of urinary

incontinence. (Lifford, Karen, et al. 2005)

Hard stool and diarrhea

With the progression of T2D, many patients often

suffer from hard stools - as hard as pebbles

sometimes. This is not just a sign of constipation, or

only related to the bowels. The hard stool is the

outcome of a combination of factors such as dry or

inflamed digestive tracts. Apart from persistent

hyperglycemia and the history of having T2D as the

factors for diarrhea, cold and unsanitary food intake

are also a strong trigger in China. In diabetic patients,

metformin is a common cause of diarrhea. (Gould,

Milena, and Joseph H. Sellin 2009) Diabetic patients

are more likely to have associated diseases (e.g.,

celiac sprue and microscopic colitis) that present with

diarrhea as the sole complaint. (Gould, Milena, and

Joseph H. Sellin 2009) Ingested sugar-free foods that

may contain sorbitol or other agents can cause

diarrhea in T2D patients. Finally, diabetic

enteropathy can itself cause diarrhea. (Gould, Milena,

and Joseph H. Sellin 2009) Chronic diarrhea can

bring about further complications.

Sputum

Diabetes is a risk factor for active tuberculosis

(TB). (Kotlarsky, Pavel, et al. 2015) Thin and thick

mucus often fails to alert patients in China, who often

think of it as the consequence of cold weather or

smoking. On the contrary, they are not only related to

the lungs but also possibly to the whole

gastrointestinal system.

Sweat

Diabetes itself makes it hard to maintain a steady

body temperature. Excessive, insufficient sweat or

sweating at odd times are strong signs of many

complications. Hyperhidrosis is very common among

T2D patients. But it is still unclear when it occurs and

what the underlying causes and effects are on the

internal organs. Sweating speeds up the deterioration

of organs by driving T2D patients to drink and urinate

more. Abnormal sweating is one of the earliest

detectable neurophysiological abnormalities in small

fiber peripheral neuropathy. (Simpson, John 2018)

Heartbeat

T2D patients often suffer from shortness of breath,

sweating, rapid and irregular heartbeats, which are all

symptoms of heart diseases that might be directly

related to the spike of blood glucose. They may also

be directly related to sleeping, emotional and digestive

problems. Without such knowledge, people may

suspect straight away that they are suffering from

heart troubles. Recent observational studies indicate

the associations of insulin treatment with an increased

risk of developing or worsening pre-existing heart

ICHIH 2022 - International Conference on Health Big Data and Intelligent Healthcare

558

failure with higher mortality rates, but with little

evidence. (Didangelos, Triantafyllos, and

Konstantinos Kantartzis 2020)

Pains

T2D patients with difficulties in glycemic

management and following a recommended exercise

plan often have chronic pains. (Krein, Sarah L., et al.

2005) Headache is common among T2D patients due

to hypertension and hyperglycemia. Toothaches and

dental problems are high at risk when the blood sugar

is poorly controlled. T2D is also associated with

higher pain severity in people with localized

osteoarthritis. (Alenazi, Obaidat, Alshehri,

Alothman, Gray, Rucker, Waitman, Kluding 2020)

Findings by Lorenzo, et.al suggest that uncontrolled

diabetes may contribute to the development of

chronic back pain. (Rinaldo, Lorenzo, et al. 2017)

Weight changes

Insulin causes significant weight gain and may

also cause serious episodes of hypoglycemia.

(Didangelos, Triantafyllos, and Konstantinos

Kantartzis 2020) Both sharp weight gain and loss in a

short period are the results of poor control of blood

sugar. Some people with T2D regard weight gain as a

positive sign of being healthy especially when their

complexion is good. One study by French S, et.al.

demonstrated that the risk of diabetes was twofold

higher in the participants whose weight fluctuated

compared to those with stable weight or moderate

fluctuation in a short-term follow-up. (Park, Kye-

Yeung, et al. 2019)

Strong emotions

Diabetes distress is a prominent issue in people

with T2D which is associated with female gender and

comorbid depressive symptoms. It is important to

consider the relationship between diabetes distress

and depression, as we look into the significant overlap

between conditions. (Perrin, et al. 2017) When the

glucose level is out of control, people with T2D

become moody without being aware of their anger,

irritability, sadness, and aggressiveness. They don't

want to talk to people and become upset very easily,

which makes communication with others very

difficult. Having trouble concentrating or thinking

clearly makes them nervous and pessimistic. Their

low energy level often makes them very frustrated

and tired. In such a state, they need directions to

control their daily emotions. Doctors need to know

what is going on in the internal organs instead of just

taking it as a psychological issue.

Sleeping problems

T2D has shown to be associated with a higher

incidence of sleep disorders, which may be due to the

disease itself, secondary complications, or the

associated comorbidities. (Khandelwal, Deepak, et al.

2017) Both high and low blood sugar cause various

sleeping problems: having trouble falling asleep, very

shallow sleep, short sleep, and waking up at night.

Poor sleep can bring about many problems to people

with T2D, and be a very strong trigger for them to

seek solutions.

Leg swelling

Swelling in the lower body including legs, ankles,

and feet caused by a buildup of fluid in the body

(Water Retention) is a common symptom and one of

the benchmarks of T2D. Other symptoms that occur at

the same time will change our understanding of the

functions of some internal organs. Diabetic muscle

infarction (DMI) is a rare microvascular complication

of spontaneous ischemic necrosis of skeletal muscle in

patients with poorly controlled diabetes. (Seaman,

Callie, et al. 2019) As a less commonly reported

complication due to poorly controlled T2D associated

with multiple end-organ microvascular sequelae, the

occurrence of painful swelling of muscles, particularly

of lower limbs, should raise suspicion of DMI.

Increased clinical awareness is important for early

recognition, particularly in a diabetic patient

presenting with a painful thigh or leg swelling.

(Jevalikar, Ganesh, et al. 2019, Grigoriadis, et al.

2000)

These triggers, the high alerts on the physical

changes in what people with T2D can see and feel in

their daily lives, are the causes of all different kinds

of complications. They can push T2D patients to

check how serious their problems are and work much

more effectively than "motivations" just for

monitoring the blood sugar without the information

about their daily problems and the needed guidance.

As these triggers are all connected with the internal

organs, the patterns found in the future will build up

a knowledge pool that will not only navigate patients

to understand their conditions and the needed actions

but also provide the evidence for the doctors' timely

intervention, treatment, and research.

A Framework for T2D Management Knowledge Discovery of Complications in the Context of Chinese Culture: From Triggers to

Causalities

559

Figure 4: The framework for diabetes patient management and knowledge discovery based on Knowledge Discovery in

Database (KDD).

4 THE FRAMEWORK FOR T2D

MANAGEMENT AND

KNOWLEDGE DISCOVERY

With a patient-controlled interface, this framework

integrates patient-generated real-time data with the

EMR, EHR, and physical examination records. By

using the anomalies of T2D patients in their daily

lives as triggers, patients go through and check all

thesymptoms, correlated with the internal organs,

they are suffering at the moment. For serious cases,

patients will be required to upload related evidence

that will be analyzed by the system to support the

doctors' decision-making. If not, the system will give

suggestions on their management. The aggregation of

these data will gradually identify the risk factors for

early intervention and unveil the underlying

biological pathways of T2D complications. New

patterns and their pathologies will be captured,

analyzed by the system, and stored in the knowledge

pool, which will paint an overarching picture about

the relationships between the triggers and the

causalities on the evolution of T2D complications.

To systematically place the data in the hands of

patients, they need to log in with any of the personal

data like the name or ID number with the most recent

records of their glucose level and blood pressure. To

help patients pin down their problems quickly, the

drop-down list of the triggers in the system will

remind them of the anomalies they may have at the

moment with all the related symptoms that are used

as part of data input. When acute and severe

symptoms are marked under one trigger, patients will

be guided to check for other related symptoms and

asked to upload pictures and videos if the evidence is

needed. Even if they don't have serious physical

problems, these triggers can still serve as reminders

for them to check about their current conditions for

learning, risk management, and prevention.

Behind the triggers, the mapping of all the related

symptoms to the corresponding internal organs is the

most basic rule of this framework. The symptoms

should be classified by their severity and body parts.

All the input symptoms behind each trigger start with

the ones that are very closely related to T2D, guiding

patients to check other possible symptoms that are not

directly related but common with complications.

Many of the symptoms in one group may overlap with

those in others. For example, strong thirst, a very

common symptom of T2D, may also be caused by

xerostomia or long-term diarrhea. Weight loss,

another strong alert of T2D, may also be caused by

inflammatory bowel disease. In other words, one

symptom may trigger patients to go through many

other ones to help form the picture of the evolution of

T2D complications.

As T2D complications affect all organs, all the

input symptoms also include those of different

complications that correlate with the corresponding

internal organs. (Alicic, Radica Z., Michele T.

Rooney, and Katherine R. Tuttle. 2017) Supported by

the known symptoms and their relationships with the

internal organs, the output of data mining can be of

high accuracy. The patterns captured can be various

with the "1 to 1", "1 to n", and "n to 1" relationships

between symptoms and organs, organs and organs.

With the increase of users over time, new patterns of

T2D and the complications can be discovered and

verified. Over time, a network of disease connections

ICHIH 2022 - International Conference on Health Big Data and Intelligent Healthcare

560

can be formed for doctors, researchers and machine

learning models to learn and apply. Across the board,

all the patterns captured in the future will give us full

pathways of T2D progression and complications.

Some will fill up the gaps about the evolution of all

the known end-stage complications of diabetes

nephropathy (DN), diabetes retinopathy (DR),

diabetic foot, cardiovascular disease, and stroke. The

different stages will be clearly marked with the

corresponding triggers at different times, which link

up all the symptoms that are related to the internal

organs. The patterns of respective phases of

complications will pave the clear paths of how they

reach the final, irreversible stage.

The associations between and among the internal

organs brought about by the triggers at different times

will, first of all, give us answers to the current puzzles

of the end-stage complications. The patterns about the

retinopathy, for example, will clearly show how the

renal injury precedes retinal damage apart from the

fact that the level of renal impairment is proportional

to the level of eye damage as DR and DN has a

unidirectional correlation (Sulaiman, Mahaboob

Khan. 2019). These can help find new markers for

designing clinical trials that evaluate clinically

pertinent endpoints (e.g., glomerular hyperfiltration,

inflammation, and fibrosis) (Powell, Cooksley,

Hanson , Searle , Halliday, Powell 1988), and even

expand our knowledge on the association between

metabolic changes and DN. Some of these patterns

will help explain why the prevalence of chronic

kidney disease (CKD) in T2D patients has not

witnessed any decrease in the last two decades and

lead to the identification of additional factors in its

progression despite the aggressive blood sugar

control (Pearce, Ian, et al. 2019). Others will help

evaluate the findings with clinical manifestations

before kidney damage becomes irreversible that can

clearly show whether there is an association between

non-alcoholic fatty liver disease (NAFLD) and

progression of diabetic nephropathy (Hum Pathol

1989).

The collected symptoms correlating to the

changes of specific internal organs behind the triggers

will probably reshape our understanding of the

functions of each individual one. Here we can take the

liver for example, because it is consistently associated

with other complications of T2D with the severity of

DR linked to a higher risk of the presence of, or

developing other micro and macrovascular

complications as well as a strong predictor of stroke

and cardiovascular disease. (Itoh, Yougel, Kawagoe

1987) Apart from the answers for the prevalence of

NAFLD in diabetes estimated at 34–74% (Diehl,

Goodman, Ishak 1988, Pinto, Baptista, Camilo,

Valente, Saragoca, de Moura, Adami, Chow, Nyren,

Berne, Linet, Ekbom, Wolk, McLaughlin, Fraumeni

1996, Wanless, Lentz 1990), the emerged new

patterns will help explain why the incidence of

cirrhosis or severe fibrosis show a significant increase

with a 2.52 SMR (standardized mortality ratio) or a

6.84 SMR in the patients going through insulin

treatment (Wideroff, Gridley, Mellemkjaer, Chow,

Linet, Keehn, Borch-Johnsen, Olsen 1996). They will

also help us understand why there is a fourfold

increased prevalence of hepatocellular carcinoma in

patients with diabetes as well as an increased

prevalence of diabetes in patients with hepatocellular

carcinoma (Fujino, Mizoue, Tokui, Yoshimura 2001,

El-Serag 2004, El-Serag, Everhart 2002, Chan,

Truman, Gurwitz, Hurley, Martinson, Platt, Everhart,

Moseley, Terrault, Ackerson, Selby 2003). The

functional changes going on in the liver along the

course will give us ideas on how acute liver failure

has appeared to be increased in patients with T2D.

(Tolman, Fonseca, Dalpiaz, & Tan, 2007) Liver, with

so many overlapping symptoms with T2D such as

fatigue, mood disorders, (D’Mello, Charlotte, and

Mark G. Swain 2014) weight loss, abdominal pain,

leg swelling, bleeding, and shortness of breath, will

probably become the real culprit of T2D. Its

deterioration and dysfunction can be the cause of the

end-stage complications and the deterioration of other

organs. If liver stagnation can reveal itself through

depressive emotions, pain in the chest or flanks and a

tendency to sigh often (Wei et al. 2018), the

overlapping symptoms correlated to emotions may all

relate to liver dysfunction.

The vertical patterns behind each trigger, like the

trigger of emotions, will probably extend or even

change our boundaries of medical science. Likewise,

the patterns behind the triggers of heartbeat and

panting, which can be directly caused by

hyperglycemia, can be a strong sign of T2D

management failure rather than that of cardiovascular

diseases. And the pattern behind the trigger of urine

problems may partially explain the leg swelling

troubles of T2D patients. The changes of stool from

normal to pebbles or diarrhea may not have a direct

relationship with the underconsumption of vegetables

and fruits, or the inflammation of the bowels.

All the causalities captured by the system together

with the known relationships between the internal

organs and the known symptoms will largely cut short

the path and time on the future research for solutions.

These outcomes will far exceed the goals that past

machine learning methods tried to achieve in

medicine to help physicians anticipate future events

A Framework for T2D Management Knowledge Discovery of Complications in the Context of Chinese Culture: From Triggers to

Causalities

561

at an expert level with the information well beyond

the individual physician’s practice experience.

(Rajkomar, Alvin, Jeffrey Dean, and Isaac Kohane

2019) At the population level, the same type of

forecasting can increase the utilization of health care

services and enable the identification of patients with

chronic diseases who will soon have high-risk

conditions. (Rajkomar, Alvin, Jeffrey Dean, and Isaac

Kohane 2019)

All the patterns and causalities will be stored in

the knowledge pool for comparison with the initial

diagnosis, which will include those of the known and

newly discovered complications, the development of

one specific or one group of symptoms related to an

organ, the functional relationships between and

among organs and how they work as a whole system

in the human body. The discrepancies from the

patterns can be reviewed together by doctors for

better understanding and solution optimization. The

curated data sets with newly uploaded evidence can

be of great value for regional prescribing practices

and at the same time, relevant variables will be

automatically extracted for ease of use.

5 CONCLUSIONS

The knowledge pool will be continually enriched and

enlarged when this framework is applied to the

management of other chronic diseases like

cardiovascular disease, respiratory disease, chronic

liver disease, chronic obstructive pulmonary disease,

chronic kidney disease, cancer, arthritis, and so on.

The overlaps and relationships within each path of the

development of chronic disease symptoms and

complications can be discovered and classified, like

those of Type-2 Diabetes, for earlier intervention and

more effective management. The focus of the future

research is to look at the changes of the internal

organs vertically and horizontally at the same time.

The emerging patterns and correlations among

diseases and organs will enable future research to

become even more targeted and translatable. With a

broadened view and the support of the knowledge

discovery framework, concerted and collaborated

consultations will become much more accurate and

effective for clinical diagnosis and treatments. The

underlying relationships with the pathological

changes of the internal organs will bring about many

new insights and even broaden our view of medicine.

Most significantly, the world of the western medicine

and TCM can be bridged up for productive

collaborations and co-operations.

ACKNOWLEDGMENTS

Conflicts of interest: None declared.

Funding:

1. The design and development of an

application for the multi-wavelength retinal image

with cross-coupled structural function. Foundation

for Major Project of Scientific Instruments of

Ministry of Science and Technology of China,

2013YQ49085901

2. Research on the service model of the

National TCM Health Tourism Demonstration Zone

for Overseas Chinese. 2021SF02

REFERENCES

ADA 2019; Prevalence of Diabetic Complications in China

Adami HO, Chow WH, Nyren O, Berne C, Linet MS,

Ekbom A, Wolk A, McLaughlin JK, Fraumeni JF Jr:

Excess risk of primary liver cancer in patients with

diabetes mellitus. J Natl Cancer Inst 88:1472–1477,

1996

Alenazi AM, Obaidat SM, Alshehri MM, Alothman S, Gray

C, Rucker J, Waitman LR, Kluding PM. Type 2

Diabetes Affects Joint Pain Severity in People with

Localized Osteoarthritis: A Retrospective Study. Pain

Med. 2020 May 1;21(5):1025-1031. doi:

10.1093/pm/pnz299. PMID: 31710675; PMCID:

PMC7209370.

Alicic, Radica Z., Michele T. Rooney, and Katherine R.

Tuttle. "Diabetic kidney disease: challenges, progress,

and possibilities." Clinical Journal of the American

Society of Nephrology 12.12 (2017): 2032-2045.

Chaki, Jyotismita, et al. "Machine learning and artificial

intelligence-based Diabetes Mellitus detection and self-

management: A systematic review." Journal of King

Saud University-Computer and Information Sciences

(2020).

Chan KA, Truman A, Gurwitz JH, Hurley JS, Martinson B,

Platt R, Everhart JE, Moseley RH, Terrault N,

Ackerson L, Selby JV: A cohort study of the incidence

of serious acute liver injury in diabetic patients treated

with hypoglycemic agents. Arch Intern Med 163:728–

734, 2003

Chinese Medical Association, Diabetes Branch. Chinese

guidelines for the prevention and treatment of type 2

diabetes mellitus (2017 edition) [J]. Chinese Journal of

Diabetes, 2018, 10(01):4-67. DOI:

10.3760/cma.j.issn.1674-5809.2018.01.003.

D’Mello, Charlotte, and Mark G. Swain. "Liver–brain

interactions in inflammatory liver diseases:

implications for fatigue and mood disorders." Brain,

behavior, and immunity 35 (2014): 9-20.

Diabetes Reduces the Rate of Sputum Culture Conversion

in Patients with Newly Diagnosed Multidrug-Resistant

Tuberculosis

ICHIH 2022 - International Conference on Health Big Data and Intelligent Healthcare

562

Didangelos, Triantafyllos, and Konstantinos Kantartzis.

"Diabetes and Heart Failure: Is it Hyperglycemia or

Hyperinsulinemia?" Current Vascular Pharmacology

18.2 (2020): 148-157.

Diehl AM, Goodman Z, Ishak KG: Alcohol-like liver

disease in nonalcoholic: a clinical and histologic

comparison with alcohol-induced liver injury.

Gastroenterology 95:1056–1062, 1988

Drivsholm, T., de Fine Olivarius, N., Nielsen, A. B. S., &

Siersma, V. (2005). Symptoms, signs, and

complications in newly diagnosed type 2 diabetic

patients, and their relationship to glycemia, blood

pressure, and weight. Diabetologia, 48(2), 210–214.

doi:10.1007/s00125-004-1625-y

El-Serag HB, Everhart JE: Diabetes increases the risk of

acute hepatic failure. Gastroenterology 122:1822–

1828, 2002

El-Serag HB, Tran T, Everhart JE, Kaserer K, Fiedler R,

Steindl P, Muller CH, Wrba F, Ferenci P, Rubbia-

Brandt L, Leandro G, Spahr L, Giostra E, Quadri R,

Male PJ, Negro F, Hui JM, Kench J, Farrell GC, Lin R,

Samarasinghe D, Liddle C, Byth K, George J, Castera

L, Hezode C, Roudot-Thoraval F, Lonjon I, Zafrani ES,

Pawlotsky JM, Dhumeaux D, Lonardo A, Adinolfi LE,

Loria P, Carulli N, Ruggiero G, Day CP: Diabetes

increases the risk of chronic liver disease and

hepatocellular carcinoma. Gastroenterology 126:460–

468, 2004

Fujino Y, Mizoue T, Tokui N, Yoshimura T: Prospective

study of diabetes mellitus and liver cancer in Japan.

Diabetes Metab Res Rev 17:374 –379, 2001

Gao, Chenchen, et al. "Mobile application for diabetes self-

management in China: Do they fit for older adults?"

International journal of medical informatics 101

(2017): 68-74.

Gould, Milena, and Joseph H. Sellin. "Diabetic diarrhea."

Current gastroenterology reports 11.5 (2009): 354-359.

Grigoriadis, E. L. I. Z. A. B. E. T. H., et al. "Skeletal muscle

infarction in diabetes mellitus." The Journal of

Rheumatology 27.4 (2000): 1063-1068.

Hong Tianpei., et al. CAPTURE. GW-ICC 2020 Poster:

GW31 –e1199.

IQVIAA Study of the Burden of Administration Modalities

in Patients with Injectable Hypoglycemia.

https://www.iqvia.com/insights/the-iqvia-

institute/reports/economic-implications-of-improving-

type-2-diabetes-management-in-china

Itoh S, Yougel T, Kawagoe K: Comparison between

nonalcoholic steatohepatitis and alcoholic hepatitis.

Am J Gastroenterol82:650–654, 1987

Jason Fung, Complications of diabetes – a disease affecting

all organs [Web URL]

https://www.dietdoctor.com/complications-diabetes-

disease-affecting-organs

Jevalikar, Ganesh, et al. "Diabetic muscle infarction in type

1 and type 2 diabetes mellitus: lessons from two cases."

International Journal of Diabetes in Developing

Countries 39.4 (2019): 764-767.

Kavakiotis, Ioannis; Tsave, Olga; Salifoglou, Athanasios;

Maglaveras, Nicos; Vlahavas, Ioannis; Chouvarda,

Ioanna (2017). Machine Learning and Data Mining

Methods in Diabetes Research. Computational and

Structural Biotechnology Journal, 15(), 104–116. doi:

10.1016/j.csbj.2016.12.005

Khandelwal, Deepak, et al. "Sleep disorders in type 2

diabetes." Indian journal of endocrinology and

metabolism 21.5 (2017): 758.

Kotlarsky, Pavel, et al. "Link between retinopathy and

nephropathy caused by complications of diabetes

mellitus type 2." International ophthalmology 35.1

(2015): 59-66.

Krein, Sarah L., et al. "The effect of chronic pain on

diabetes patients’ self-management." Diabetes care

28.1 (2005): 65-70.

Lee ET, Keen H, Bennett PH, Fuller JH, Lu M (2001)

Follow-up of the WHO Multinational Study of

Vascular Disease in Diabetes: general description and

morbidity. Diabetologia 44(Suppl 2): S3–S13

Li Yongze, et al., Prevalence of diabetes recorded in

mainland China using 2018 diagnostic criteria from the

American Diabetes Association: national cross pal

study. BMJ 2020;369:m997 DOI: 10.1136/bmj.m997

Lifford, Karen L., et al. "Type 2 diabetes mellitus and risk

of developing urinary incontinence." Journal of the

American Geriatrics Society 53.11 (2005): 1851-1857.

Liu, Xiaoxue et al. “Trends in the Incidence and Mortality

of Diabetes in China from 1990 to 2017: A Joinpoint

and Age-Period-Cohort Analysis.” International journal

of environmental research and public health vol. 16,1

158. 8 Jan. 2019, doi:10.3390/ijerph16010158Broome,

David T., C. Beau Hilton, and Neil Mehta. "Policy

Implications of Artificial Intelligence and Machine

Learning in Diabetes Management." Current Diabetes

Reports 20.2 (2020): 5.

Ma, Ronald CW. "Epidemiology of diabetes and diabetic

complications in China." Diabetologia 61.6 (2018):

1249-1260.

Mosenzon O, Alguwaihes A, Arenas Leon J.L., et al.

CAPTURE Abstract 158. Presented at the 56th Annual

Meeting of the European Association of the Study of

Diabetes, Macrovascular complications and beyond,

10:15 CDT on 24 September 2020.

Nam, Soohyun, et al. "Barriers to diabetes management:

patient and provider factors." Diabetes research and

clinical practice 93.1 (2011): 1-9.

Nam, Soohyun, et al. "Barriers to diabetes management:

patient and provider factors." Diabetes research and

clinical practice 93.1 (2011): 1-9.

Park, Kye-Yeung, et al. "Bodyweight fluctuation as a risk

factor for type 2 diabetes: results from a nationwide

cohort study." Journal of clinical medicine 8.7 (2019):

950.

Pearce, Ian, et al. "Association between diabetic eye disease

and other complications of diabetes: implications for

care. A systematic review." Diabetes, Obesity and

Metabolism 21.3 (2019): 467-478.

Perrin, N. E., et al. "The prevalence of diabetes‐specific

emotional distress in people with Type 2 diabetes: a

systematic review and meta‐analysis." Diabetic

Medicine 34.11 (2017): 1508-1520.

A Framework for T2D Management Knowledge Discovery of Complications in the Context of Chinese Culture: From Triggers to

Causalities

563

Pinto HC, Baptista A, Camilo ME, Valente A, Saragoca A,

de Moura MC: Nonalcoholic steatohepatitis:

clinicopathological comparison with alcoholic hepatitis

in ambulatory and hospitalized patients. Dig Dis Sci

41:172–179, 1996

Powell EE, Cooksley WG, Hanson R, Searle J, Halliday

JW, Powell LW: The natural history of nonalcoholic

Rajkomar, Alvin, Jeffrey Dean, and Isaac Kohane.

"Machine learning in medicine." New England Journal

of Medicine 380.14 (2019): 1347-1358.

Report on nutrition and chronic diseases of the Chinese

population (2015) [M]. Bureau of Disease Prevention

and Control, National Health and Family Planning

Commission. Beijing: People's Health Publishing

House, 2015

Rinaldo, Lorenzo, et al. "Diabetes and back pain: markers

of diabetes disease progression are associated with

chronic back pain." Clinical Diabetes 35.3 (2017): 126-

131.

Seaman, Callie, et al. "Diabetic Muscle Infarction: A Rare

End-Organ Vascular Complication of Diabetes."

Marshall Journal of Medicine 5.4 (2019): 28.

Shumaker S, Schron E, Ockene J, McBee W. The handbook

of health behavior change. New York: Springer; 2004

Simpson, John. "Abnormal sweating in diabetes--

implications for screening for diabetic peripheral

neuropathy." Diabetic Foot Journal 21.4 (2018).

Steatohepatitis: a follow-up study of forty-two patients for

up to 21 years. Hepatology 11:74–80, 1990 Lee RG:

Nonalcoholic steatohepatitis: a study of 49 patients.

Hum Pathol 20:594 –598, 1989

Sulaiman, Mahaboob Khan. "Diabetic nephropathy: recent

advances in pathophysiology and challenges in dietary

management." Diabetology & metabolic syndrome

11.1 (2019): 7.

Tolman, K. G., Fonseca, V., Dalpiaz, A., & Tan, M. H.

(2007). Spectrum of Liver Disease in Type 2 Diabetes

and Management of Patients with Diabetes and Liver

Disease. Diabetes Care, 30(3), 734–743.

doi:10.2337/dc06-1539

Wanless IR, Lentz JS: Fatty liver hepatitis (steatohepatitis)

and obesity: an autopsy study with analysis of risk

factors. Hepatology 12:1106–1110, 1990

Wasserman, Jason Adam, and Brian Philip Hinote.

"Chronic illness as incalculable risk: Scientific

uncertainty and social transformations in medicine."

Social Theory & Health 9.1 (2011): 41-58.

Wei et al. (Wei, Y., Wang, T., Wu, H., Yamei, H., Wu, M.,

Zheng, M., Zhou, R. et al. (March, 2018). Biological

mechanisms underlying the liver’s regulation of

emotions in women: A study using the Trier Social

Stress Test. Journal of Traditional Chinese Medical

Sciences, 5(2), 110-118. doi: 10.1016/…. et al. 2018)

Wideroff L, Gridley G, Mellemkjaer L, Chow WH, Linet

M, Keehn S, Borch-Johnsen K, Olsen JH: Cancer

incidence in a population-based cohort of patients

hospitalized with diabetes mellitus in Denmark. J Natl

Cancer Inst 89:1360–1365, 1997

YangW, LuJ, WengJ, et al. Prevalence of diabetes among

men and women in China[J]. N Engl J Med, 2010,

362(12):1090-1101. DOI: 10.1056/NEJMoa0908292.

Yao, Grace, et al. "Development and verification of validity

and reliability of the WHOQOL-BREF Taiwan

version." Journal of the Formosan Medical Association

101.5 (2002): 342-351.

Zhao, Fang, et al. "Burden of insulin injection-related

needlestick injuries in mainland China–prevalence,

incidence, and healthcare costs." International journal

of nursing studies 97 (2019): 78-83.

ICHIH 2022 - International Conference on Health Big Data and Intelligent Healthcare

564