Digital health technologies for diabetes-centered five-condition co-management in China: Theoretical foundations, practical experience, and technical challenges

Table 2 Digital health monitorable indicators

Core monitoring indicators	Trigger thresholds (refer to 2024 CDS guidelines)	Intervention actions	Responsible subjects
HbA1c	≥ 7.0% or increase ≥ 0.5% within 3 months	(1) Adjust hypoglycemic regimen (prioritize GLP-1RA); (2) Strengthen diet/exercise intervention; and (3) Increase monitoring frequency to ≥ 3 times/week	Endocrinologist + dietitian
Systolic blood pressure/diastolic blood pressure	≥ 130/80 mmHg	(1) Initiate or adjust antihypertensive drugs (synergistic with hypoglycemic drugs); (2) Restrict sodium intake (< 5 g/day); and (3) Recommend aerobic exercise	Physician + health management nurse
LDL-C	High risk ≥ 1.8 mmol/L; medium-low risk ≥ 2.6 mmol/L	(1) Initiate statins; (2) Adjust diet structure (reduce saturated fat); and (3) Monitor liver function	Physician + dietitian
Uric acid	Male ≥ 420 μmol/L; female ≥ 360 μmol/L	(1) Restrict high-purine foods in diet; (2) Increase water intake (≥ 2000 mL/day); and (3) Initiate uric acid-lowering drugs if necessary	Physician + nurse
Body weight/BMI	BMI ≥ 28 kg/m² or increase ≥ 5% within 3 months	(1) Use weight loss-oriented hypoglycemic drugs (GLP-1RA); (2) Formulate individualized exercise prescription (150 minutes moderate-intensity exercise/week); and (3) Diet calorie control	Physician + exercise therapist + dietitian
Waist circumference	Male ≥ 90 cm; female ≥ 85 cm	(1) Core strength training; and (2) Reduce risk factors related to abdominal obesity (sedentary/high-sugar diet)	Exercise therapist + dietitian
Urinary microalbumin/creatinine ratio	≥ 30 mg/g	(1) Prefer SGLT2i/GLP-1RA; (2) Control blood pressure < 130/80 mmHg; and (3) Recheck every 3 months	Physician + nurse

Trigger thresholds strictly follow the requirements of the “China Guidelines for the Prevention and Treatment of Diabetes (2024 Edition)” and the Healthy China Action Plan. The responsible subjects clarify the division of labor within the diabetes center to ensure the intervention closed loop. HbA1c: Glycated hemoglobin; GLP-1RA: Glucagon-like peptide-1 receptor agonist; LDL-C: Low-density lipoprotein cholesterol; BMI: Body mass index; SGLT2i: Sodium-glucose cotransporter-2 inhibitor; CDS: Chinese Diabetes Society.