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

Figure 2 Diabetes-centered clinical implementation framework for five-condition co-management. At the initial visit, patients undergo a baseline metabolic assessment covering glycemia (glycated hemoglobin and/or fasting plasma glucose), blood pressure, lipids, serum uric acid, and body weight/waist circumference. Risk stratification is then performed according to overall target attainment and complication status, yielding three tiers: High risk (≥ 2 targets unmet with complications), managed by a multidisciplinary team (endocrinologist lead, nutritionist, exercise therapist, pharmacist, and health manager); intermediate risk (1-2 targets unmet), managed with endocrinologist guidance and structured health-manager follow-up; and low risk (all targets met), managed primarily in the community by a community physician with patient self-management. Digital enablement is embedded across tiers: High/intermediate-risk patients receive comprehensive digital intervention (smart monitoring devices, artificial intelligence decision support, and medication reminders), while low-risk patients use digital self-management (app logging and regular data synchronization). Follow-up intensity is tiered (high risk: Every 1-3 months; intermediate risk: Every 3-6 months; low risk: Every 6-12 months), with periodic re-evaluation of targets to maintain the regimen when controlled or to adjust/intensify strategies when targets are not met, forming a closed-loop management pathway. HbA1c: Glycated hemoglobin; FPG: Fasting plasma glucose; BP: Blood pressure; WC: Waist circumference; AI: Artificial intelligence; MDT: Multidisciplinary team.