Mortality Trends in a Population-based Type 1 Diabetes Cohort

Individuals with type 1 diabetes (T1D) have significantly higher mortality rates than their peers in the general population. Major advances in the management of T1D occurred during the 1980s and 1990s, but recent data on their long-term effects on overall and cause-specific mortality are limited, especially in the United States. A phenomenon, known as dead-in-bed syndrome, is of particular concern as it occurs in young, healthy T1D individuals who are unexpectedly found dead in bed. Using follow-up data from a large population-based cohort, this dissertation provides contemporary mortality rates in persons with long-standing T1D. Cause-specific mortality is also explored, focusing on how mortality rates from major causes compare to the general population and on characterizing T1D deaths that meet the criteria for dead-in-bed syndrome. Overall, the mortality of individuals with T1D is seven times higher than seen in the general population. T1D individuals diagnosed more recently have significantly lower mortality rates than those diagnosed earlier, even after controlling for age. The greatest improvements in mortality have occurred in deaths from diabetes-related causes (diabetic coma, renal disease, cardiovascular disease, or infection), suggesting long-term benefits to improved T1D care. In a pattern quite contrary to what is seen in the general population, females with T1D have a higher mortality than males with T1D, especially from diabetes-related causes. While African-Americans with T1D have much higher mortality rates than T1D Caucasians in this cohort, this racial difference was similar to that seen in the general population. Finally, dead-in-bed syndrome in this population appears associated with male sex, low BMI, and disturbed metabolic control (high HbA1c, high daily insulin dose, and a history of severe hypoglycemia). The public health implications of this dissertation are considerable, as it provides insight into the causes of premature mortality in T1D, permitting the development of more effective and targeted preventative strategies. These findings also have the potential to change routine care practices to address disparities by race and sex in T1D mortality, and resolve disparities in health and life insurance provisions, since antiquated T1D mortality estimates are currently used, which do not account for recent advances in T1D treatments

Risk of cardiovascular disease and total mortality in adults with type 1 diabetes: Scottish registry linkage study

<p>Background: Randomized controlled trials have shown the importance of tight glucose control in type 1 diabetes (T1DM), but few recent studies have evaluated the risk of cardiovascular disease (CVD) and all-cause mortality among adults with T1DM. We evaluated these risks in adults with T1DM compared with the non-diabetic population in a nationwide study from Scotland and examined control of CVD risk factors in those with T1DM.</p> <p>Methods and Findings: The Scottish Care Information-Diabetes Collaboration database was used to identify all people registered with T1DM and aged ≥20 years in 2005–2007 and to provide risk factor data. Major CVD events and deaths were obtained from the national hospital admissions database and death register. The age-adjusted incidence rate ratio (IRR) for CVD and mortality in T1DM (n = 21,789) versus the non-diabetic population (3.96 million) was estimated using Poisson regression. The age-adjusted IRR for first CVD event associated with T1DM versus the non-diabetic population was higher in women (3.0: 95% CI 2.4–3.8, p<0.001) than men (2.3: 2.0–2.7, p<0.001) while the IRR for all-cause mortality associated with T1DM was comparable at 2.6 (2.2–3.0, p<0.001) in men and 2.7 (2.2–3.4, p<0.001) in women. Between 2005–2007, among individuals with T1DM, 34 of 123 deaths among 10,173 who were <40 years and 37 of 907 deaths among 12,739 who were ≥40 years had an underlying cause of death of coma or diabetic ketoacidosis. Among individuals 60–69 years, approximately three extra deaths per 100 per year occurred among men with T1DM (28.51/1,000 person years at risk), and two per 100 per year for women (17.99/1,000 person years at risk). 28% of those with T1DM were current smokers, 13% achieved target HbA1c of <7% and 37% had very poor (≥9%) glycaemic control. Among those aged ≥40, 37% had blood pressures above even conservative targets (≥140/90 mmHg) and 39% of those ≥40 years were not on a statin. Although many of these risk factors were comparable to those previously reported in other developed countries, CVD and mortality rates may not be generalizable to other countries. Limitations included lack of information on the specific insulin therapy used.</p> <p>Conclusions: Although the relative risks for CVD and total mortality associated with T1DM in this population have declined relative to earlier studies, T1DM continues to be associated with higher CVD and death rates than the non-diabetic population. Risk factor management should be improved to further reduce risk but better treatment approaches for achieving good glycaemic control are badly needed.</p&gt

Type 1 diabetes and cardiovascular disease

The presence of cardiovascular disease (CVD) in Type 1 diabetes largely impairs life expectancy. Hyperglycemia leading to an increase in oxidative stress is considered to be the key pathophysiological factor of both micro- and macrovascular complications. In Type 1 diabetes, the presence of coronary calcifications is also related to coronary artery disease. Cardiac autonomic neuropathy, which significantly impairs myocardial function and blood flow, also enhances cardiac abnormalities. Also hypoglycemic episodes are considered to adversely influence cardiac performance. Intensive insulin therapy has been demonstrated to reduce the occurrence and progression of both micro- and macrovascular complications. This has been evidenced by the Diabetes Control and Complications Trial (DCCT) / Epidemiology of Diabetes Interventions and Complications (EDIC) study. The concept of a metabolic memory emerged based on the results of the study, which established that intensified insulin therapy is the standard of treatment of Type 1 diabetes. Future therapies may also include glucagon-like peptide (GLP)-based treatment therapies. Pilot studies with GLP-1-analogues have been shown to reduce insulin requirements

Mortality in childhood-onset type 1 diabetes

It is well-recognized that diabetes-related complications are the leading cause of the still increased morbidity and mortality from diabetes and exert a heavy economic burden on society. The discovery of insulin led to a dramatic change in life expectancy of patients with type 1 diabetes (T1D). Furthermore, it caused a major shift in the distribution of causes of death - from diabetic coma in the pre-insulin era, to long-term complications being the predominant causes of death nowadays. The aim of the present review is to assess the trends in the absolute and the relative mortality rates as well as the leading causes of death among patients with childhood-onset (< 18 years) T1D in populations from different latitudes. It is also observed how disease duration, age at diagnosis, and year of diagnosis affect these mortality trends. Eight population-based studies published in English in the last 14 years, as well as another one, published in 2001, with different duration of follow-up, are included in the review. However, it is hard to compare different populations due to the dissimilarities in the study methods and the characteristics of the examined cohorts

Type 1 diabetes

Type 1 diabetes is a chronic autoimmune disease characterised by insulin deficiency and resultant hyperglycaemia. Knowledge of type 1 diabetes has rapidly increased over the past 25 years, resulting in a broad understanding about many aspects of the disease, including its genetics, epidemiology, immune and β-cell phenotypes, and disease burden. Interventions to preserve β cells have been tested, and several methods to improve clinical disease management have been assessed. However, wide gaps still exist in our understanding of type 1 diabetes and our ability to standardise clinical care and decrease disease-associated complications and burden. This Seminar gives an overview of the current understanding of the disease and potential future directions for research and care

Sex-specific-differences in cardiovascular risk in type-1-diabetes : a cross sectional study

Background: Little is known about the impact of sex-specific differences in the management of type 1 diabetes (T1DM). Thus, we evaluated the influence of gender on risk factors, complications, clinical care and adherence in patients with T1DM. Methods: In a cross-sectional study, sex-specific disparities in glycaemic control, cardiovascular risk factors, diabetic complications, concomitant medication use and adherence to treatment recommendations were evaluated in 225 consecutive patients (45.3% women) who were comparable with respect to age, diabetes duration, and body mass index. Results: Although women with T1DM had a higher total cholesterol than men, triglycerides were higher in obese men and males with HbA1c>7% than in their female counterparts. No sex differences were observed in glycaemic control and in micro- or macrovascular complications. However, the subgroup analysis showed that nephropathy was more common in obese men, hyperlipidaemic women and all hypertensive patients, whereas peripheral neuropathy was more common in hyperlipidaemic women. Retinopathy was found more frequently in women with HbA1c>7%, obese men and in both sexes with a long duration of diabetes. The multivariate analysis revealed that microvascular complications were associated with the duration of disease and BMI in both sexes and with hyperlipidaemia in males. The overall adherence to interventions according to the guidelines was higher in men than in women. This adherence was concerned particularly with co-medication in patients diagnosed with hypertension, aspirin prescription in elderly patients and the achievement of target lipid levels following the prescription of statins. Conclusions: Our data showed sex differences in lipids and overweight in patients with T1DM. Although glycaemic control and the frequency of diabetic complications were comparable between the sexes, the overall adherence to guidelines, particularly with respect to the prescription of statins and aspirin, was lower in women than in men

Learning about sex: Results from Natsal 2000.

11-13 September 2002

Epidemiology of Type 1 Diabetes Complications in African-Americans

Unlike type 2 diabetes, where prevention is possible, type 1 diabetes is a lifelong incurable metabolic disorder. The annual incidence of type 1 diabetes continues to rise annually. Despite increased access to treatment and improved disease management, type 1 diabetes is associated with excess morbidity and early mortality. African-Americans with type 1 diabetes are at increased risk of premature mortality compared to Caucasians. This disparity is likely fueled by differences in the prevalence of complications; however, there is limited information available on the racial differences in type 1 diabetes complications in individuals of African descent (i.e. African-American, Afro-Caribbean). Using the data from the U.S. Virgin Islands Childhood Diabetes Registry, this dissertation provides contemporary insights on the incidence of childhood diabetes in African-American youth and for the first time evaluates type 1 diabetes mortality in African-Americans, in the U.S. Virgin Islands. In addition, this dissertation assesses racial differences in the prevalence of type 1 diabetes complications and risk factors using a national sample from the National Health and Nutrition Examination Survey. The incidence of type 1 and type 2 diabetes in youth in the U.S. Virgin Islands is rapidly increasing. The well-established pubertal increase in type 1 diabetes incidence appears to be missing in African-American boys. Individuals diagnosed at later ages (>14), have significantly higher risk of mortality compared to those diagnosed at earlier ages. Despite advances in diabetes care, there were no temporal improvements observed in mortality in the U.S. Virgin Islands. African-Americans in the U.S. Virgin Islands had a similar type 1 diabetes mortality experience as African-Americans in Allegheny County, PA. African-Americans in the national sample had significantly higher rates of nephropathy and retinopathy. Race was associated with both complications, even after adjusting for clinical and demographic factors. The public health implications of this dissertation are considerable, as it provides insight on the burden of type 1 diabetes in the U.S. Virgin Islands and African-Americans in the U.S. These findings provide evidence to support additional services and potentially intensive diabetes management strategies for African-Americans with type 1 diabetes

Clinical problems caused by obesity

Over the past few decades the incidence of obesity has doubled worldwide and current estimates classify more than 1.5 billion adults as overweight and at least 500 million of them as clinically obese, with body mass index (BMI) over 25 kg/m2 and 30 kg/m2, respectively. Obesity prevalence rates are steadily rising in the majority of the modern Western societies, as well as in the developing world. Moreover, alarming trends of weight gain are reported for children and adolescents, undermining the present and future health status of the pediatric population. To highlight the related threat to public health, the World Health Organization has declared obesity a global epidemic, also stressing that it remains an under-recognized problem of the public health agenda