BMI and mortality in patients with new-onset type 2 diabetes: a comparison with age- and sex-matched control subjects from the general population

Objective: Type 2 diabetes is strongly associated with obesity, but the mortality risk related to elevated body weight in people with type 2 diabetes compared with people without diabetes has not been established. Research Design and Methods: We prospectively assessed short- and long-term mortality in people with type 2 diabetes with a recorded diabetes duration ≤5 years identified from the Swedish National Diabetes Registry between 1998 and 2012 and five age- and sex-matched control subjects per study participant from the general population. Results: Over a median follow-up of 5.5 years, there were 17,546 deaths among 149,345 patients with type 2 diabetes (mean age 59.6 years [40% women]) and 68,429 deaths among 743,907 matched control subjects. Short-term all-cause mortality risk (≤5 years) displayed a U-shaped relationship with BMI, with hazard ratios (HRs) ranging from 0.81 (95% CI 0.75-0.88) among patients with diabetes and BMI 30 to <35 kg/m2 to 1.37 (95% CI 1.11-1.71) with BMI ≥40 kg/m2 compared with control subjects after multiple adjustments. Long-term, all weight categories showed increased mortality, with a nadir at BMI 25 to <30 kg/m2 and a stepwise increase up to HR 2.00 (95% CI 1.58-2.54) among patients with BMI ≥40 kg/m2, that was more pronounced in patients <65 years old. Conclusions: Our findings suggest that the apparent paradoxical findings in other studies in this area may have been affected by reverse causality. Long-term, overweight (BMI 25 to <30 kg/m2) patients with type 2 diabetes had low excess mortality risk compared with control subjects, whereas risk in those with BMI ≥40 kg/m2 was substantially increased

Age and sex differences in cause-specific excess mortality and years of life lost associated with COVID-19 infection in the Swedish population

Background Estimating excess mortality and years of life lost (YLL) attributed to coronavirus disease 19 (COVID-19) infection provides a comprehensive picture of the mortality burden on society. We aimed to estimate the impact of the COVID-19 pandemic on age- and sex-specific excess mortality and YLL in Sweden during the first 17 months of the pandemic. Methods In this population-based observational study, we calculated age- and sex-specific excess all-cause mortality and excess YLL during 2020 and the first 5 months of 2021 and cause-specific death [deaths from cardiovascular disease (CVD), cancer, other causes and deaths excluding COVID-19] in 2020 compared with an average baseline for 2017-19 in the whole Swedish population. Results COVID-19 deaths contributed 9.9% of total deaths (98 441 deaths, 960 305 YLL) in 2020, accounting for 75 151 YLL (7.7 YLL/death). There were 2672 (5.7%) and 1408 (3.0%) excess deaths, and 19 141 (3.8%) and 3596 (0.8%) excess YLL in men and women, respectively. Men aged 65-110 years and women aged 75-110 years were the greatest contributors. Fewer deaths and YLL from CVD, cancer and other causes were observed in 2020 compared with the baseline adjusted to the population size in 2020. Conclusions Compared with the baseline, excess mortality and YLL from all causes were experienced in Sweden during 2020, with a higher excess observed in men than in women, indicating that more men died at a younger age while more women died at older ages than expected. A notable reduction in deaths and YLL due to CVD suggests a displacement effect from CVD to COVID-19

COVID-19 in people aged 18-64 in Sweden in the first year of the pandemic: Key factors for severe disease and death

Background: Studies on risk factors for severe COVID-19 in people of working age have generally not included non-working persons or established population attributable fractions (PAFs) for occupational and other factors. Objectives: We describe the effect of job-related, sociodemographic, and other exposures on the incidence, relative risks and PAFs of severe COVID-19 in individuals aged 18–64. Methods: We conducted a registry-based study in Swedish citizens aged 18–64 from 1 January 2020 to 1 February 2021 with respect to COVID-19-related hospitalizations and death. Results: Of 6,205,459 persons, 272,043 (7.5%) were registered as infected, 3399 (0.05%) needed intensive care, and 620 (0.01%) died, with an estimated case fatality rate of 0.06% over the last 4-month period when testing was adequate. Non-Nordic origin was associated with a RR for need of intensive care of 3·13, 95%CI 2·91–3·36, and a PAF of 32·2% after adjustment for age, sex, work, region and comorbidities. In a second model with occupation as main exposure, and adjusted for age, sex, region, comorbidities and origin, essential workers had an RR of 1·51, 95%CI, 1·35–1·6, blue-collar workers 1·18, 95%CI 1·06–1·31, school staff 1·21, 95%CI 1·01–1·46, and health and social care workers 1·89, 95%CI 1·67–2·135) compared with people able to work from home, with altogether about 13% of the PAF associated with these occupations. Essential workers and blue-collar workers, but no other job categories had higher risk of death, adjusted RRs of 1·79, 95%CI 1·34–2·38 and 1·37, 95%CI 1·04–1·81, with adjusted PAFs of altogether 9%. Conclusion: Among people of working age in Sweden, overall mortality and case fatality were low. Occupations that require physical presence at work were associated with elevated risk of needing intensive care for COVID-19, with 14% cases attributable to this factor, and 9% of deaths

Patienters upplevelse av trötthet. En kvantitativ punktprevalensstudie vid tre olika vårdavdelningar

I en tid då sjukhusavdelningarna upplever ett åldrande patientklientel och patienttrycket är högt skall vården vid Sahlgrenska Universitetssjukhuset enligt ledningen, vara personcentrerad och patientens berättelse ligga i fokus för en god patientvård. Denna uppsats fokuserar kring patienters upplevelse av symtomet Fatigue (Kronisk trötthet) under en dag på sjukhus. Syftet är att beskriva frekvens och intensitet av kronisk trötthet, samt korrelation med socioekonomisk situation och andra parallellt förekommande symtom. En pilotstudie genomfördes som en punktprevalensstudie i december 2010, med syfte att kartlägga patientdemografi och symtomförekomst hos 41 stycken inneliggande patienter på tre vårdavdelningar. Därefter har en statistisk analys utförts och presenterats som resultat. Resultatet visade att av de 41 patienter som undersöktes svarade 33 stycken att de upplevde trötthet. Intensiteten de upplevde var i snitt 6, 91 med en standardavvikelse på 2,417. Dessa patienter upplevde ett besvär på 6,98 med en standardavvikelse på 3,260. Resultatet kunde inte korreleras till socioekonomiska parametrar utan visar en signifikant korrelation mellan intensiv trötthet och intensivt illamående och en tydlig tendens till att kunna kopplas till intensiv smärta. Resultatet visar även en signifikant korelation mellan besvärande trötthet och sömnsvårigheter. Diskussionen grundar sig på vetenskaplig litteratur som funnits genom en systematisk litteratursökning. Denna diskuterar den funna prevalensen av trötthet samt signifikanta korrelationer mellan trötthet och andra symtom. Denna studie visar att trötthet är ett högprevalent symtom på tre specialistkliniker vid SU. Det finns patienter som rapporterar att tröttheten är det som besvärar dem allra mest, och funna sökta vetenskapliga artiklar belyser trötthet och dess negativa påverkan på livskvalité. De sökta artiklarna visar på spridda samband mellan trötthet och andra symtom och de interventioner som föreslås relaterar ofta till information om symtomet samt patientens förmåga att hantera symtom

Obesity in diabetes. Cardiovascular outcomes and risk factor trajectories

Introduction: The association between body mass index (BMI) and mortality in diabetes is complex and sparsely investigated for cardiovascular (CVD) outcomes. We aimed to investigate these relationships among patients with type 1 and type 2 diabetes using data from the Swedish national diabetes registry (NDR), with focus on potential reverse causality. Considering recent fi ndings of marked excess risks among patients with early onset of type 1 diabetes we aimed to investigate risk factor trajectories based on age at onset. Methods: The thesis is based on data from the Swedish national diabetes registry (Study I-IV) and matched controls taken from the general population (Study I and III), using statistical methods such as Cox regression, linear regression, mixed models and machine learning. Results: Study I, the short-term risk of death (<5 years from baseline) in patients with type 2 diabetes was slightly lower among obese patients than in age- and sex matched controls, with a nadir among obese patients varying between 30-<40 kg/m2, depending on age. Long-term mortality (≥5 years from baseline) exhibited a stepwise increase from BMI 25-<30 kg/m2, where patients with BMI ≥40 kg/m2 had a 2-fold risk of death compared to the general population, with similar fi ndings for CVD death. In Study II, we found a slight increase in the risk of death, CVD death, major CVD (stroke or acute myocardial infarction [AMI]) and heart failure (HF) with rising BMI in patients with type 1 diabetes, but no increase in risk in patients with normal weight after exclusion of individuals with poor metabolic control, smokers and patients with follow-up shorter than 10 years. In Study III, the association between BMI and the risk of AMI was essentially fl at but worsened with poor glycemic control, while, in contrast, there was a markedly increasing risk for HF with rising BMI with a nadir as low as ~18.5 kg/m2. The risk of HF was further exaggerated by poor glycemic control with an 8-fold excess risk of HF among patients with BMI ≥40 kg/m2 and hemoglobin A1c (HbA1c) ≥70 mmol/mole. In Study IV, patients with an onset of type 1 diabetes ≤15 years had a high mean HbA1c of ~70 mmol/mole in early adulthood, whereas patients with a later onset (16-30 years) displayed a gradual increase in HbA1c up to a mean at ~65 mmol/mole, common for all groups regardless of age at onset. Machine learning models showed that baseline HbA1c (duration of diabetes >1 year) was linked to age, educational level and CVD risk factors. Conclusions: Among patients with type 1 and type 2 diabetes our analyses provided no support for an obesity paradox for the outcomes of death (type 1 diabetes) and CVD complications including HF after considering the infl uence of reverse causality. The strong relationship between obesity and HF which was worsened by poor glycemic control, was absent for AMI, indicating different pathophysiological mechanisms behind these two outcomes. The age at onset of type 1 diabetes seems to be an important predictor of glycemic control during the fi rst years of adulthood, as well as for the prevalence of albuminuria leading to a more rapid decline in eGFR from an early age. Our study also stresses the importance of early optimization of CVD risk factors, in particular glycemic control, in patients with type 1 diabetes

Trajectories in HbA1c and other risk factors among adults with type 1 diabetes by age at onset

Introduction In type 1 diabetes, potential loss of life-years is greatest in those who are youngest at the time of onset. Using data from a nationwide cohort of patients with type 1 diabetes, we aimed to study risk factor trajectories by age at diagnosis.Research design and methods We stratified 30 005 patients with type 1 diabetes aged 18–75 years into categories based on age at onset: 0–10, 11–15, 16–20, 21–25, and 26–30 years. HbA1c, albuminuria, estimated glomerular filtration rate (eGFR), body mass index (BMI), low-denisty lipoprotein (LDL)-cholesterol, systolic blood pressure (SBP), and diastolic blood pressure trends were analyzed using mixed models. Variable importance for baseline HbA1c was analyzed using conditional random forest and gradient boosting machine approaches.Results Individuals aged ≥16 years at onset displayed a relatively low mean HbA1c level (~55–57 mmol/mol) that gradually increased. In contrast, individuals diagnosed at ≤15 years old entered adulthood with a mean HbA1c of approximately 70 mmol/mol. For all groups, HbA1c levels stabilized at a mean of approximately 65 mmol/mol by about 40 years old. In patients who were young at the time of onset, albuminuria appeared at an earlier age, suggesting a more rapid decrease in eGFR, while there were no distinct differences in BMI, SBP, and LDL-cholesterol trajectories between groups. Low education, higher age, and poor risk factor control were associated with higher HbA1c levels.Conclusions Young age at the diabetes onset plays a substantial role in subsequent glycemic control and the presence of albuminuria, where patients with early onset may accrue a substantial glycemic load during this period

Severe COVID-19 Infection in Type 1 and Type 2 Diabetes During the First Three Waves in Sweden

OBJECTIVE Type 2 diabetes is an established risk factor for hospitalization and death in COVID-19 infection, while findings with respect to type 1 diabetes have been diverging. RESEARCH DESIGN AND METHODS Using nationwide health registries, we identified all patients aged &amp;gt;= 18 years with type 1 and type 2 diabetes in Sweden. Odds ratios (ORs) describe the general and age-specific risk of being hospitalized, need for intensive care, or dying, adjusted for age, socioeconomic factors, and coexisting conditions, compared with individuals without diabetes. Machine learning models were used to find predictors of outcomes among individuals with diabetes positive for COVID-19. RESULTS Until 30 June 2021, we identified 365 (0.71%) and 11,684 (2.31%) hospitalizations in 51,402 and 504,337 patients with type 1 and 2 diabetes, respectively, with 67 (0.13%) and 2,848 (0.56%) requiring intensive care unit (ICU) care and 68 (0.13%) and 4,020 (0.80%) dying (vs 7,824,181 individuals without diabetes [41,810 hospitalizations (0.53%), 8,753 (0.11%) needing ICU care, and 10,160 (0.13%) deaths). Although those with type 1 diabetes had moderately raised odds of being hospitalized (multiple-adjusted OR 1.38 [95% CI 1.24-1.53]), there was no independent effect on ICU care or death (OR of 1.21 [95% CI 0.94-1.52] and 1.13 [95% CI 0.88-1.48], respectively). Age and socioeconomic factors were the dominating features for predicting hospitalization and death in both types of diabetes. CONCLUSIONS Type 2 diabetes was associated with increased odds for all outcomes, whereas patients with type 1 diabetes had moderately increased odds of hospitalization but not ICU care and death.Funding Agencies|Swedish state under an agreement concerning research and education of doctors [ALFGBG-966211]; Swedish Heart and Lung Foundation [2021-0345]; Swedish Research Council [2018-02527, 2020-05792, 2021-06525]</p

BMI, mortality, and cardiovascular outcomes in type 1 diabetes: findings against an obesity paradox

Objective: Low weight has been associated with increased mortality risks in type 1 diabetes. We aimed to investigate the importance of weight and weight gain/loss in the Swedish population diagnosed with type 1 diabetes. Research Design and Methods: Patients with type 1 diabetes (n = 26,125; mean age 33.3 years; 45% women) registered in the Swedish National Diabetes Registry from 1998 to 2012 were followed from the first day of study entry. Cox regression was used to calculate risk of death from cardiovascular disease (CVD), major CVD events, hospitalizations for heart failure (HF), and total deaths. Results: Population mean BMI in patients with type 1 diabetes increased from 24.7 to 25.7 kg/m2 from 1998 to 2012. Over a median follow-up of 10.9 years, there were 1,031 deaths (33.2% from CVD), 1,460 major CVD events, and 580 hospitalizations for HF. After exclusion of smokers, patients with poor metabolic control, and patients with a short follow-up time, there was no increased risk for mortality in those with BMI &lt;25 kg/m2, while BMI &gt;25 kg/m2 was associated with a minor increase in risk of mortality, major CVD, and HF. In women, associations with BMI were largely absent. Weight gain implied an increased risk of mortality and HF, while weight loss was not associated with higher risk. Conclusions: Risk of major CVD, HF, CVD death, and mortality increased with increasing BMI, with associations more apparent in men than in women. After exclusion of factors associated with reverse causality, there was no evidence of an obesity paradox

Trajectories in HbA1c and other risk factors among adults with type 1 diabetes by age at onset

Introduction: In type 1 diabetes, potential loss of life-years is greatest in those who are youngest at the time of onset. Using data from a nationwide cohort of patients with type 1 diabetes, we aimed to study risk factor trajectories by age at diagnosis. Research design and methods: We stratified 30 005 patients with type 1 diabetes aged 18–75 years into categories based on age at onset: 0–10, 11–15, 16–20, 21–25, and 26–30 years. HbA1c, albuminuria, estimated glomerular filtration rate (eGFR), body mass index (BMI), low-denisty lipoprotein (LDL)-cholesterol, systolic blood pressure (SBP), and diastolic blood pressure trends were analyzed using mixed models. Variable importance for baseline HbA1c was analyzed using conditional random forest and gradient boosting machine approaches. Results: Individuals aged ≥16 years at onset displayed a relatively low mean HbA1c level (~55–57 mmol/mol) that gradually increased. In contrast, individuals diagnosed at ≤15 years old entered adulthood with a mean HbA1c of approximately 70 mmol/mol. For all groups, HbA1c levels stabilized at a mean of approximately 65 mmol/mol by about 40 years old. In patients who were young at the time of onset, albuminuria appeared at an earlier age, suggesting a more rapid decrease in eGFR, while there were no distinct differences in BMI, SBP, and LDL-cholesterol trajectories between groups. Low education, higher age, and poor risk factor control were associated with higher HbA1c levels. Conclusions: Young age at the diabetes onset plays a substantial role in subsequent glycemic control and the presence of albuminuria, where patients with early onset may accrue a substantial glycemic load during this period