Life Expectancy in a Large Cohort of Type 2 Diabetes Patients Treated in Primary Care (ZODIAC-10)

Background: Most longitudinal studies showed increased relative mortality in individuals with type 2 diabetes mellitus until now. As a result of major changes in treatment regimes over the past years, with more stringent goals for metabolic control and cardiovascular risk management, improvement of life expectancy should be expected. In our study, we aimed to assess present-day life expectancy of type 2 diabetes patients in an ongoing cohort study. Methodology and Principal Findings: We included 973 primary care type 2 diabetes patients in a prospective cohort study, who were all participating in a shared care project in The Netherlands. Vital status was assessed from May 2001 till May 2007. Main outcome measurement was life expectancy assessed by transforming actual survival time to standardised survival time allowing adjustment for the baseline mortality rate of the general population. At baseline, mean age was 66 years, mean HbA(1c) 7.0%. During a median follow-up of 5.4 years, 165 patients died (78 from cardiovascular causes), and 17 patients were lost to follow-up. There were no differences in life expectancy in subjects with type 2 diabetes compared to life expectancy in the general population. In multivariate Cox regression analyses, concentrating on the endpoints 'all-cause' and cardiovascular mortality, a history of cardiovascular disease: hazard ratio (HR) 1.71 (95% confidence interval (CI) 1.23-2.37), and HR 2.59 (95% CI 1.56-4.28); and albuminuria: HR 1.72 (95% CI 1.26-2.35), and HR 1.83 (95% CI 1.17-2.89), respectively, were significant predictors, whereas smoking, HbA(1c), systolic blood pressure and diabetes duration were not. Conclusions: This study shows a normal life expectancy in a cohort of subjects with type 2 diabetes patients in primary care when compared to the general population. A history of cardiovascular disease and albuminuria, however, increased the risk of a reduction of life expectancy. These results show that, in a shared care environment, a normal life expectancy is achievable in type 2 diabetes patients

Skin autofluorescence as a noninvasive marker of vascular damage in patients with type 2 diabetes

OBJECTIVE - Advanced glycation end products (AGES) are thought to have a role in the pathogenesis of diabetes complications. We recently reported the association between skin autofluorescence, as a measure of tissue AGE accumulation, and diabetic neuropathy in a selected diabetic population. In this study, we investigated the relation between skin autofluorescence and clinical variables including micro- and macrovascular complications in a type 2 diabetes primary care population. RESEARCH DESIGN AND METHODS - Clinical data and skin autofluorescence were obtained in the type 2 diabetes group (n = 973) and in a control group (n = 231). Skin autofluorescence was assessed by illumination of the lower arm with a fluorescent tube (peak intensity similar to 370 nm). RESULTS - Skin autofluorescence was significantly higher in type 2 diabetic patients compared with control subjects in each age category. Multiple regression analysis showed significant correlation of skin auto fluorescence with age, sex, diabetes duration, BMI, smoking, HbA(1c), plasma creatinine, HDL cholesterol, and albumin-to-creatinine ratio in the type 2 diabetes group (R-2 = 25%) and with age and smoking in the control group (R-2 = 46%). Skin auto fluorescence was significantly higher in the type 2 diabetes group, with both micro- and macrovascular disease, compared with the group without complications and the group with only microvascular complications. CONCLUSIONS - This study confirms in a large group of type 2 diabetic patients that skin autofluorescence is higher compared with age-matched control subjects and is associated with the severity of diabetes-related complications. Skin auto fluorescence reflecting vascular damage might be a rapid and helpful tool in the diabetes outpatient clinic for identifying diabetic patients who are at risk for developing complications

Orthostatic hypotension, diabetes, and falling in older patients:a cross-sectional study

Background: Although orthostatic hypotension (OH) is more prevalent in old age, and in patients with diabetes, the prevalence of OH in older patients with type 2 diabetes mellitus is unknown. Aim: To establish the prevalence of OH, and its association with falling, in home-dwelling older participants with and without type 2 diabetes. Design and setting: A cross-sectional study in primary care in the Netherlands. Method: A total of 352 patients with type 2 diabetes, and 211 without participated in this study. OH was defined as a fall in blood pressure of at least 20 mmHg systolic or 10 mmHg diastolic after either 1 or 3 minutes in an upright position. Feelings of dizziness, light-headedness, or faintness during the standing period were documented as orthostatic complaints. Fall risk was assessed with a validated risk profile instrument. Results: The prevalence of OH was 28% (95% CI = 24% to 33%) and 18% (95% CI = 13% to 23%) in participants with and without type 2 diabetes, respectively. OH was not related to falling, while the presence of orthostatic complaints in itself was associated with both previous fall incidents as well as a high fall risk, even after adjustment for OH. The adjusted odds ratios were 1.65 (95% CI = 1.00 to 2.72) and 8.21 (95% CI = 4.17 to 16.19), respectively. Conclusion: OH is highly prevalent in home-dwelling older people with and without type 2 diabetes. Those with orthostatic complaints had an increased risk for falling, whereas those with OH were not

Baseline characteristics of type 2 diabetes patients: total and subdivided in survivors and non-survivors expressed as mean±SD or <i>n</i> (%).

<p>Seven patients were lost to follow-up and did not define the baseline characteristics of the survivors/non-survivors.</p>a<p>Median and interquartile range.</p>b<p>Angiotensin-converting enzyme inhibitors and Angiotensin II receptor blockers.</p>c<p>Large majority represented by statins (99%). Reference values of the laboratory: HbA_1c 4.0–6.0%, creatinine 70–110 µmol/l, creatinine clearance (Cockcroft-formula) 80–120 ml/min, urinary albumin-to-creatinine ratio 0–2.5 for men and 0–3.5 for women, total cholesterol 3.5–5.0 mmol/l.</p

Kaplan-Meier plot of the cumulative proportions of deaths against Standardised Survival Time.

<p>Survival curve for survival expressed as Standardised Survival Time (SST) in the entire type 2 diabetes group. The median SST in type 2 diabetes mellitus (T2DM) 1.00 is not different from the general Dutch population 1.00 (Expected); the observed mortality (all-cause) at SST 0.25 and 0.50 of 0.09, respectively 0.20 does not significantly differ from the general Dutch population (0.08 respectively 0.18, p>0.1).</p

Kaplan-Meier plot of the cumulative proportions of deaths in patients with albuminuria against Standardised Survival Time.

<p>Cumulative proportions of deaths (all causes) against Standardised Survival Time (SST) in type 2 diabetes patients with albuminuria (Alb) yes/no (+/−), compared to the expected deaths of the general population. Differences in mortality between the type 2 diabetes-subgroups and the general population are tested at SST = 0.25 and SST = 0.5. Mortality rate at SST 0.25 is 0.15 [95% confidence interval (CI) 0.10–0.19] and the expected value is 0.076 (p = 0.002). At SST 0.50 mortality rate is 0.26 (95% CI 0.19–0.33), which was also higher than the expected value of 0.18 (p = 0.014).</p

Flowchart of the enrolment of the type 2 diabetes study cohort from 32 general practitioners of a district in The Netherlands.

<p>Flowchart of the enrolment of the type 2 diabetes study cohort from 32 general practitioners of a district in The Netherlands.</p

Kaplan-Meier plot of the cumulative proportions of deaths in patients with previous cardiovascular disease against Standardised Survival Time.

<p>Cumulative proportions of deaths (all causes) against Standardised Survival Time (SST) in type 2 diabetes patients with previous cardiovascular disease (CVD) yes/no (+/−), compared to the expected deaths of the general population. Differences in mortality between the type 2 diabetes-subgroups and the general population are tested at SST = 0.25 and SST = 0.5. Mortality rate at SST 0.25 is 0.13 (95% CI 0.096–0.17) and an expected value is 0.076, p<0.001. At SST 0.50 mortality rate is 0.25 (95% CI 0.19–0.30) and the expected value is 0.18, p<0.0001.</p

Predictors of overall mortality in type 2 diabetes mellitus by univariate and multivariate Cox regression analysis using “survival in years” ( = standard method) and using “standardised survival time”.

<p>Abbreviations: HR, hazard ratio; CI, confidence interval; NS, not significant.</p>a<p>The standardised survival time was calculated as the ratio between the observed survival time of an individual and the median residual life span of individuals with the same age in the general population.</p

Kaplan-Meier survival curve for survival in years in the entire type 2 diabetes group.

<p>Kaplan-Meier survival curve for survival in years in the entire type 2 diabetes group.</p