Influence of diabetes and diabetes-gender interaction on the risk of death in patients hospitalized with congestive heart failure

OBJECTIVES: The purpose of this study was to investigate the influence of diabetes on long-term mortality in a large cohort of patients hospitalized with heart failure (HF). BACKGROUND: Diabetes is common in HF patients, but information on the prognostic effect of diabetes is sparse. METHODS: The study is an analysis of survival data comprising 5,491 patients consecutively hospitalized with new or worsening HF and screened for entry into the Danish Investigations of Arrhythmia and Mortality on Dofetilide (DIAMOND). Screening, which included obtaining an echocardiogram in 95% of the patients, took place at Danish hospitals between 1993 and 1995. The follow-up time was five to eight years. RESULTS: A history of diabetes was found in 900 patients (16%), 41% of whom were female. Among the diabetic patients, 755 (84%) died during follow-up, compared with 3,200 (70%) among the non-diabetic patients, resulting in a risk ratio (RR) of death in diabetic patients of 1.5 (95% confidence interval [CI] 1.4 to 1.6, p < 0.0001). In a multivariate analysis, the RR of death in diabetic patients was 1.5 (CI 1.3 to 1.76, p < 0.0001), but a significant interaction between diabetes and gender was found. Diabetes increased the mortality risk more in women than in men, with the RR for diabetic men being 1.4 (95% CI 1.3 to 1.6, p < 0.0001) and 1.7 for diabetic women (95% CI 1.4 to 1.9, p < 0.0001). The effect of diabetes on mortality was similar in patients with depressed and normal left ventricular systolic function. CONCLUSIONS: Diabetes is a potent, independent risk factor for mortality in patients hospitalized with HF. The excess risk in diabetic patients appears to be particularly prominent in females.     

Influence of diabetes on peripheral bone mineral density in men: a controlled study

Abstract The aims of the study were to (1) compare peripheral bone mineral density (BMD) in men with diabetes to peripheral BMD in non-diabetic men, and (2) explore factors which may predict BMD in diabetic men. Ninety men with type 2 diabetes and 35 men with type 1 diabetes were randomly selected for participation via a computerised database. Fifty healthy males were also recruited. All patients had peripheral BMD measured by dual energy Xray absorptiometry (DEXA) at the non-dominant distal radius. Information on a number of clinical parameters was obtained by direct questioning, and from patient case notes. The mean age (95% confidence interval (CI)) of the type 1 diabetic group, type 2 diabetic group and control group were, respectively: 49.3 years (44.6–53.9), 62.8 years (60.7–64.8) and 38.5 (34.9–42.1) years. Median (95% CI) Z-scores for the three groups were: -0.18 (-0.68 to +0.32), +0.19 (-0.14 to +0.49) and -0.02 (-0.4 to +0.31), respectively (p=not significant). Only body mass index (BMI) was correlated with BMD in the type 1 diabetic group, and only BMI and age were correlated with BMD in type 2 diabetics. There was no correlation between BMD and glycosylated haemoglobin concentration (HbA₁c), disease duration or presence of microvascular or macrovascular complications in either of the diabetic groups. We did not find any significant difference in peripheral BMD between patients with type 1 diabetes, type 2 diabetes and controls.     

Diabetes mellitus,impaired glucose tolerance and mortality among elderly men: The Finnish cohorts of the seven countries study

Summary We studied the association of glucose intolerance with total and cause-specific mortality during a 5-year follow-up of 637 elderly Finnish men aged 65 to 84 years. Total mortality was 276 per 1000 for men aged 65 to 74 years and 537 per 1000 for men aged 75 to 84 years. Five-year total mortality adjusted for age was 364 per 1000 in diabetic men, 234 per 1000 in men with impaired glucose tolerance and 209 per 1000 in men with normal glucose tolerance. The relative risk of death among diabetic men was 2.10 (95% confidence interval 1.26 to 3.49) and among men with impaired glucose tolerance 1.17 (95% confidence interval 0.71 to 1.94) times higher compared with men with normal glucose tolerance. Cardiovascular disease was the most common cause of death in every glucose tolerance group. The multivariate adjusted relative risk of cardiovascular death was increased (1.55) in diabetic patients, albeit non-significantly (95% confidence interval 0.84 to 2.85). Diabetes resulted in an increased risk of cardiovascular mortality among men aged 65–74 years but not among the 75–84-year-old men. Relative risk of death from non-cardiovascular causes was slightly increased among diabetic subjects. In conclusion, diabetes mellitus is a significant determinant of mortality among elderly Finnish men.     

Changes in all-cause and cardiovascular disease mortality in three different Finnish population cohorts with and without diabetes

Background

We aimed to assess changes in cardiovascular (CVD) and all-cause mortality among diabetic and non-diabetic individuals between three large study cohorts with baseline assessments of 10 years apart and followed up for 10 years.

Methods

Six population surveys were carried out in 1972, 1977, 1982, 1987, 1992 and 1997 in Finland. For the analyses we combined the 1972 and 1977 cohorts (cohort 1), the 1982 and 1987 cohorts (cohort 2) and similarly also the 1992 and 1997 cohorts (cohort 3).

Results

Age-adjusted hazard ratio (HR) of all-cause mortality and CVD in men without diabetes showed that both had a statistically significant decreased risk of all-cause mortality compared to the first cohort. No statistically significant changes in all-cause mortality were observed in men and women with diabetes between the latter two cohorts compared with the first after controlling for several covariates. In both men and women without diabetes, cohort 2 (men, HR = 0.65; 95% CI 0.51–0.82; women, HR = 0.54; 95% CI 0.32–0.89) and cohort 3 (men, HR = 0.32; 95% CI 0.22–0.47; women, HR = 0.31; 95% CI 0.14–0.68) showed a statistically significant decreased risk of CVD mortality compared to cohort 1. Age-adjusted HRs in regard to CVD mortality in men (HR = 0.22; 95% CI 0.07–0.69) and women (HR = 0.22; 95% CI 0.05–0.99) with diabetes of cohort 3 were statistically significantly lower than in cohort 1.

Conclusions

There seems to be a decrease in CVD mortality in people with diabetes indicating that treatment of diabetes and cardiovascular risk factors in diabetes patients may have improved during the last decade.     

Known type 2 diabetes mellitus among the Kuwaiti population

The reported prevalence of type 2 diabetes among the Kuwaiti population varied from one source to another. This study was undertaken to define the magnitude of the problem and to suggest plans for future diabetic care. All type 2 Kuwaiti diabetic subjects registered and continuing to attend regularly in two health areas Mubarak Health Area (MHA) and Farwania Health Area (FHA)] were selected for the study. There were 3222 in MHA and 5114 in FHA among the Kuwaiti population aged 20 years and above, accounting for a total crude prevalance of 7.6% in both health areas and for a prevalence rate of 5.6% in MHA and 10.0% in FHA. The age-specific prevalence of type 2 diabetes in both areas combined rose from 2.639 per 100 population in the age group 20–39 years to 15.350% and 26.252% in the age groups 40–59 and 60 and above, respectively. The female to male ratio was 1.7, 1.6, 1.1, respectively, in MHA and 1.7, 2.0, 0.9 in FHA for the age groups 20–39, 40–59, and 60 and above. This study shows that type 2 diabetes is a major public health problem in Kuwait, with a female preponderance. Obesity is a characteristic feature of the population studied, with a mean body mass index of 31.8±6.3 and 28.5±5.1 in women and men, respectively. A positive family history of diabetes mellitus was reported in 63% of the diabetic subjects. There is a need to standardize methods of reporting and to plan a national screening survey.     

Plasma N-terminal pro-brain natriuretic peptide as an independent predictor of mortality in diabetic nephropathy

Aims/hypothesis Raised N-terminal pro-brain natriuretic peptide (NT-proBNP) is independently associated with an increased risk of death in chronic heart failure and acute coronary syndromes in nondiabetic populations. Diabetic nephropathy is characterised by an increased risk of cardiovascular morbidity and mortality. This study investigated the prognostic value of NT-proBNP in a large cohort of type 1 diabetic patients with and without diabetic nephropathy.Methods In a prospective observational follow-up study, 198 type 1 diabetic patients with overt diabetic nephropathy (122 men, age [mean±SD] 41±10 years, duration of diabetes 28±8 years, GFR 74±33 ml min^–1) and a matched control group of 188 patients with longstanding type 1 diabetes and persistent normoalbuminuria (114 men, age 43±10 years, duration of diabetes 27±9 years) were followed for 9.3 (0.0–9.5) years. Plasma NT-proBNP concentration was determined by immunoassay at baseline.Results In patients with diabetic nephropathy, plasma NT-proBNP concentration was elevated to (median [range]) 110 (5–79640) ng l^–1 vs. 27 (5–455) ng l^–1 in normoalbuminuric patients (p<0.0001). Among patients with nephropathy, 39 (39%) patients with plasma NT-proBNP concentrations above the median and 12 (12%) with values below the median died from any cause (unadjusted hazard ratio 3.86 [95% CI 2.02–7.37], p<0.0001; covariate-adjusted hazard ratio 2.28 [1.04–4.99], p=0.04). This lower mortality rate was attributable to fewer cardiovascular deaths: 31 (31%) and 7 (7%) above and below the median NT-proBNP level respectively (unadjusted hazard ratio 5.25 [2.31–11.92], p<0.0001; covariate-adjusted hazard ratio 3.81 [1.46–9.94], p=0.006).Conclusions/interpretation Elevated circulating NT-proBNP is a new independent predictor of the excess overall and cardiovascular mortality in diabetic nephropathy patients without symptoms of heart failure.Per Hildebrandt has received an honorarium and served as consultant in a scientific advisory board for Roche.     

Prevalence of diabetes, obesity and hypertension in a Turkish population (Trabzon city).

OBJECTIVE: The objectives of this study were to determine the prevalence of diabetes mellitus in Trabzon city, Turkey, using standardized diagnostic criteria, and to evaluate associated factors. METHODS: A total of 3000 eligible study subjects were selected. Of those, 2646 subjects participated in the study. Individuals aged > or =20 years were selected from their family health cards and were invited to the health station. Anthropometric and demographic data were obtained for each subject. Plasma glucose was measured by an autoanalyser. People without previously diagnosed diabetes were categorized according to WHO diagnostic criteria as follows. Diabetes: a fasting plasma glucose (FPG)> or =140 mg/dl or 2-h plasma glucose > or =200 mg/dl after a 75-g oral glucose load. RESULTS: The overall prevalence of diabetes in those > or =20 years of age was 6.0% (n=160). Among diabetic subjects, 69 were newly diagnosed diabetes mellitus. Age, body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP) and FPG were higher in diabetic subjects than in non-diabetic subjects. The prevalence of diabetes showed significant association with increased age (P<0.0001). The overall prevalence of obesity was 19.2%. The combined prevalence of both overweight and obesity was 60.6%. The prevalence of obesity was 27.4% among women and 10.7% among men (P<0.0001). Prevalence of diabetes increased with degree of obesity (P<0.0001). The rate of obesity in diabetic subjects was 35.6%. In the study population as a whole, the prevalence of obesity increased with age, being highest in the 50-59 years age group, but lower again in the 60+ age group. Prevalence of SBP> or =140 mmHg was 12.0% and of DBP> or =90 mmHg was 8.2%.     

Type 2 diabetes and risk of non-embolic ischaemic stroke in Japanese men and women

Aims/hypothesis The aim of this study was to examine the relationship between type 2 diabetes and risk of ischaemic stroke in Asian populations.Methods We conducted a 17-year prospective cohort study in 10,582 Japanese individuals (4287 men and 6295 women) aged 40–69 years living in five communities in Japan. All subjects were free of stroke and CHD at baseline. Diabetes was defined as a fasting glucose level of 7.0 mmol/l, a non-fasting glucose of 11.1 mmol/l, or receiving medication for diabetes.Results The risk of non-embolic ischaemic stroke was approximately two-fold higher in diabetic subjects than in subjects with normal glucose levels. The multivariate relative risk after adjustment for age, community, hypertensive status, BMI, triceps and subscapular skinfold thickness (TSF and SSF), and other known cardiovascular risk factors was 1.8 (95% CI 1.0–3.2) for men and 2.2 (1.2–4.0) for women. This excess risk was primarily observed among non-hypertensive subjects and individuals with higher values for measures of adiposity (BMI, TSF and SSF values above the median), particularly those with higher values for SSF. The association between non-embolic ischaemic stroke and glucose abnormality was particularly strong among non-hypertensive subjects with higher SSF values: the multivariate relative risk was 1.9 (1.0–3.7) for borderline diabetes and 4.9 (2.5–9.5) for diabetes.Conclusions/interpretation In this cohort, type 2 diabetes was a significant risk factor for non-embolic ischaemic stroke, particularly in non-hypertensive and non-lean individuals. Due to the nationwide decrease in blood pressure and increase in mean BMI among the Japanese population, with current levels approaching those observed in Western countries, the impact of glucose abnormalities on risk of ischaemic stroke represents a forthcoming public health issue in Japan.     

Prevalence and incidence of Type 2 diabetes and its complications 1996–2003—estimates from a Swedish population‐based study

Aims To determine the prevalence and incidence of Type 2 diabetes and its complications in Uppsala county, Sweden between 1996 and 2003. Methods Retrospective population‐based study of patients with Type 2 diabetes identified in computerized medical records at 26 county primary care centres. Prevalence and incidence of Type 2 diabetes were estimated in the population aged 30–39, 40–49, 50–59, 60–69, 70–79 and ≥ 80 years. Mortality, prevalence and incidence of complications in patients with Type 2 diabetes were determined through linkage to national inpatient, uraemia and cause‐of‐death registers. Results Crude prevalence of Type 2 diabetes increased from 2.2 to 3.5% between 1996 and 2003. In the population aged ≥ 30 years, the age‐ and sex‐adjusted period increase was 53%[odds ratio (OR) 1.53, 95% confidence interval (CI) 1.47–1.58]. Crude population incidence was approximately stable after 1997 (3.7 cases/1000 residents in 1997 compared with 3.8/1000 in 2003). Age‐ and sex‐adjusted mortality rates in Type 2 diabetic patients decreased by 4% per year (OR 0.96, 95% CI 0.94–0.97). Prevalence rates of cardiovascular disease in Type 2 diabetic patients were essentially stable, affecting 13.8% of females and 18.0% of males in 2003. No trend was detected for prevalence of renal failure or incidence of acute myocardial infarction, stroke and amputation. Conclusions Prevalence of Type 2 diabetes increased in Uppsala county between 1996 and 2003 as a consequence of approximately stable incidence since 1997 and declining mortality. Rates of diabetes‐related complications, notably cardiovascular disease, continued to impose a substantial burden.     

Prevalence of diabetes mellitus and impaired glucose tolerance in Benghazi Libya

OBJECTIVES: To assess, by a house to house study, the prevalence of diabetes, impaired glucose tolerance (IGT) and their associated risk factors in Benghazi, Libya using 75 gram oral glucose tolerance test (OGTT) and ADA 1997 and WHO 1998 diagnostic criteria. MATERIAL AND METHODS: A multistage cluster sampling was used to select the study population. A total of 314 men and 554 women underwent a standard 75 grams OGTT. The response rate was 77.7% for males and 89.2% for females. RESULTS: The overall prevalence of IGT was 8.5% (95% confidence interval (CI) 5.8 - 11.3) (men 8.6% 95% CI 7.7-9.6, women 8.5% 95% CI 5.0 -11.9), and that of diabetes was 14.1% (95% CI 10.9-17.1) (men 16.3% 95% CI 14.5-18.3 women 13.0% 95% CI 10.0 - 16.1). Diabetes was present in 19.4% (95% CI 15.4-20.5) (men 22.7% 95% CI 20.2-25.4, women 17.6% 95% CI 14.1-19.1) in 30-64 years age range. Prevalence of diabetes was slightly higher in urban than in rural areas (14.5% vs 13.5%). The prevalence of newly diagnosed diabetes in urban and rural areas were 3.6% and 7.3% respectively and that of known diabetes were 10.9% and 6.3% respectively. Associated risk factors with diabetes and IGT were age, family history of diabetes, hypertension, BMI, WHR and serum cholesterol. CONCLUSION: Diabetes is emerging as an important public health problem in Libya and should rank very high in the priority list of health planners.     

Remission of nephrotic-range albuminuria reduces risk of end-stage renal disease and improves survival in type 2 diabetic patients

Aims/hypothesis We evaluated the impact of remission of nephrotic-range albuminuria (>2500 mg/24 h) (NRA) on end-stage renal disease (ESRD) and mortality in type 2 diabetic patients with nephropathy.Methods This was a follow-up observational study involving all 79 patients (35%; 62 men, 17 women) with NRA from a cohort of type 2 diabetic patients with nephropathy that was followed for at least 3 years at the Steno Diabetes Center (n=227). Patients were followed from the onset of NRA until death or January 2005. The mean age (±SD) was 60±8 years and known diabetes duration was 14±7 years. Remission of NRA was defined as sustained albuminuria <600 mg/24 h for at least 1 year.Results The duration of follow-up after onset of NRA was 6.5 years (range 2–20 years). Remission was induced in 20 (25%) of the patients, all treated with ACE inhibitors or angiotensin-II receptor blockers. Remission lasted 4.1 years (range 1–10 years) and only three patients relapsed. At the end of follow-up, only 30% (two ESRD and four deaths) of the 20 patients with remission had reached the composite endpoint of ESRD or death, in contrast to 66% (16 ESRD and 23 deaths) of the 59 patients without remission (p<0.01). Cox regression analysis revealed that remission was associated with a risk reduction of 67% (95% CI 10–87) for reaching the composite endpoint of ESRD or death and of 69% (95% CI 21–88%) for death alone. Male sex, greater age and systolic blood pressure at onset of NRA were also independently associated with an increased risk of ESRD and death.Conclusions/interpretation Aggressive antihypertensive treatment can lead to long-term remission of NRA in a sizeable proportion of patients with type 2 diabetes. Such remission is associated with a slower progression of nephropathy and substantially improved survival.     

Ethnicity and sex are strong determinants of diabetes in an urban Western society: implications for prevention

Aims/hypothesis This study was conducted to investigate the prevalence of diabetes and its association with ethnicity and sex, to identify subgroups at special risk.Methods We performed a population-based cross-sectional survey of 30- to 67-year-olds in an area of Oslo with low socio-economic status, and collected data using questionnaires, physical examinations and serum analyses for the 2,513 participants (attendance rate 49.3%).Results In the age group 30–59 years, mean BMI was 28.5 (95% CI: 27.5–29.6) for South Asian women, 26.1 (25.9–26.4) for Western women, 26.7 (26.1–27.4) for South Asian men and 27.2 (26.9–27.5) for Western men. The diabetes prevalence rates were 27.5% (18.1–36.9) for South Asian women, 2.9% (1.9–3.4) for Western women, 14.3% (8.0–20.7) for South Asian men and 5.9% (4.2–7.5) for Western men. The age-adjusted odds ratio (OR) for diabetes for women vs men was 1.9 (0.9–4.1) for South Asians, and 0.4 (0.3–0.6) for the Western population (p<0.001). The age-adjusted OR for diabetes for South Asians vs Westerners was 11.0 (5.8–21.1) for women and 3.0 (1.6–5.4) for men, and after adjustment for WHR the ORs were 7.7 (3.9–15.3) for women and 2.6 (1.4–4.9) for men. After additional adjustments for physical activity, education, body height and fertility for women, the OR was 6.0 (2.3–15.4) for women and 1.9 (0.9–4.0) for men.Conclusions/interpretation The alarmingly high prevalence of diabetes among South Asian women in Norway needs further investigation, as it has considerable public health implications. Ethnic differences in OR for diabetes persisted after adjustment for age, adiposity, physical activity and education. These differences were still present for women after additional adjustment for body height and fertility.     

Ten-year cardiovascular mortality in relation to risk factors and abnormalities in lipoprotein composition in Type 2 (non-insulin-dependent) diabetic and non-diabetic subjects

Summary The purpose of the present study was to examine 10-year cardiovascular morbidity and mortality in patients with newly-diagnosed Type 2 (non-insulin-dependent) diabetes mellitus and non-diabetic control subjects and to evaluate the effects of general risk factors, plasma insulin, urinary albumin excretion, lipoprotein abnormalities characteristic of Type 2 diabetes and the degree of hyperglycaemia in diabetic patients on cardiovascular mortality. Furthermore, the extent to which the above-mentioned factors could contribute to the excessive cardiovascular mortality observed in diabetic patients was examined. In the years 1979–1981, altogether 133 (70 men, 63 women) newly-diagnosed patients with Type 2 diabetes and 144 (62 men, 82 women) non-diabetic control subjects aged 45–64 years were studied. Both groups were re-examined in the years 1985–1986 and 1991–1992. The impact of different factors on cardiovascular mortality was examined by univariate analyses after adjustment for age and sex and by multiple logistic regression analyses. The age-standardized total and cardiovascular mortality rates were substantially higher in diabetic men (17.8 and 15.0%, total and cardiovascular mortality, respectively p = 0.06 and NS) and women (18.5 and 16.6%, p<0.01 for both) than in non-diabetic control men (5.2 % both total and cardiovascular mortality) and women (4.2 and 2.2 %). Cardiovascular mortality was not related to the treatment modality (diet, oral drugs, insulin) at 5 years from diagnosis. Use of diuretics, beta-blocking agents or their combination at baseline did not make a significant contribution to cardiovascular mortality either. In multiple logistic regression analysis on diabetic patients, age, LDL triglycerides, smoking, blood glucose and ischaemic ECG at baseline had independent associations with cardiovascular mortality. Interestingly, urinary albumin excretion rate measured at 5-year examination also predicted 10-year cardiovascular mortality after adjustment for the effects of major risk factors including lipoprotein abnormalities, but its predictive power reduced to a nonsignificant level when the effect of plasma glucose was taken into account. The relative risk of cardiovascular mortality associated with diabetes was 8.2 after allowing for age alone, but it declined to 3.7 when all contributing factors from the baseline examination (except blood glucose) were taken into account. In conclusion, the present results indicate that LDL triglycerides and/or other changes in lipoprotein composition characteristic of Type 2 diabetes and manifesting as elevated serum triglycerides are atherogenic and they strongly predict increased cardiovascular mortality. Furthermore, it is hypothesized that the consequences of long-term hyperglycaemia could explain a large proportion of the remaining excessive cardiovascular mortality risk among Type 2 diabetic patients.     

Increasing prevalence of diabetes mellitus in Oman.

AIMS: To determine the prevalence of diabetes mellitus and impaired fasting glucose by age, gender, and by region and compare results with the 1991 survey; and estimate previously undiagnosed diabetes mellitus in the Omani population. METHODS: Cross-sectional survey containing a probability random sample of 5838 Omani adults aged >or= 20 years. Diabetes and impaired fasting glucose (IFG) were assessed by fasting venous plasma glucose using 1999 World Health Organization's diagnostic criteria (normoglycaemia < 6.1 mmol/l, IFG >or= 6.1 but < 7 mmol/l,and diabetes >or= 7 mmol/l). The 1991 survey was reanalysed using the same diagnostic criteria, and results were compared. RESULTS: In 2000, the age-adjusted prevalence of diabetes among Omanis aged 30-64 years reached 16.1% (95% confidence interval (CI) 14.7-17.4) compared with 12.2% (95% CI11.0-13.4) in 1991. IFG was found among 7.1% (95% CI6.2-8.1) of males and 5.1% (95% CI 4.4-6.0) of females. Generally, diabetes was more common in urban then rural regions. Only one-third of diabetic subjects knew that they had diabetes. Nearly half of the study population had a body mass index > 25 kg/m2. CONCLUSIONS: The prevalence of diabetes is high in Oman and has increased over the past decade. The high rate of abnormal fasting glucose together with high rates of overweight and obesity in the population make it likely that diabetes will continue to be a major health problem in Oman. Primary prevention programmes are urgently needed to counteract major risk factors that promote the development of diabetes.     

A multicentre study of the prevalence of diabetic peripheral neuropathy in the United Kingdom hospital clinic population

Summary A cross-sectional multicentre study of randomly selected diabetic patients was performed using a standardised questionnaire and examination, to establish the prevalence of peripheral neuropathy in patients attending 118 hospital diabetes clinics in the UK. Vibration perception threshold was performed in two centres to compare with the clinical scoring systems. A total of 6487 diabetic patients were studied, 53.9% male, median age 59 years (range 18– 90 years), 37.4% Type 1 (insulin-dependent) diabetes mellitus, with a median duration of diabetes 8 years (0–62 years). The overall prevalence of neuropathy was 28.5% (27.4– 29.6 %) (95 % confidence interval) in this population. The prevalence in Type 1 diabetic patients was 22.7% (21.0– 24.4 %) and in Type 2 (non-insulin-dependent) diabetic patients it was 32.1 % (30.6–33.6 %). The prevalence of diabetic peripheral neuropathy increased with age, from 5% (3.1– 6.9 %) in the 20–29 year age group to 44.2 % (41.1–47.3 %) in the 70–79 year age group. Neuropathy was associated with duration of diabetes, and was present in 20.8 % (19.1–22.5 %) of patients with diabetes duration less than 5 years and in 36.8 % (34.9–38.7 %) of those with diabetes duration greater than 10 years. Mean vibration perception threshold measured at the great toe was 21.1±13.5 SD volts and correlated with the neuropathy disability score, r=0.8 p<0.001. In conclusion, diabetic peripheral neuropathy is a common complication associated with diabetes. It increases with both age and duration of diabetes, until it is present in more than 50% of Type 2 diabetic patients aged over 60 years. An increased awareness of the high prevalence of peripheral neuropathy, especially in older patients, should result in improved screening programmes in order to reduce the high incidence of neuropathic diabetic foot ulceration.     

The mortality of children with Type 1 (insulin-dependent) diabetes mellitus in Norway, 1973–1988

Summary The mortality status of all individuals in Norway with the onset of Type 1 (insulin-dependent) diabetes mellitus from 1973 through 1982 and age at onset below 15 years was determined as of 1 July 1988. Of the 1908 cases included in the follow-up, 20 had died (15 males and 5 females) and 10 had emigrated. A two-fold increased risk for early mortality was exhibited among this cohort. Life-table analyses did not find sex or age at onset of Type 1 diabetes to be statistically significant predictors of survival when controlling for diabetes duration. A review of death certificates revealed that accidents and suicides accounted for 40% of the deaths in the total cohort and that this cause of death occured only among male subjects. Acute diabetes related complications were the underlying causes of death for 35% of the subjects. Diabetic renal disease and death by cardiovascular disease were not documented in this young cohort with a maximum age of 30 years and maximum diabetes duration of 15.5 years. This is the first mortality report of a population-based registered cohort of Type 1 diabetic patients for Norway. While still being at increased risk for premature death, this cohort appears to be at decreased risk of early death when compared to a cohort of young diabetic patients from Oslo, Norway diagnosed in 1925–1955, suggesting improvements in the survival of individuals with Type 1 diabetes in Norway.     

Impact of Diabetes on Stroke Risk and Outcomes: Two Nationwide Retrospective Cohort Studies

Several limitations existed in previous studies which suggested that diabetic patients have increased risk of stroke. We conducted this study to better understand the stroke risk and poststroke outcomes in patients with diabetes.From the claims data of Taiwan''s National Health Insurance, we identified 24,027 adults with new-diagnosed diabetes and 96,108 adults without diabetes between 2000 and 2003 in a retrospective cohort study. Stroke events (included hemorrhage, ischemia, and other type of stroke) during the follow-up period of 2000 to 2008 were ascertained and adjusted risk of stroke associated with diabetes was calculated. A nested cohort study of 221,254 hospitalized stroke patients (included hemorrhage, ischemia, and other type of stroke) between 2000 and 2009 was conducted. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for adverse events after stroke hospitalization in patients with and without diabetes.The incidences of stroke in cohorts with and without diabetes were 10.1 and 4.5 per 1000 person-years, respectively. During the follow-up period, diabetic patients had an increased risk of stroke (adjusted hazard ratio: 1.75; 95% CI: 1.64–1.86) than those without diabetes. Associations between diabetes and stroke risk were significant in both sexes and all age groups. Previous diabetes was associated with poststroke mortality (OR: 1.33; 95% CI: 1.19–1.49), pneumonia (OR: 1.30; 95% CI: 1.20–1.42), and urinary tract infection (OR: 1.66; 95% CI: 1.55–1.77). The impact of diabetes on adverse events after stroke was investigated particularly in those with diabetes-related complications.Diabetes was associated with stroke risk, and diabetic patients had more adverse events and subsequent mortality after stroke.     

Prevalence of diabetes and obesity in the adult population of the Seychelles.

The prevalence of diabetes and obesity were assessed in an age- and sex-stratified sample of 1078 individuals living in Mahé, The Republic of Seychelles. Presence or absence of diabetes mellitus was assessed by measuring glucose concentration in fasting venous blood. Prevalence of obesity (standardized for age) was elevated five-fold in women compared with men (20.9 vs 4.2%). In women, it increased from 8.9% at age 25-34 years to 29.4% at age 35-44 years and plateaued thereafter, whereas it did not change with age in men. Prevalence of diabetes (standardized for age) was 3.4% for men and 4.6% for women. It increased markedly with age, from 0.0 and 0.8% at age 25-34 years to 8.8 and 13.4% at age 55-64 years in men and women, respectively. A strong association of diabetes with excess body weight was observed. Most cases of diabetes can be attributed to Type 2 (non-insulin-dependent) diabetes. Fifty-five percent of diabetic individuals were unaware of their disease at the time of the survey.     

Incidence of Type 1 (insulin-dependent) diabetes mellitus in Catalonia, Spain

Summary The incidence of Type 1 (insulin-dependent) diabetes mellitus was prospectively evaluated in Catalonia, Spain in patients up to 30 years of age during the period 1987–1990. The population at risk (0–29 years) consisted of 2,690,394 inhabitants (total population of Catalonia 5,978,638). All the cases were independently identified from four sources: endocrinologists, sales of blood glucose monitors and insulin pen injectors, diabetes societies and diabetic summer camps. The degree of ascertainment was 90.1 %. The overall observed incidence rate was 10.7 per 100,000 per year, being 11.5 per 100,000 per year in the 0–14 age group. The incidence in males (12.0 per 100,000 per year) was higher than in females (9.3 per 100,000 per year), with a male/female ratio of 1.36/l. The sex differences were only present in cases over 14 years of age. Age specific incidence rates per 100,000 per year were 4.4 (confidence interval 95%: 3.2–5.7) in the age group 0–4, 9.9 (8.5–11.4) in 5–9, 17.5 (15.7–19.4) in 10–14, 11.4 (9.9–13.0) in 15–19, 11.3 (9.7–13.0) in 20–24 and 8.5 (7.2–9.9) in 25–29. There was a seasonal onset pattern, with the highest incidence in winter (December–February). We conclude that the incidence of Type 1 diabetes observed in Catalonia during the period 1987–1990 is higher than that recently reported in other Mediterranean countries. This study offers the first standardized data on Type 1 diabetes incidence in Catalonia, including cases up to 30 years, and contributes to the knowledge of the epidemiology of diabetes in South Europe.     

The role of diabetes mellitus in the aetiology of renal cell cancer

Summary To investigate the relation between diabetes mellitus and the risk of renal cell cancer we carried out a population-based retrospective cohort study. Patients identified in the Swedish Inpatient Register who were discharged from hospitals with a diagnosis of diabetes mellitus between 1965 and 1983 formed a cohort of 153 852 patients (80 005 women and 73 847 men). The cohort members were followed up to 1989 by record linkage to three nation-wide registries. Standardized incidence ratios (SIRs) and standardized mortality ratios (SMRs) were computed using age-specific sex-specific and period-specific incidence and mortality rates derived from the entire Swedish population. After exclusion of the first year of observation, a total of 267 incidences of renal cell cancer (ICD-7 : 180.0) occurred in diabetic patients compared with the 182.4 that had been expected. Increased risks were observed in both women (SIR = 1.7, 95 % confidence interval, CI = 1.4–2.0) and men (SIR = 1.3; 95 % CI = 1.1–1.6) throughout the duration of follow-up (1–25 years). A higher risk was seen for kidney cancer (ICD-7 : 180) mortality (SMR = 1.9; 95 % CI = 1.7–2.2, women; SMR 1.7, 95 % CI = 1.4–1.9, men). In comparison with the general population, patients with diabetes mellitus have an increased risk of renal cell cancer. [Diabetologia (1999) 42: 107–112] Received: 12 December 1997 and in final revised form: 25 August 1998