The British Diabetic Association Cohort Study, II: cause-specific mortality in patients with insulin-treated diabetes mellitus.

AIMS: To measure cause-specific mortality, by age, in patients with insulin-treated diabetes incident at a young age. METHODS: A cohort of 23 752 patients with insulin-treated diabetes diagnosed under the age of 30 years, from throughout the United Kingdom, was identified during 1972-93 and followed to February 1997. Death certificates have been obtained for deaths during the follow-up period and cause-specific mortality rates and standardized mortality ratios by age and sex are reported. RESULTS: During the follow-up period 949 deaths occurred and at all ages mortality rates were considerably higher than in the general population. Acute metabolic complications of diabetes were the greatest single cause of excess death under the age of 30 years. Cardiovascular disease was responsible for the greatest proportion of the deaths from the age of 30 years onwards. CONCLUSIONS: Deaths in patients with diabetes diagnosed under the age of 30 have been reported and comparisons drawn with mortality in the general population. To reduce these deaths attention must be paid both to the prevention of acute metabolic deaths and the early detection and treatment of cardiovascular disease and associated risk factors.     

Mortality of South Asian patients with insulin-treated diabetes mellitus in the United Kingdom: a cohort study.

AIMS: To investigate mortality in South Asian patients with insulin-treated diabetes and compare it with mortality in non South Asian patients and in the general population. METHODS: A prospective cohort study was conducted of 828 South Asian and 27 962 non South Asian patients in the UK with insulin-treated diabetes diagnosed at ages under 50 years. The patients were followed for up to 28 years. Ethnicity was determined by analysis of names. Standardized mortality ratios (SMRs) were calculated, comparing mortality in the cohort with expectations from the mortality experience of the general population. RESULTS: SMRs were significantly raised in both groups of patients, particularly the South Asians, and especially in women and subjects with diabetes onset at a young age. The SMRs for South Asian patients diagnosed under age 30 years were 3.9 (95% CI 2.0-6.9) in men and 10.1 (5.6-16.6) in women, and in the corresponding non South Asians were 2.7 (2.6-2.9) and 4.0 (3.6-4.3), respectively. The SMR in women was highly significantly greater in South Asians than non South Asians. The mortality in the young-onset patients was due to several causes, while that in the patients diagnosed at ages 30-49 was largely due to cardiovascular disease, which accounted for 70% of deaths in South Asian males and 73% in females. CONCLUSIONS: South Asian patients with insulin-treated diabetes suffer an exceptionally high mortality. Clarification of the full reasons for this mortality are needed, as are measures to reduce levels of known cardiovascular disease risk factors in these patients.     

Mortality from heart disease in a cohort of 23,000 patients with insulin-treated diabetes

AIMS/HYPOTHESIS: Although ischaemic heart disease is the predominant cause of mortality in older people with diabetes, age-specific mortality rates have not been published for patients with Type 1 diabetes. The Diabetes UK cohort, essentially one of patients with Type 1 diabetes, now has sufficient follow-up to report all heart disease, and specifically ischaemic heart disease, mortality rates by age. METHODS: A cohort of 23,751 patients with insulin-treated diabetes, diagnosed under the age of 30 years and from throughout the United Kingdom, was identified during the period 1972 to 1993 and followed for mortality until December 2000. Age- and sex-specific heart disease mortality rates and standardised mortality ratios were calculated. RESULTS: There were 1437 deaths during the follow-up, 536 from cardiovascular disease, and of those, 369 from ischaemic heart disease. At all ages the ischaemic heart disease mortality rates in the cohort were higher than in the general population. Mortality rates within the cohort were similar for men and women under the age of 40. The standardised mortality ratios were higher in women than men at all ages, and in women were 44.8 (95%CI 20.5-85.0) at ages 20-29 and 41.6 (26.7-61.9) at ages 30-39. CONCLUSIONS/INTERPRETATION: The risk of mortality from ischaemic heart disease is exceptionally high in young adult women with Type 1 diabetes, with rates similar to those in men with Type 1 diabetes under the age of 40. These observations emphasise the need to identify and treat coronary risk factors in these young patients.     

Cause-specific and total mortality in the Canterbury (New Zealand) insulin-treated Diabetic Registry population: a 15-year follow-up study.

AIMS: To establish all-cause and cause-specific death rates, and risk factors for mortality in insulin-treated diabetic individuals living in the province of Canterbury, New Zealand. METHODS: Insulin-treated diabetic subjects (n = 995) on the Canterbury Diabetes Registry were followed up over 15 years and vital status determined. Death rates were standardized and hazard regression was used to model the effects of demographic covariates on relative survival time. RESULTS: There were 419 deaths in 11 226.3 person-years of follow-up with a standardized mortality ratio (SMR) of 2.0 (95% confidence interval (CI) 1.8-2.2). Relative mortality was greatest for the group aged 0-29 years (SMR 3.0 (95% CI 2.4-3.7)). After controlling for diabetes duration and gender, a 10-year increment in age of onset was associated with a 33% decrease in relative hazard (95% CI 29-36%), indicating that excess mortality due to diabetes declines with rising age of onset. After controlling for age of onset and gender, each 10-year increment in duration of diabetes is associated with a 26% decrease in relative hazard (95% CI 24-29%), indicating that with longer survival the mortality hazard approaches the general population hazard. Relative mortalities were increased for cardiovascular, renal and respiratory disease, but not malignancy. Relative mortality from acute metabolic complications was increased in the subgroup with age of onset of diabetes < 30 years and requiring insulin within 1 year of diagnosis. CONCLUSIONS: Mortality rates are high for insulin-treated diabetic individuals relative to the general population.     

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.     

Mortality of all incident cases of diabetes mellitus in Sweden diagnosed 1983-1987 at age 15-34 years. Diabetes Incidence Study in Sweden (DISS) Group.

From 1983 all incident cases of diabetes in the age group 15-34 years in Sweden have been recorded prospectively. The aim of the present study was to assess the mortality pattern of cases reported for 1983-87 and followed until the end of 1987. Eighteen deaths were identified by linkage to the national death register. When comparing the mortality in the cohort with Swedish males and females in general, an excess mortality was found in all the groups studied. It is, however, less pronounced if the analysis is restricted to those with Type 1 diabetes (standardized mortality ratio (SMR) and 95% confidence interval = 2.1; 0.8, 4.6), Type 2 diabetes (SMR = 4.8; 1.3, 12.3) or Type 1 + Type 2 (SMR = 2.7; 1.3, 5.0). Eight (44%) of the deaths were in patients with secondary diabetes, a diagnosis that applied to less than 3% of the cohort. Alcohol abuse was prevalent in six cases and suspected in another two. Hypoglycaemia was established as a cause of death in only one case but could not be excluded in a further six. Only one death was associated with ketoacidosis. No valid support for an increased risk of the 'dead in bed' syndrome was found. We suggest that diabetes was decisively important for the death in two cases and less important in 10. In the remaining six cases the existing documentation precludes a proper judgement.     

Long-term mortality in a nationwide cohort of childhood-onset type 1 diabetic patients in Norway

Aims/hypothesis We examined long-term total and cause-specific mortality in a nationwide, population-based Norwegian cohort of patients with childhood-onset type 1 diabetes. Materials and methods All Norwegian type 1 diabetic patients who were diagnosed between 1973 and 1982 and were under 15 years of age at diagnosis were included (n=1,906). Mortality was recorded from diabetes onset until 31 December 2002 and represented 46,147 person-years. The greatest age attained among deceased subjects was 40 years and the maximum diabetes duration was 30 years. Cause of death was ascertained by reviews of death certificates, autopsy protocols and medical records. The standardised mortality ratio (SMR) was based on national background statistics. Results During follow-up 103 individuals died. The mortality rate was 2.2/1000 person-years. The overall SMR was 4.0 (95% CI 3.2–4.8) and was similar for males and females. For ischaemic heart disease the SMR was 20.2 (7.3–39.8) for men and 20.6 (1.8–54.1) for women. Acute metabolic complications of diabetes were the most common cause of death under 30 years of age (32%). Cardiovascular disease was responsible for the largest proportion of deaths from the age of 30 years onwards (30%). Violent death accounted for 28% of the deaths in the total cohort (35% among men and 11% among women). Conclusions/interpretation Childhood-onset type 1 diabetes still carries an increased mortality risk when compared with the general population, particularly for cardiovascular disease. To reduce these deaths, attention should be directed to the prevention of acute metabolic complications, the identification of psychiatric vulnerability and the early detection and treatment of cardiovascular disease and associated risk factors. Electronic Supplementary Materials Supplementary material is available in the online version of this article at . T. Skrivarhaug et al.: Mortality of type 1 diabetes in Norway     

Epidemiology of duodenal ulcer perforation: a study on hospital admissions in Norfolk, United Kingdom

BACKGROUND: Studies on the incidence of perforated duodenal ulcer are limited and in the United Kingdom, data are largely based on findings observed over two decades ago. To provide updated epidemiological data on duodenal ulcer perforation, the incidence of the disease in Norfolk, United Kingdom was determined. METHODOLOGY: Medical records of patients with duodenal ulcer perforation were reviewed to confirm the diagnosis and obtain information on possible risk factors, namely, Helicobacter pylori infection, smoking and intake of non-steroidal anti-inflammatory drugs. The patients were admitted between 1 January 1996 and 31 December 1998, and were residents of Norfolk, United Kingdom. RESULTS: Sixty-eight cases of duodenal ulcer perforation were identified, 36 (52.9%) were males and 32 (47.1%) were females. The age-standardised incidence rate was 3.77 per 100,000 population per year (95% confidence interval 3.72-3.83). The mean age upon admission for all cases was 72.3 years (standard deviation: 17.8). The mean age for males was 67.7 years (standard deviation: 19.4) and for females 77.6 years (standard deviation: 15.7), which differed significantly (difference in means: 9.9, 95% confidence interval 1.5-18.3). There were 29 deaths (42.7%), of which 19 were females. After adjustment for covariates, the odds ratio of mortality in women was 4.57 (95% confidence interval 1.28-16.29). There were 25 (36.8%) smokers and 22 (32.4%) patients were non-steroidal anti-inflammatory drug users. Helicobacter pylori infection was assessed in only 14 (20.6%) patients; 2 were positive, 3 were negative, and in the rest the results were unrecorded. CONCLUSIONS: The incidence rates were lower compared to previous studies in the United Kingdom conducted in the 1960's and 1980's, which could reflect either improved health care or decreasing exposure to known risk factors. Furthermore, the difference in age distribution of incident cases between males and females may explain the higher mortality in females.     

Under utilisation of evidence-based treatment partially explains for the unfavourable prognosis in diabetic patients with acute myocardial infarction.

AIMS: The prognosis after an acute myocardial infarction is worse for patients with diabetes mellitus than for those without. We investigated whether differences in the use of evidence-based treatment may contribute to the differences in 1-year survival in a large cohort of consecutive acute myocardial infarction patients with and without diabetes mellitus. METHODS: We included patients below the age of 80 years from the Register of Information and Knowledge about Swedish Heart Intensive care Admissions (RIKS-HIA), which included all patients admitted to coronary care units at 58 hospitals during 1995-1998. In all 5193 patients had the combination of acute myocardial infarction and diabetes mellitus while 20440 had myocardial infarction but no diabetes diagnosed. Multivariate logistical regression analyses were performed to evaluate the influence of diabetes mellitus on the use of evidence-based treatment and its association with survival during the first year after the index hospitalisation. RESULTS: The prevalence of diabetes mellitus was 20.3% (males 18.5%; females 24.4%). The 1-year mortality was substantially higher among diabetic patients compared with those without diabetes mellitus (13.0 vs. 22.3% for males and 14.4 vs. 26.1% for female patients, respectively) with an odds ratio (OR) (95% confidence interval (CI)) in three different age groups: <65 years 2.65 (2.23-3.16); 65-74 years 1.81 (1.61-2.04) and >75 years 1.71 (1.50-1.93). During hospital stay patients with diabetes mellitus received significantly less treatment with heparins (37 vs. 43%; p<0.001), intravenous beta blockade (29 vs. 33%; p<0.001), thrombolysis (31 vs. 41%; p<0.001) and acute revascularisation (4 vs. 5%; p<0.003). A similar pattern was apparent at hospital discharge. After multiple adjustments for dissimilarities in baseline characteristics between the two groups, patients with diabetes were significantly less likely to be treated with reperfusion therapy (OR 0.83), heparins (OR 0.88), statins (OR 0.88) or to be revascularised within 14 days from hospital discharge procedures (OR 0.86) while the use of ACE-inhibitors was more prevalent among diabetic patients compared to non-diabetic patients (OR 1.45). The mortality reducing effects of evidence-based treatment like reperfusion, heparins, aspirin, beta-blockers, lipid-lowering treatment and revascularisation were, in multivariate analyses, of equal benefit in diabetic and non-diabetic patients. INTERPRETATION: Diabetes mellitus continues to be a major independent predictor of 1-year mortality following an acute myocardial infarction, especially in younger age groups. This may partly be explained by less use of evidence-based treatment although treatment benefits are similar in both patients with and without diabetes mellitus. Thus a more extensive use of established treatment has a potential to improve the poor prognosis among patients with acute myocardial infarction and diabetes mellitus.     

Markedly increased renal disease mortality and incidence of renal replacement therapy among IDDM patients in Japan in contrast to Allegheny County,Pennsylvania, USA

Summary The aim of this study was to evaluate factors related to the markedly increased risk of dying from diabetic renal disease in Japanese insulin-dependent diabetic patients compared to those in the USA. The study was based on two population-based cohorts consisting of 1374 cases from Japan and 995 cases from Allegheny County, Pennsylvania, USA, who were diagnosed between 1 January 1965 and 31 December 1979. The living status and dialysis experience were determined as of 1 January 1990. The duration-adjusted renal-failure-related mortality rates in the Japanese cohort and the USA cohort were 277.2 and 130.9 per 100,000 person-years, and the duration-adjusted incidence rates of dialysis were 564.9 and 295.6 per 100,000 person-years, respectively. After adjustment for sex, age at onset, calendar year of onset, and duration of diabetes, individuals with insulin-dependent diabetes in the Japanese cohort were still 2.4-fold more likely to receive dialysis compared to those in the USA cohort. Ten of the 36 renal-failure-related deaths in the Japanese cohort had never been treated by dialysis, while all renal-failure-related deaths in the USA cohort had been treated by dialysis. Survival after initiation of dialysis in the Japanese cohort was virtually the same as the USA cohort. These data suggest that a greater frequency of diabetic end-stage renal disease and reduced access to acceptance at dialysis underlie much of the excess of diabetic renal deaths in Japan.Abbreviations DERI study Diabetes Epidemiology Research International study - ESRD end-stage renal disease - C. I. confidence interval - RRT renal replacement therapy     

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     

Renal damage in patients with Type 2 diabetes: a strong predictor of mortality.

AIMS: (i) To compare mortality rates in a cohort of Type 2 diabetic patients with those of the general population; (ii) to assess the prognostic role of pre-existing chronic conditions; (iii) to evaluate the impact of different severity of renal damage on mortality. METHODS: All 3892 patients with Type 2 diabetes attending our Diabetic Clinic during 1995 and alive on 1 January 1996 were identified and followed for 4.5 years. Information on vital status (100% complete) and causes of death (98.5% complete) for 599 deceased subjects was derived from death certificates. RESULTS: In comparison with the general population, standardized mortality ratios (x 100) were: 125 (95% confidence interval 104-148) in patients aged < 75 and 85 (75-95) in patients > or = 75 years. Cardiovascular diseases and diabetes were responsible for most of the excess deaths. In a Cox-proportional hazard model, renal damage was a powerful predictor of death (hazard ratio = 2.39; 95% confidence intervals = 2.00-2.85). The severity of renal damage was associated with increasing hazard ratios for death from all-cause mortality and from specific causes (especially coronary artery disease, other cardiovascular causes and diabetes) after multiple adjustments. Other significant predictors of death were: greater age, glycated haemoglobin, smoking, lower body mass index, pre-existing coronary and peripheral artery disease and known co-morbidity (cirrhosis and cancer). CONCLUSIONS: Renal damage of any severity is significantly associated with subsequent mortality from all causes and from cardiovascular diseases. These associations are not confounded by pre-existing co-morbidity or coronary diseases.     

Comparative hospitalisation and mortality rates of Aboriginal and non-Aboriginal Western Australians in their sixth and seventh decades

Background: Aboriginals have higher hospitalisation and mortality rates and die, on average, about 15 years earlier than non-Aboriginals in Western Australia (WA).
Aims: To investigate Aboriginal morbidity and mortality rates in WA in comparison with the rest of the population, with particular reference to the ages of 50 to 65 years.
Methods: Mortality rates from 1983–1989 inclusive for Aboriginals and non-Aboriginals in WA were compared. Major causes of Aboriginal mortality in males and females were matched to the ages at which similar rates from the same causes occurred in non-Aboriginals. Rate ratios (Aboriginahnon-Aboriginal) for causes of death at ages 60–64 years were determined. Hospitalisation rates for Aboriginal and non-Aboriginal people aged 50–64 years in WA in 1988 were used to estimate hospitalisation rate ratios.
Results: Hospitalisation rates in WA were much higher among 50 to 64 year old Aboriginals than non-Aboriginals for most diseases, particularly for infectious and parasitic diseases, and injury and poisoning. Admissions for circulatory diseases were double to four times as frequent among Aboriginals. The main causes of deaths in Aboriginal males were circulatory diseases, injury and poisoning, respiratory diseases, neoplasms, and digestive diseases; in Aboriginal females the main causes of deaths were circulatory diseases, neoplasms, diabetes, respiratory diseases, and injury and poisoning. Except for neoplasms, deaths from these causes occurred among 50–54 year old Aboriginals at rates that were experienced by non-Aboriginal people ten to 30 years later in life. These results underline special needs of the Aboriginal population that have not been adequately met by appropriate services.     

Trends in Mortality of Childhood-onset Insulin-dependent Diabetes Mellitus in Leicestershire: 1940–1991

The relative risk of death by calendar date of diagnosis was investigated in a population-based incident cohort of 845 (463 males:382 females) IDDM diagnosed in Leicestershire before the age of 17 years between 1940 and 1989. The mortality status of 844 (99.9 %) patients was determined as of the 31 December 1991, representing 14 346 person-years of risk. Trends in relative risk of death were investigated using Cox proportional hazards modelling for within cohort comparisons and age/sex and calendar time adjusted standardized mortality ratios (SMR) using generalized linear modelling for external comparisons. Median age at diagnosis was 10 years (range 3 months to 16 years); median duration of diabetes 15 years (range 1–51 years). Forty-four patients had died (5.2 %; median age at death 31 years, range 11–51 years). A further four patients died at presentation (within 24 h) from ketoacidosis and are excluded from all analyses. Calendar date of diagnosis was found to be an important predictor of mortality. Adjusting for attained age there was evidence of a decline in relative risk of death with calendar date of diagnosis of 3.4 % (95 % CI, 0.005–6.9 %) per annum, equivalent to a 32 % fall per decade (95 % CI, 5–51 %), or 84 % (95 % CI, 21–97) from 1940 to 1989. The data are consistent with a large fall in mortality between the 1940s and 1950s representing over 50 % of the total reduction in mortality between 1940 and 1991. Neither sex nor age at diagnosis were significant predictors of mortality. Over the study period 1940–89 the SMR (male and female combined) fell from 981 (541–1556) to 238 (60–953) relative to the general population. This population-based study shows that the prognosis for Type 1 (insulin-dependent) diabetes mellitus has improved markedly over the period 1940–1991.     

Are sulphonylureas all the same? A cohort study on cardiovascular and cancer‐related mortality

BACKGROUND: Aim of the present study is the comparison of all-cause, cardiovascular and non-cardiovascular mortality, and cardiac morbidity, between patients treated with glibenclamide and gliclazide. METHODS: A retrospective observational cohort study was performed on a consecutive series of 568 outpatients (282 women, 286 men) with type 2 diabetes treated with either glibenclamide (n = 378) or gliclazide (n = 190). Information on all-cause mortality and on causes of death up to 31 December 2004 was obtained by the City of Florence Registry Office. Non-fatal cases requiring hospitalization were identified through the regional hospital discharge system using International Classification of Diseases. RESULTS: Mean follow-up was 5.0 +/- 1.6 and 4.4 +/- 2.0 years for death and cardiac events, respectively; during follow-up, 33 and 11 deaths were observed in the glibenclamide and gliclazide groups, with a yearly mortality rate of 4.3 and 2.2%, respectively (p < 0.05). At Cox regression, after adjustment for potential confounders, including comorbidity, glibenclamide treatment was associated with a significant increase in all-cause mortality [OR 2.1(1.2;2.7), p < 0.05], while the difference in cardiovascular mortality was not statistically significant after adjustment for age and sex. Mortality for malignancies was significantly higher in patients treated with glibenclamide after adjustment for age, sex, BMI, and insulin and metformin treatment, [OR 3.6(1.1;11.9); p < 0.05]. A higher incidence of cardiac events was associated with glibenclamide treatment only in patients with previously known ischaemic heart disease. CONCLUSIONS: Treatment with glibenclamide could be associated with higher mortality for cardiovascular diseases and malignancies, in comparison with gliclazide.     

Mortality and causes of death in type 2 diabetic patients. A long-term follow-up study in Osaka District, Japan

A follow-up study of 1939 diabetic patients with a mean observation period of 9.4 years was carried out in Osaka, Japan. The mortality rates per 1000 person-years were 31.35 for males and 21.99 for females, and the ratios of observed to expected number of deaths were 1.69 for males and 1.74 for females, indicating an excess mortality for diabetic patients of both sexes and higher mortality in males than in females in Japan. Factors related to the prognosis of the patients were age, elevated fasting glucose level, lower obesity index, hypertension, diabetic retinopathy, and albuminuria at entry to the study. Insulin treatment was also associated with poor prognosis. Cerebro-cardiovascular and renal disease were the major causes of death in diabetic patients; heart disease killed 19.5%, cerebrovascular disease 16.7% and renal disease 13.1%. The relatively high frequency of renal disease as a cause of death in type 2 diabetes, especially in patients with a lower age of onset, was noteworthy, suggesting some difference in the clinical manifestations of diabetes between Japan and Western countries. Malignant neoplasms accounted for 25% of deaths, and cirrhosis of the liver for 6.4%.     

Mortality in people diagnosed with type 2 diabetes at an older age: a systematic review

OBJECTIVES: To review all published observational studies reporting on all-cause mortality in patients with type 2 diabetes to determine the degree of increased mortality when diagnosed at an older age. DESIGN: Systematic literature search. SETTING: The review included studies carried out in populations from Germany, United Kingdom, United States, Japan, Italy, Western Australia, Netherlands and Sweden. MEASUREMENTS: Medline, CINAHL, EMBASE, National Research Register and Cochrane Reviews were systematically searched from 1975 to 2004. We identified observational studies that reported overall mortality for people diagnosed with type 2 diabetes when they were over the age of 60, compared with a non-diabetic population. Outcome measures were expressed as risk ratios or relative risks. RESULTS: Among 14 eligible studies, one study reported reduced mortality for patients diagnosed with type 2 diabetes over the age of 60, whereas another found virtually no increased risk of mortality. However, 7 of the 14 studies reported increased mortality in all patients diagnosed when older, and 5 studies for certain subgroups only. A meta-analysis showed the combined relative risks (with 95% CI) of increased mortality for men diagnosed between the ages of 60 and 70 to be 1.38 (1.08-1.76) and 1.13 (0.88-1.45) for men diagnosed aged 70 years or older. A similar pattern was found for the same age groups for women, with combined relative risks of 1.40 (1.10-1.79) and 1.19 (0.93-1.52) respectively. CONCLUSION: Increased mortality associated with a diagnosis of type 2 diabetes at an older age is lower than that reported for the general older diabetic population.     

Excess mortality in incident cases of diabetes mellitus aged 15 to 34 years at diagnosis: a population-based study (DISS) in Sweden

Aims/hypothesis The objective of the study was to analyse the mortality, survival and cause of death patterns in incident cases of diabetes in the 15–34-year age group that were reported to the nationwide prospective Diabetes Incidence Study in Sweden (DISS). Materials and methods During the study period 1983–1999, 6,771 incident cases were reported. Identification of deaths was made by linking the records to the nationwide Cause of Death Register. Results With an average follow-up of 8.5 years, resulting in 59,231 person-years, 159 deaths were identified. Diabetes was reported as the underlying cause of death in 51 patients (32%), and as a contributing cause of death in another 42 patients (26%). The standardised mortality ratio (SMR) was significantly elevated (RR=2.4; 95% CI: 2.0–2.8). The SMR was higher for patients classified by the reporting physician as having type 2 diabetes at diagnosis than for those classified as type 1 diabetic (2.9 and 1.8, respectively). Survival analysis showed significant differences in survival curves between males and females (p=0.0003) as well as between cases with different types of diabetes (p=0.005). This pattern was also reflected in the Cox regression model showing significantly increased hazard for males vs females (p=0.0002), and for type 2 vs type 1 (p=0.015) when controlling for age. Conclusions/interpretation This study shows a two-fold excess mortality in patients with type 1 diabetes and a three-fold excess mortality in patients with type 2 diabetes. Thus, despite advances in treatment, diabetes still carries an increased mortality in young adults, even in a country with a good economic and educational patient status and easy access to health care. An erratum to this article can be found at     

Type 2 (non-insulin-dependent) diabetes mellitus and cardiovascular disease — putative association via common antecedents; further evidence from the whitehall study

Summary Fifteen year mortality rates are reported for men participating in the Whitehall Study in 1968–1970. Subjects were divided into four groups — normoglycaemic (centiles 1–95 of the blood glucose distribution: n=17,051), glucose intolerant (centiles 96–100: n = 999), newly diagnosed diabetic patients (n=56) and previously diagnosed diabetic patients (n=121) treated with diet±tablets. Relative risks for all causes mortality and from coronary and cardiovascular disease deaths were calculated. Age adjusted relative risks were highest in the newly diagnosed diabetic patients and were also increased in glucose intolerant and previously diagnosed diabetic men (p<0.05), but did not increase with increasing duration of diabetes. With adjustment for other risk factors, relative risks were similar in newly diagnosed and previously diagnosed diabetic men. There was no significant linear trend of adjusted relative risks with duration of diabetes when all diabetic men were pooled and person years at risk calculated. The lack of effect of duration upon relative risk together with other observations suggests common, possibly genetic, antecedents of both Type 2 (non-insulin-dependent) diabetes and coronary heart disease.