Cause-specific mortality in diabetes: recent changes in trend mortality (original) (raw)

Journal Article

,

Diabetology

, Endocrinology and Nutrition Department, Hôpital Bichat-Claude Bernard, Paris, France

INSERM Unit 695

, Faculty of Medicine Xavier-Bichat, Paris, France

University of Denis-Diderot – Paris VII

, Paris-France

Charbel Abi Khalil, Diabetology, Endocrinology and Nutrition Department, Hôpital Bichat-Claude Bernard, Paris, France Email: charbel.abi-khalil@bch.aphp.fr

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,

Diabetology

, Endocrinology and Nutrition Department, Hôpital Bichat-Claude Bernard, Paris, France

INSERM Unit 695

, Faculty of Medicine Xavier-Bichat, Paris, France

University of Denis-Diderot – Paris VII

, Paris-France

Search for other works by this author on:

,

Diabetology

, Endocrinology and Nutrition Department, Hôpital Bichat-Claude Bernard, Paris, France

INSERM Unit 695

, Faculty of Medicine Xavier-Bichat, Paris, France

University of Denis-Diderot – Paris VII

, Paris-France

Search for other works by this author on:

,

Cardiology Department

, Hôpital Européen Georges-Pompidou, Paris, France

Search for other works by this author on:

Diabetology

, Endocrinology and Nutrition Department, Hôpital Bichat-Claude Bernard, Paris, France

INSERM Unit 695

, Faculty of Medicine Xavier-Bichat, Paris, France

University of Denis-Diderot – Paris VII

, Paris-France

Search for other works by this author on:

Received:

22 September 2010

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Charbel Abi Khalil, Ronan Roussel, Kamel Mohammedi, Nicolas Danchin, Michel Marre, Cause-specific mortality in diabetes: recent changes in trend mortality, European Journal of Preventive Cardiology, Volume 19, Issue 3, 1 June 2012, Pages 374–381, https://doi.org/10.1177/1741826711409324
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Abstract

Diabetes is one of the most chronic diseases in Western populations. Mortality rates in diabetic patients are higher than in the general population and their prognosis following any cardiovascular event is generally worse. Type 1 diabetic patients’ acute complications-related mortality decreases with time and the interval free from the diagnosis of diabetes until the development of chronic complications is larger although global mortality is still higher than that of sex- and age-matched healthy individuals. As a consequence of better primary and secondary preventions, recent data in the general population show that there is a trend towards decreased cardiovascular events and increased life expectancy. The same thing applies for type 2 diabetic patients. However, increased survival in the general population associated to epidemic bursts of obesity and sedentarily all over the globe, leads to a higher incidence of type 2 diabetes worldwide. This counteracts the diminution of diabetes-related mortality that would move forward on an ascending slope in the next decades.

Introduction

Diabetes has reached epidemic proportions around the globe. In 1995, the communications from the World Health Organization (WHO) diabetes database1 suggested that there were at least 135 million people worldwide suffering from diabetes; this figure is likely to be more than double by 2025 with 300 million expected to have diabetes. In 2005, these numbers are going towards the expected rise with 171 million estimated at that time and unless appropriate action is taken, it is predicted that there will be at least 366 million people in the world with diabetes by the year 2030.2 Diabetics have higher mortality rates than age- and sex-matched non-diabetic individuals, the excess global mortality attributable to diabetes was estimated to be 2.9 million deaths, equivalent to 5.2% of all deaths.3 Cause-specific mortality such as cardiac-related pathologies, nephropathy, and diabetic ketoacidosis are all potentially treatable complications. Their incidence could therefore be modified with the development of healthcare facilities and diagnostic and treatment strategies. During the past decades, many relevant guidelines endorsing optimal glycaemic control and diabetes-associated complications have emerged, parallel to the availability of newer treatments targeting both conditions. Did these regimens have an impact on mortality and modified the course of the disease?

We tried to answer to this question by performing a comprehensive search in MEDLINE to identify studies in English language between 1980 and 31 December 2010, using the search terms: cause-specific mortality – diabetes, trend mortality – diabetes, temporal changes in mortality – diabetes, and survival – diabetes as well as combinations of these terms. Data concerning study design, baseline patient characteristics, follow-up, and results were extracted from these reports. Inclusion criteria were cohorts, national databanks, and registries reporting cause-specific mortality in type 1 and type 2 diabetes (see Tables 1 and 2 and Appendix).

Table 1.

Cause-specific mortality in children and young adults with type 1 diabetes

Inclusion criteria were cohorts, national databanks, and registries with follow-up of at least 500 children and young adults with type 1 diabetes with mean age at diagnosis <15 years and mean age of death <30 years old when communicated. We excluded studies that reported cause-specific mortality only in adult type 1 diabetes patients or when cause-specific mortality was mixed for all age intervals (i.e. references 4 and 13) and studies also excluded from Table 2, as specified in the Appendix.

Table 1.

Cause-specific mortality in children and young adults with type 1 diabetes

Inclusion criteria were cohorts, national databanks, and registries with follow-up of at least 500 children and young adults with type 1 diabetes with mean age at diagnosis <15 years and mean age of death <30 years old when communicated. We excluded studies that reported cause-specific mortality only in adult type 1 diabetes patients or when cause-specific mortality was mixed for all age intervals (i.e. references 4 and 13) and studies also excluded from Table 2, as specified in the Appendix.

Table 2.

Cause-specific mortality in individuals with type 2 diabetes

Inclusion criteria were cohorts, national databanks, and registries with follow-up of at least 500 adults with type 2 diabetes. We excluded studies also excluded from Table 1, as specified in the Appendix. aOn death certificate of this study, more than one cause-specific mortality for each patient could be registered. bTotal cardiovascular events were communicated. cOnly nephritis and nephrosis.

Table 2.

Cause-specific mortality in individuals with type 2 diabetes

Inclusion criteria were cohorts, national databanks, and registries with follow-up of at least 500 adults with type 2 diabetes. We excluded studies also excluded from Table 1, as specified in the Appendix. aOn death certificate of this study, more than one cause-specific mortality for each patient could be registered. bTotal cardiovascular events were communicated. cOnly nephritis and nephrosis.

Type 1 diabetes

Type 1 diabetes (T1D) accounts for less than 10% of diabetes. Earlier data concerning mortality in T1D patients were reported by the DERI study published in the early 1990s.4 Data were very heterogeneous and differed from a country to another: overall mortality was higher in Japan and the USA than in Finland. A clear image was given by the Wisconsin Epidemiologic Study of Diabetic Retinopathy5 that regrouped a larger number of T1D patients who were followed for a longer period (Table 1). At the end of the 21st century, new data was put in evidence by the long-term follow-up of the Allenghy county registry.6 Temporal trends were examined by dividing the cohort into three groups by year of diagnosis 1965–1969, 1970–1974 and 1975–1979. A significant improvement of long-term survival was noticed, parallel to the development of new diagnostic and therapeutic tools. Although disparities exist between regions and ethnic groups, the decrease in trend mortality from diabetic complications affects all age intervals.

What about childhood mortality? Data analysis from the National Center for Health Statistics and the Bureau of Health Professions Area Resource showed that all-cause childhood mortality in T1D declined between 1968 and 1998.7 In Norway, a nationwide cohort of childhood-onset T1D patients reported in 2006 a mortality rate of 2.2/1000 person-years.8 Cardiovascular disease (CVD) was responsible for the largest proportion of deaths from the age of 30 years onwards whereas violent death accounted for 28% of deaths. Recent data in 2007 reported a significant excess mortality following the diagnosis of T1D in childhood before the onset of late complications: EURODIAB, a European population based register of T1D in 13 countries9 reported that one-third of deaths are directly attributable to diabetes, mainly due to ketoacidosis whereas the half is unrelated to diabetes. Although it is difficult to compare the situation in Europe and the USA to the rest of the world, one could observe that there is a decrease in acute complications, mainly in ketoacidosis although this life-threatening condition is unacceptably still high in childhood knowing that diagnostic and therapeutic approaches are largely available in industrialized countries.10 This hypothesis is concordant with the recent publication of the Yorkshire register of diabetes in children and young adults.11 In fact, a follow-up of T1D diabetic patients diagnosed between 1978 and 2004 revealed that nearly half of deaths of patients younger than 30 years old were due to acute and chronic complications whereas other new cause-specific mortality such as drug misuse-related death is an emergency trend.

Microangiopathy, especially nephropathy is a serious long-term complication of T1D. Although diabetic nephropathy is the most common cause of renal failure in the developed world, the incidence of death is not just related to end stage renal disease (ESRD) but these patients are more likely to die from CVD.12 Therefore, data about mortality are very contradictory and are limited by the duration of follow-up and the method of registration of death: The cause of death could be registered as renal, indirect causative of the cardiovascular arrest, or simply be done in the cardiovascular column. The clearest example of this is the difference between the 2.8% given by the Wisconsin Epidemiologic Study of Diabetic Retinopathy5 and the 21% number communicated in the WHO multinational study of vascular disease in diabetes.13 The proportion of individuals who progress to ESRD used to be estimated at 30–40%.14 Recently, newer studies indicate lower values: during their follow-up of T1D patients in Finland for about 37 years, Finne et al. reported that the cumulative incidence of ESRD was 2.2% at 20 years and 7.8 % at 30 years whereas it used to be reported as 20% in 25 years in the same population,15 the lowest risk was confined to the patients diagnosed recently. That could be explained by the implementation of guidelines targeting routine blood glucose monitoring (easier home measurements), strict control of blood pressure and HBA1c and routine screening of microalbuminuria. These measures applied simultaneously led to the regression of microalbuminuria and diminution of patients requiring dialysis and/or transplantation as reported by the Diabetes Control and Complications Trial (DCCT) and the Epidemiology of Diabetes Interventions and Complications (EDIC) study.16 Early screening of albumin excretion and glycaemic control are not the only two factors responsible of reducing microangiopathy but the introduction of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers later on had a huge impact on delaying the progression of kidney failure and adverse cardiovascular events.17 This multidisciplinary approach decreased the cumulative incidence of diabetic microangiopathy in T1D over the past 35 years.18

The findings are at the same time both hopeful and concerning: hopeful because mortality rates for T1D-related chronic complications show signs of decreasing; concerning because most of the studies come from industrialized countries and little is known on the evolution in developing countries. Even in industrialized countries, disparities do exist resulting in worse results in socioeconomic disadvantaged areas and in individuals of minority race/ethnicity.19 Finally, an emphasis on preventing acute complications early after diagnosis as well as preventing or delaying chronic diabetes complications would likely result in major improvements in lifespan for individuals with T1D.

Type 2 diabetes

A great concern is given to the growing incidence of type 2 diabetes (T2D) It is often assumed that the increasing number of patients with diabetes is a consequence of obesity, physical inactivity and increasing incidence rates. These patients are usually diagnosed with diabetes at an age where the body is more susceptible to cardiovascular, metabolic, infectious, and cancerous pathologies than at a younger age as in the case of T1D. In fact, complications such as cardiovascular ones could happen early after diagnosis if not already established.20 Moreover, some individuals could be diagnosed with diabetes during an acute cardiovascular event. This result in 2.5-fold increase in the odds of mortality in both men and women over the first 5 years from diagnosis.21

The burden of total death attributable to diabetes is estimated to be 3.6% in the USA, that of CVD death is 5.2%.22 What are the specific causes of mortality in T2D? In the early 1990s, the Wisconsin Epidemiologic Study of Diabetic Retinopathy reported that heart disease was the leading underlying cause of death, followed by acute diabetes complications, malignant neoplasms, and cerebrovascular disease (Table 2). Using that same register, Zhou et al.23 assessed the impact of screening, prevention, and treatment strategies on T2D and its complications. They predicted mortality to be 51% at 10 years. The prevalence of stroke and myocardial infarction were predicted to be 18 and 19%, respectively, that of non-proliferative diabetic retinopathy, proliferative retinopathy, and macular oedema were predicted to be 45, 16, and 18%, respectively; that of microalbuminuria, proteinuria, and ESRD were predicted to be 19, 39, and 3%, respectively; and the prevalence of clinical neuropathy and amputation were predicted to be 52 and 5%, respectively, at 10 years based on a computer-simulated model. Newer studies with larger numbers and longer follow-ups have emerged ever since. The National Health and Nutrition Examination Survey (NHANES) is an independent, nationally representative health survey of the US population conducted from 1971 to 1975 and followed up initially in 1992–1993.24 Changes in mortality in T2D was better highlighted by Gregg et al. by analysing longer periods of follow-up of the initial survey:25 among diabetic men, the all-cause mortality rate decreased by 18.2 annual deaths per 1000 persons between 1971 to 1986 and 1988 to 2000, accompanying decreases in the non-diabetic population. Trends for cardiovascular disease mortality paralleled those of all-cause mortality, with 26.4 annual deaths per 1000 persons in 1971 to 1986 and 12.8 annual deaths per 1000 persons in 1988 to 2000. Additionally, a recent American study26 reported that there are reductions in main cardiovascular cause-specific mortality rates among both men and women with T2D in North Dakota when comparing data between 1992–1998 and 1999–2003. Even with these relatively optimistic numbers, the USA is confronted to an increase in the prevalence of diabetes. Mainous et al. expected the prevalence of diabetes to rise from 3.7% in 2001 to 5.2% in 2031 among individuals aged 30 to 39 years old who are not currently targeted for screening according to age.27 This fact counteracts the decrease in CVD death in diabetes and leads to an increase in total CVD mortality. Data provided by New York state department of health are concordant with this theory: in fact, comparing death certificate data for 1989–1991 and 1999–2001 and hospital discharge data for 1988–2002, Fang and Alderman28 reported an increase in the proportion of diabetes-related mortality and morbidity in New York city, including diabetes-associated myocardial infarction hospitalization, parallel to an almost doubling in the prevalence of diabetes nationwide.

Moving to the north of the American continent, Booth et al. highlighted the recent trends in cardiovascular complications among diabetic patients in Canada.29 Between 1992 and 2000, the rate of patients admitted for acute myocardial infarction and stroke fell in the general population. Diabetic patients experienced similar reductions in case-fatality rates related to acute myocardial infarction, all cause-mortality, and stroke than those without diabetes. European data come essentially from an Italian study that followed up T2D patients since 1986 in Verona city.30 Results are similar to data published by the WHO Multinational Study of Vascular Disease in Diabetes13 that reported a decade ago that CVD accounted for about 50 % of deaths in T2D (Table 2). The South Tees diabetes mortality study reported in 2002 that T2D patients have higher cardiovascular death rates and renal disease than in non-diabetic individuals; however, relative death rates declined with age for both sexes.31 Recently, Eliasson et al. recently reported an improved survival in both men and women in a Swedish cohort study from 1980 to 2004.32 In the same context, Sorensen et al. studied the incidence of patients starting renal replacement therapy (RTT) in Denmark from 1990 to 2004.33 They observed that the number of diabetic patients starting RRT increased steadily from 1990 to 2002. However, during 2003 and 2004 this number was significantly reduced by 15% due to a 22% reduction in the number of T2D. This decrease was parallel to an increase in the age of diabetic patients.

How could we explain this improvement in CVD-related mortality? Early and aggressive treatment with multiple drug combinations or insulin is commonly used in the management of T2D. Therapeutic approaches towards treating atherosclerosis, dyslipidaemia, hypertension, and renal, cardiac, and cerebrovascular complications have emerged through the past decades: the efficacy of a combination of these measures on cardiovascular complications of diabetes, as well as on mortality were studied at the Steno diabetes centre. Intensive versus standard treatment targeting hyperglycaemia, hypertension, dyslipidaemia, and microalbuminuria associated with behaviour modification and a regular intake of aspirin decreased the progression of nephropathy, retinopathy, and autonomic neuropathy in T2D diabetic patients.34 Some years later, the same team reported that this multidisciplinary approach reduced combined cardiovascular and microvascular events by about 50%.35 As a consequence of that, the rates of death from any cause and from cardiovascular causes were also lower during the intensive intervention.36 However, the Steno Diabetes centre study has its limitations. It was not designed to identify which elements of intensive diabetes therapy contributed most to the reduction in cardiovascular risk. Paradoxically, recent studies targeting only aggressive glycaemic control failed to prove a long-term benefit over major cardiovascular events.37–39

Since CVD are on the top of the list for T2D mortality worldwide, less data have emerged on cancer-, infection- and depression-related mortality. However, available data have already shown that T2D patients are more vulnerable than non-diabetic individuals:

Dankner et al. examined the association between fasting and post-load plasma glucose and insulin, and the 20-year incidence of cancer. They reported an increased long-term cancer risk for individuals with all-cause hyperglycaemia.40 Lipscombe et al. found that diabetes was associated with a close to 40% increase in mortality within the first 5 years following breast cancer.41 The public health sciences department at the University of Edinburgh reported that breast cancer- and diabetes-related mortality was approximately twice as high as that of the general female population.42 Nagel and Göke linked the higher mortality rate among diabetic patients with colorectal carcinoma in comparison to the general population to the premise that elevated plasma levels of insulin and free IGF-1 promote the proliferation of colon cells in favour of colon carcinoma cells.43 A 20-year follow-up of insulin-treated diabetic patients in New Zealand resulted in a higher than expected respiratory malignancy and respiratory disease-related mortality comparing to non-diabetic patients.44

Kornum et al. reported that T2D and admission hyperglycaemia predict increased pneumonia-related mortality although its presence did not predict pulmonary complications or bacteraemia.45 Brazilian T2D patients have six-fold excess infection-related mortality than the general population.46 No firm conclusion was given for this association but it is already established that hyperglycaemia induces non-enzymatic glycation of proteins and that the resulting advanced glycation end products stimulate interleukin-6 expression leading to a secretion of tissue necrosis factor alpha and C-reactive protein by the liver. This finally amplifies the infection and contributes to CVD pathogenesis.

Using survival analysis from the NHAES I, Zhang et al. reported that the presence of severe depression in diabetic patients was associated with a higher mortality rate.47 Additionally, both major and minor depression were associated with increased mortality over 3 years in a large American health maintenance organization.48 Analysis of cause-specific mortality in diabetes shows that depression increases mainly all caused mortality and death not caused by cancer or CVD.49

With the aging population, especially in industrialized countries, the prevalence of diabetes in elderly individuals increases. Once diagnosed with diabetes, elderly patients have higher mortality rates and more adverse events comparing to age-matched individuals. That was confirmed by Bethel et al.50 who reported in a longitudinal follow-up of elderly patients diagnosed with diabetes an excess mortality of 9.2% by year 11 compared with a control group of non-diabetic elderly individuals.

Conclusion

It appears that cause-specific mortality in type 1 diabetic patients has changed in the 21st century comparing to the past decades. The mortality due to acute metabolic complications has regressed although it could be considered insufficient in the case of early periods following the diagnosis in young people. Chronic complications, especially nephropathy, experience an evolution in the course of the disease as both the periods of nephropathy-free years after the diagnosis of diabetes and survival when renal failure is established have increased.

In type 2 diabetes, cardiovascular disease is still the leading cause of death worldwide. There seems to be a decrease in its related mortality, believed to be due to the aggressive multidisciplinary approach in treating it; however, it is still alarming to know that the increasing number of diabetic patients results in a higher number of events in the general population, especially in individuals less than 40 years old and in elderly, although exact data regarding age-specific incidence of diabetes are lacking. The increasing prevalence of diabetes seems to be a consequence of two factors: changing demographic structure and increasing survival. With an ageing population – even with constant incidence rates – the number of people with diabetes will increase as the risk increases with age. This factor, together with the global growth in total population number, represents the most important driving force towards an increasing number of individuals with diabetes. These facts would probably counteract the current decrease in cardiovascular mortality and makes us believe that, despite recent and more efficacious therapeutic options, T2D-related mortality would move forward on an ascending slope in the next decades. Although it is well known that diabetic patients are more vulnerable to infections and cancers, data concerning new trend mortality is missing.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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Appendix

In both Tables 1 and 2, we excluded the following studies:

(1) those that reported cause-specific mortality in diabetic patients without separating them into type I and type II diabetes (or new onset and late onset according to old classification):

• Raymond NT, Langley JD, Goyder E, Botha JL, Burden AC and Hearnshaw JR. Insulin treated diabetes mellitus: causes of death determined from record linkage of population based registers in Leicestershire, UK. J Epidemiol Community Health 1995; 49(6): 570–574.
• Swerdlow AJ and Jones ME. Mortality during 25 years of follow-up of a cohort with diabetes. Int J Epidemiol 1996; 25(6): 1250–1261.
• Gu K, Cowie CC and Harris MI. Mortality in adults with and without diabetes in a national cohort of the U.S. population, 1971–1993. Diabetes Care 1998; 21(7): 1138–1145.
• Brown LJ, Scott RS and Moir CL. All-cause mortality in the Canterbury (New Zealand) insulin-treated Diabetic Registry population. Diabetes Care 2001; 24(1): 56–63.
• Dawson SI, Willis J, Florkowski CM and Scott RS. Cause-specific mortality in insulin-treated diabetic patients: a 20-year follow-up. Diabetes Res Clin Pract 2008; 80(1): 16–23.

(2) those that didn’t report clearly cause-specific mortality as selected cause of death in percentage or number of events:

• Roper NA, Bilous RW, Kelly WF, Unwin NC and Connolly VM. Excess mortality in a population with diabetes and the impact of material deprivation: longitudinal, population based study. BMJ 2001; 322(7299): 1389–1393.
• Roper NA, Bilous RW, Kelly WF, Unwin NC and Connolly VM; South Tees Diabetes Mortality Study. Cause-specific mortality in a population with diabetes: South Tees Diabetes Mortality Study. Diabetes Care 2002; 25(1): 43–48.
• Secrest AM, Becker DJ, Kelsey SF, LaPorte RE and Orchard TJ. All-cause mortality trends in a large population-based cohort with long-standing childhood-onset type 1 diabetes: the Allegheny County type 1 diabetes registry. Diabetes Care 2010; 33(12): 2573–2579.
• Gregg EW, Gu Q, Cheng YJ, Narayan KM and Cowie CC. Mortality trends in men and women with diabetes, 1971 to 2000. Ann Intern Med 2007; 147(3): 149–155.
• Booth GL, Kapral MK, Fung K and Tu JV. Recent trends in cardiovascular complications among men and women with and without diabetes. Diabetes Care 2006; 29(1): 32–37.

© The European Society of Cardiology 2012

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