W. Gatling

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

Aims/hypothesisAlthough 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.MethodsA 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.ResultsThere 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/interpretationThe 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.

Prognostic value of the Framingham cardiovascular risk equation and the UKPDS risk engine for coronary heart disease in newly diagnosed Type 2 diabetes: results from a United Kingdom study

Aims  To determine the prognostic value of the Framingham equation and the United Kingdom Prospective Diabetes Study (UKPDS) risk engine in patients with newly diagnosed Type 2 diabetes.

Cancer incidence and mortality in patients with insulin-treated diabetes : a UK cohort study

Raised risks of several cancers have been found in patients with type II diabetes, but there are few data on cancer risk in type I diabetes. We conducted a cohort study of 28 900 UK patients with insulin-treated diabetes followed for 520 517 person-years, and compared their cancer incidence and mortality with national expectations. To analyse by diabetes type, we examined risks separately in 23 834 patients diagnosed with diabetes under the age of 30 years, who will almost all have had type I diabetes, and 5066 patients diagnosed at ages 30–49 years, who probably mainly had type II. Relative risks of cancer overall were close to unity, but ovarian cancer risk was highly significantly raised in patients with diabetes diagnosed under age 30 years (standardised incidence ratio (SIR)=2.14; 95% confidence interval (CI) 1.22–3.48; standardised mortality ratio (SMR)=2.90; 95% CI 1.45–5.19), with greatest risks for those with diabetes diagnosed at ages 10–19 years. Risks of cancer at other major sites were not substantially raised for type I patients. The excesses of obesity- and alcohol-related cancers in type II diabetes may be due to confounding rather than diabetes per se.

Microalbuminuria in Diabetes: A Population Study of the Prevalence and an Assessment of Three Screening Tests

A single observer reviewed 842 of the 917 known diabetic patients registered with 40 GPs in the Poole area. A midstream urine specimen was tested for proteinuria using Albustix (Ames) and cultured to detect bacterial infection. After the first 3 months of the survey, the aliquot of this specimen was frozen for later determination of the random albumin/creatinine ratio (R‐Alb/Creat). Patients were requested to submit a timed overnight urine collection for estimation of urinary albumin excretion rate (AER).

Mortality From Cerebrovascular Disease in a Cohort of 23 000 Patients With Insulin-Treated Diabetes

Background and Purpose— Disease of the cardiovascular system is the main cause of long-term complications and mortality in patients with type I (insulin-dependent) and type II (non-insulin-dependent) diabetes. Cerebrovascular mortality rates have been shown to be raised in patients with type II diabetes but have not previously been reported by age and sex in patients with type I diabetes. Methods— A cohort of 23 751 patients with insulin-treated diabetes, diagnosed under the age of 30 years from throughout the United Kingdom, was identified during 1972 to 1993 and followed up for mortality until the end of December 2000. Age- and sex-specific mortality rates and standardized mortality ratios (SMRs) were calculated. Results— There were 1437 deaths during the follow-up, 80 due to cerebrovascular disease. Overall, the cerebrovascular mortality rates in the cohort were higher than the corresponding rates in the general population, and the SMRs were 3.1 (95% CI, 2.2 to 4.3) for men and 4.4 (95% CI, 3.1 to 6.0) for women. When stratified by age, the SMRs were highest in the 20- to 39-year age group. After subdivision of cause of death into hemorrhagic and nonhemorrhagic origins, there remained a significant increase in mortality from stroke of nonhemorrhagic origin. Conclusions— Analyses of mortality from this cohort, essentially one of patients with type I diabetes, has shown for the first time that cerebrovascular mortality is raised at all ages in these patients. Type I diabetes is at least as great a risk factor for cerebrovascular mortality as type II diabetes.

The Prevalence, Detection, and Epidemiological Correlates of Peripheral Vascular Disease: A Comparison of Diabetic and Non-diabetic Subjects in an English Community

A cross‐sectional study was performed to investigate the distribution, methods of detection, and potential risk factors for peripheral vascular disease in a diabetic population with comparison to an age and sex matched non‐diabetic group. The population came from a geographically defined area consisting of 10 general practices (total list size 97 034) and covered rural and urban districts of East Dorset. Peripheral vascular disease was defined as an ankle/brachial Doppler pressure ratio of 0.9 or less. Of the diabetic subjects reviewed, 864 were classified as having Type 2 diabetes and 213 Type 1 diabetes. The prevalence of peripheral vascular disease in Type 1 diabetes was 8.7% (95% CI 4.9–12.5) and in Type 2 diabetes 23.5% (95% CI 20.5–26.5), which after adjusting for age was not significantly different (odds ratio 1.5, 95% CI 0.8–2.7, p = 0.18). There was no difference in the frequency of symptomatic peripheral vascular disease or the site of occlusion between diabetic and non‐diabetic subjects with peripheral vascular disease. Age, cerebrovascular disease, coronary artery disease, glucose, body mass index, and cholesterol in Type 2 diabetes and age and proteinuria in Type 1 diabetes were significant predictors of peripheral vascular disease. In the non‐diabetic group, age and cigarettes smoked were significant variables. These findings suggest that clinical features of peripheral vascular disease in diabetic and non‐diabetic subjects are similar but risk determinants may be different.

The Prevalence of Diabetic Distal Sensory Neuropathy in an English Community

The prevalence of lower limb neuropathy was determined in a known diabetic population. From a general population of 97034 subjects, a total of 1150 diabetic patients were identified of whom 1077 (93.7%) were reviewed. Neuropathy was defined as symptoms plus one abnormal physical finding, or two abnormal physical findings. An age‐ and sex‐matched non‐diabetic control group of 480 individuals was also examined by the same single observer. The prevalence of neuropathy was 16.3 (95% CI 14.6–19.0)% in diabetic patients and 2.9 (95% CI 1.4–4.4)% in non‐diabetic subjects, yielding a prevalence odds of 6.75 (95% CI 3.87–11.79), p < 0.001. In Type 1 diabetes, the prevalence was 12.7 (95% CI 8.0–17.6)% and in Type 2 diabetes 17.2 (95% CI 15.9–18.5)%. After adjusting for age, the difference was not significant (odds ratio (OR) 1.60 (95% CI 0.95–2.76)). The prevalence of neuropathy increased with age in diabetic and non‐diabetic subjects. Multiple logistic regression analysis of selected (variables revealed that height (OR per cm 1.06 (95% CI 1.00–1.13), p < 0.05) and retinopathy (OR 9.00 (95% CI 7.72–10.30), p < 0.001) in Type 1 diabetes and age (OR per year 1.02 (95% CI 1.00–1.05)), height (OR per cm 1.06 (95% CI 1.03–1.08), p < 0.001),) alcohol intake (OR per unit of alcohol consumed per week 1.03 (95% CI 1.00–1.05), p = 0.005), HbA1 (OR per 1% 1.21 (95% CI 1.08–1.35), p = 0.005), and any retinopathy (OR 2.14 (95% CI 1.67–2.62), p = 0.002) in Type 2 diabetes were significant predictors of neuropathy. The prevalence of neuropathy increased with the duration of diabetes but an independent association was not found for either type of diabetes.

Evidence of an increasing prevalence of diagnosed diabetes mellitus in the Poole area from 1983 to 1996.

This study examined the prevalence of diagnosed diabetes mellitus in a defined population over 13 years by undertaking cross‐sectional surveys on 3 occasions between 1983 and 1996. The study population consisted of all the people registered with 10 general (primary care) practices at the time of each survey; 90 660 in 1983/4; 97 122 in 1988/9; and 86 287 in 1996. Ascertainment of cases was by a surveillance programme in general practice and the hospital diabetes department. The number of diabetic patients increased significantly over the study period: in 1983/4, there were 917 patients, crude prevalence 1.01 % (95 % CI 0.95–1.08 %); in 1988/9, 1150 patients, crude prevalence 1.17 % (1.12–1.25 %); and in 1996, 1604 patients, crude prevalence 1.86 % (1.77–1.95 %). The prevalence adjusted to the age and sex distribution of the UK was 0.97 % (95 % CI 0.90–1.03 %) in 1983/4, 1.05 % (0.99–1.11 %) in 1988/9 and 1.55 % (1.48–1.63 %) in 1996. The main increase in prevalence was due to Type 2 diabetes mellitus, crude prevalence 0.75 % (95 % CI 0.69–0.81 %) in 1983/4, 0.92 % (0.86–0.98 %) in 1988/9 and 1.52 % (1.44–1.60 %) in 1996 rather than Type 1 diabetes mellitus, crude prevalence 0.25 % (0.21–0.28 %) in 1983/4, 0.25 % (0.22–0.28 %) in 1988/9 and 0.34 % (0.30–0.38 %) in 1996. During the study period, the crude prevalence of diagnosed diabetes was significantly greater in men than women; in 1983/4 men 1.1 % (95 % CI 1.00–1.20 %) versus women 0.93 % (0.84–1.02 %); in 1988/9, men 1.31 % (1.21–1.41 %) versus women 1.07 % (0.98–1.16 %); and in 1996, men 2.13 % (2.00–2.27 %) versus women 1.60 % (1.49–1.72 %). This difference was statistically significant in the 1988/9 and 1996 surveys. In conclusion, over 13 years there was a significant increase of 83.6 % in the prevalence of diagnosed diabetes mellitus in the Poole area, with the UK age and sex adjusted prevalence increasing by 60.7 %. Copyright

Mortality in Diabetic Subjects: An Eleven-year Follow-up of a Community-based Population

In 1979, all the known diabetic subjects (849) were identified from a community (population 81851), of whom 717 (85%) were reviewed by a single observer. Using the NHS Central Register, follow‐up was completed for 98% of subjects. After 11 years, 306 (42.7%) diabetic subjects had died, of whom 65 were insulin treated and 241 were non‐insulin treated. Circulatory disease accounted for 168 (54.9%) deaths, of which 124 (73.8%) were due to ischaemic heart disease. The standardized mortality ratio (SMR) for all causes of death, based on data from England and Wales, was significantly raised for both insulin‐treated and non‐insulin‐treated patients (1.75, 95% CI 1.35 to 2.24 and 1.32, 95% CI 1.15 to 1.50, respectively). SMRs for all cause mortality were significantly greater for diabetic subjects in the 45–64 (SMR, 1.97, 95% CI 1.34 to 2.80), 65–74 (SMR 1.59, 95% CI 1.27 to 1.97 and 75 years and over (SMR, 1.26, 95% CI 1.08 to 1.45) age ranges. Using a proportional hazards model, after adjusting for age and gender, systolic blood pressure and vibration threshold were significant predictors of all cause mortality in insulin‐treated subjects. For non‐insulin‐treated subjects, blood glucose, systolic blood pressure, glycated haemoglobin, retinopathy, proteinuria, coronary artery disease, and stroke were significant baseline predictors of mortality. No association was found for serum cholesterol, body mass index, diastolic pressure or cigarette smoking in either treatment group.

Microalbuminuria in Diabetes: Relationships Between Urinary Albumin Excretion and Diabetes‐related Variables

A single observer reviewed 842 of the 917 known diabetic patients registered with 40 GPs in the Poole area. Fifty‐nine per cent (493) of those reviewed submitted a timed overnight urine collection to measure albumin excretion rate (AER) and overnight albumin/creatinine ratio (ON‐Alb/Creat); 43 samples were excluded because of urinary tract infection and/or proteinuria. A random urine sample was obtained in 607 diabetic patients to measure the random albumin/creatinine ratio (R‐Alb/Creat); 68 specimens were excluded because of infection and/or proteinuria, and in a further 10 samples urinary creatinine was not measured. Stepwise multiple regression analyses found significant associations with the following variables: for AER, blood glucose (p=0.001), smoking category (p=0.002), sex (p=0.034), and systolic blood pressure (p=0.035); for R‐Alb/Creat, blood glucose (p=0.001), retinopathy (p=0.004), systolic blood pressure (p=0.004), diastolic blood pressure (p=0.015), coronary artery disease (p=0.02), sex (p=0.034), and vibration sense (p=0.038). Interestingly, glycosylated haemoglobin was not a significant determinant of albuminuria in either analysis.