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

Suicide death, suicidal ideation and suicide attempt in patients with diabetes: A systematic review and meta-analysis

AIMS

Diabetes has been indicated to be a risk factor for suicide. We aim to estimate the prevalence of suicide in patients with diabetes.

DESIGN

A meta-analysis using PRISMA methodology was adopted to examine the incidence of suicide in diabetic patients.

DATA SOURCES

From inception to October 2022, three online databases (PubMed, China National Knowledge Infrastructure and Web of Science) were used to search studies.

REVIEW METHODS

We used random-effects model to analysis. And our primary outcome was the incidence of suicide death per 100 person-years, and other outcomes were prevalence of suicidal ideation and suicide attempt. To explore the sources of heterogeneity in our study, we performed subgroup and meta-regression analyses.

RESULTS

The suicide death rate in diabetic patients was 0.027 per 100 person-years, with a higher rate for Type 1 Diabetes Mellitus compared to Type 2 Diabetes Mellitus. The prevalence of suicidal ideation in diabetes patients was 0.175, with a higher prevalence in Type 1 Diabetes Mellitus compared to Type 2 Diabetes Mellitus. The prevalence of suicide attempts in diabetes patients was 0.033, indicating a higher rate for Type 2 Diabetes Mellitus compared to Type 1 Diabetes Mellitus.

CONCLUSIONS

The results indicate a high rate of suicide among people with diabetes, and this study identifies populations and regions at high risk for suicide. Our review emphasizes interventions in mental health and the improvement of suicide prevention programmes.

IMPACT

The study investigated suicide death, suicidal ideation and suicide attempt in diabetic individuals. Suicide rates are elevated among diabetic patients, and various patient groups face distinct suicide risks. It is important to prioritize the mental well-being of diabetic individuals and enhance interventions, including personalized approaches, to inform public health efforts aimed at preventing and addressing suicide among diabetic patients.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public involvement.

Suicide Risk in Youth and Young Adults with Type 1 Diabetes: a Review of the Literature and Clinical Recommendations for Prevention

PURPOSE OF REVIEW

The manuscript reviews the extant literature on suicide-related thoughts and behaviors among youth and young adults with pediatric diabetes. This evidence is presented within the context of current theories of the etiology of suicidal behavior to highlight how diabetes may contribute to suicide risk, and to support providers in understanding the interplay between pediatric diabetes and suicide risk. The manuscript also reviews evidence-based approaches to suicide prevention suitable for use in pediatric healthcare settings, with suggestions for their application to this unique population.

RECENT FINDINGS

Several recent studies identify heightened rates of suicidal ideation, suicide attempts, and suicide among youth and young adults with pediatric diabetes, as compared with their peers without diabetes. Evidence-based suicide prevention approaches frequently emphasize the importance of reducing suicidal youths' access to potentially lethal means for suicidal behavior. This approach may require special considerations for youth with pediatric diabetes, due to their need to carry sufficient quantities of insulin and the dangers of inaccurate insulin dosing and/or overdose. Suggestions for suicide prevention for this population include risk screening as part of routine diabetes care, early prevention, education for youth and families, and provider awareness of risk factors, warning signs, and implications for diabetes care. Youth and young adults with diabetes reported elevated rates of suicide-related behaviors as compared with their peers without diabetes. Existing suicide prevention approaches may require substantial adaptation for use with youth and young adults with diabetes. Further research is needed to examine how to best prevent suicidal behaviors among this population.

MANAGEMENT OF ENDOCRINE DISEASE: Suicide risk in patients with diabetes: a systematic review and meta-analysis

BACKGROUND

Previous studies investigating the risk of suicide in diabetes patients reported controversial findings. We did a systematic review and meta-analysis to comprehensively estimate the risk and incidence rate of suicide in diabetic patients.

METHODS

PubMed, EMBASE and PsycINFO were searched for eligible studies. Random-effects meta-analysis was used to calculate the relative risk (RR) and the incidence rate of suicide in diabetes patients. We also calculated the proportion of deaths attributable to suicide among diabetes patients.

RESULTS

54 studies were finally included, including 28 studies on the suicide risk associated with diabetes, 47 studies on the incidence rate of suicide and 45 studies on the proportion of deaths attributable to suicide. Meta-analysis showed that diabetes could significantly increase the risk of suicide (RR = 1.56; 95% CI: 1.29-1.89; P < 0.001). Subgroup analysis showed that the RR of suicide associated with type 1 diabetes was 2.25 (95% CI: 1.50-3.38; P < 0.001). The pooled incidence rate of suicide in patients with diabetes was 2.35 per 10 000 person-years (95% CI: 1.51-3.64). The pooled proportions of long-term deaths attributable to suicide in type 1 diabetes patients and type 2 diabetes patients were 7.7% (95% CI: 6.0-9.8) and 1.3% (95% CI: 0.6-2.6), respectively.

CONCLUSION

This meta-analysis suggests that diabetes can significantly increase the risk of suicide. Suicide has an obvious contribution to mortality in diabetic patients, especially among type 1 diabetes patients. Effective strategies to decrease suicide risk and improve mental health outcomes in diabetes patients are needed.

Causes of death in childhood-onset Type 1 diabetes: long-term follow-up

AIMS

To assess the causes of death and cause-specific standardized mortality ratios in two nationwide, population-based cohorts diagnosed with Type 1 diabetes during the periods 1973-1982 and 1989-2012, and to evaluate changes in causes of death during the follow-up period.

METHODS

People with Type 1 diabetes who were aged < 15 years at diagnosis were identified in the Norwegian Childhood Diabetes Registry and followed from diagnosis until death, emigration or September 2013 (n = 7871). We assessed causes of death by linking data to the nationwide Cause of Death Registry and through a review committee that evaluated medical records, autopsy reports and death certificates.

RESULTS

During a mean (range) follow-up of 16.8 (0-40.7) years, 241 individuals (3.1%) died, representing 132 143 person-years. The leading cause of death before the age of 30 years was acute complications (41/119, 34.5%). After the age of 30 years cardiovascular disease was predominant (41/122, 33.6%), although death attributable to acute complications was still important in this age group (22/122, 18.0%). A total of 5% of deaths were caused by 'dead-in-bed' syndrome. The standardized mortality ratio was elevated for cardiovascular disease [11.9 (95% CI 8.6-16.4)] and violent death [1.7 (95% CI 1.3-2.1)] in both sexes combined, but was elevated for suicide only in women [2.5 (95% CI 1.2-5.3)]. The risk of death from acute complications was approximately half in women compared with men [hazard ratio 0.43 (95% CI 0.25-0.76)], and did not change with more recent year of diagnosis [hazard ratio 1.02 (0.98-1.05)].

CONCLUSIONS

There was no change in mortality attributable to acute complications during the study period. To reduce premature mortality in people with childhood-onset diabetes focus should be on prevention of acute complications. Male gender implied increased risk.

All-cause mortality in a nationwide cohort of childhood-onset diabetes in Norway 1973-2013

AIMS/HYPOTHESIS

The aim of this study was to assess the association between all-cause mortality and sex, age at diagnosis and year of diagnosis in Norwegian patients with childhood-onset diabetes.

METHODS

The study was based on the nationwide, population-based Norwegian Childhood Diabetes Registry, which includes all newly diagnosed cases of childhood-onset diabetes at age 0-14 years in 1973-1982 and 1989-2012 (n = 7,884). Patients were followed until date of death, emigration or 30 September 2013.

RESULTS

Among the 7,884 patients, representing 132,420 person-years, 249 (3.2%) died during a mean follow-up of 16.8 (range 0.0-40.7) years. The standardised mortality ratio (SMR) for the total cohort was 3.6 (95% CI 3.1, 4.0), increasing by attained age. Absolute mortality was significantly lower in females than in males (HR 0.50 [95% CI 0.38, 0.65]), although the SMRs were similar. Cox regression analysis showed a significant decrease in mortality of 49% (HR 0.51 [95% CI 0.28, 0.93]) for those diagnosed in 1999-2012 compared with those diagnosed in 1973-1982 (p = 0.03).

CONCLUSIONS/INTERPRETATION

In spite of improved diabetes care, mortality is still three to four times higher in those with childhood-onset diabetes compared with the general population in Norway. However, absolute mortality has declined among children diagnosed most recently (1999-2012) compared with those diagnosed in the earliest period (1973-1982).

A meta-analysis of the relative risk of mortality for type 1 diabetes patients compared to the general population: exploring temporal changes in relative mortality

Aims

Type 1 diabetes has been associated with an elevated relative risk (RR) of mortality compared to the general population. To review published studies on the RR of mortality of Type 1 diabetes patients compared to the general population, we conducted a meta-analysis and examined the temporal changes in the RR of mortality over time.

Methods

Systematic review of studies reporting RR of mortality for Type 1 diabetes compared to the general population. We conducted meta-analyses using a DerSimonian and Laird random effects model to obtain the average effect and the distribution of RR estimates. Sub-group meta-analyses and multivariate meta-regression analysis was performed to examine heterogeneity. Summary RR with 95% CIs was calculated using a random-effects model.

Results

26 studies with a total of 88 subpopulations were included in the meta-analysis and overall RR of mortality was 3.82 (95% CI 3.41, 3.4.29) compared to the general population. Observations using data prior to 1971 had a much larger estimated RR (5.80 (95% CI 4.20, 8.01)) when compared to: data between; 1971 and 1980 (5.06 (95% CI 3.44, 7.45)); 1981–90 (3.59 (95% CI 3.15, 4.09)); and those after 1990 (3.11 (95% CI 2.47, 3.91)); suggesting mortality of Type 1 diabetes patients when compared to the general population have been improving over time. Similarly, females (4.54 (95% CI 3.79–5.45)) had a larger RR estimate when compared to males (3.25 (95% CI 2.82–3.73) and the meta-regression found evidence for temporal trends and sex (p<0.01) accounting for heterogeneity between studies.

Conclusions

Type 1 diabetes patients’ mortality has declined at a faster rate than the general population. However, the largest relative improvements have occurred prior to 1990. Emphasis on intensive blood glucose control alongside blood pressure control and statin therapy may translate into further reductions in mortality in coming years.

Diabetes mellitus and suicide

Relationship of diabetes mellitus (DM) with metal health disorders such as depression has been explored extensively in the published literatures. However, association of diabetes mellitus with suicidal tendencies has been evaluated less extensively. The present narrative review aimed to assess the literature relating to diabetes mellitus and suicide. As a part of the review, Pubmed and Google Scholar databases were searched for English language peer reviewed published studies with keywords relating to diabetes and suicide. Additional references were identified using cross-references. The available literature suggests that suicidal ideas and attempts are more frequent in patients with diabetes mellitus than healthy or medically ill controls. Although, a few studies report evidence to the contrary. Suicide accounts for a large proportion of deaths in patients with diabetes mellitus type I (T1DM), and their mortality rate is higher than that of age matched control population. Psychological morbidity, including depression, precedes suicidal ideas and attempts; though many other factors can be hypothesized to impact and modulate this association. A common method of suicide attempt in patients with diabetes includes uses of high doses of insulin and its congeners or medications to treat the disease. Regular screening and prompt treatment of depression and suicidality is suggested for patients with DM.

Suicide risk in type 1 diabetes mellitus: A systematic review

BACKGROUND

Research has shown that suicide risk is often present in patients suffering from type 1 diabetes mellitus (DM-1).

OBJECTIVES

The aim of the present paper was to investigate whether there was a relationship between DM-1 and suicidal behavior and to determine whether or not people affected by DM-1 are at an increased risk of completed suicide, attempted suicide, and suicidal ideation.

DATA SOURCES

We performed a careful MedLine, ExcerptaMedica, PsycLit, PsycInfo and Index Medicus search to identify all papers on the topic for the period 1970 to 2013 written in English. The following search terms were used: (suicide OR suicide attempt OR ideation) AND (diabetes mellitus). Where a title or abstract seems to describe a study eligible for inclusion, the full article was examined.

ELIGIBILITY CRITERIA

We included only original articles published in English peer-reviewed journals. We excluded meta-analyses and systematic reviews, studies that were not clear about follow-up times, the method of statistical analysis, diagnostic criteria or the number of patients included, and studies only on patients affected by type 2 diabetes mellitus (DM-2).

RESULTS

The research reviewed indicated that patients with DM-1 are at an increased risk for suicide, although no clear consensus exists regarding the level of the increased risk.

LIMITATIONS

The studies used different measurement techniques and different outcomes, and they assessed patients at different time points.

CONCLUSIONS AND IMPLICATIONS

Our findings support the recommendation that a suicide risk assessment of patients with DM-1 should be part of the routine clinical assessment. The assessment of patients at risk should consist of the evaluation of current and previous suicidal behaviors (both suicidal ideation and attempted suicide).

Standardised mortality is increased three-fold in a population-based sample of children and adolescents with type 1 diabetes

There are no type 1 diabetes (T1DM) mortality data on Australian children and limited contemporary data on their international counterparts. Fatalities in children and adolescents (1-17 yr) with T1DM were identified from the Western Australia Children's Diabetes Database between 1987-2011. Seventeen thousand four hundred and fifty-three patient-years of diabetes data were analysed and 13 deaths were confirmed (six male). The overall standardised mortality ratio was 3.1 [95% confidence interval (CI), 1.7-5.3] and was highest in the 10-14 yr age group, at 4.6 (95% CI, 1.5-10.8). Median age at death was 16.4 yr (range 5 to 17.8 yr), and median haemoglobin A1c at death was 10.5% (range 6.7 to >14). Cause of death was attributed to diabetes in 10 (77%) cases. Two patients were found 'dead-in-bed'. All diabetes-related deaths in subjects with known T1DM occurred outside the hospital setting.

Causes of death in young Australians with type 1 diabetes: a review of coronial postmortem examinations

OBJECTIVE

To determine the causes of death in Australians with type 1 diabetes mellitus who died aged 40 years or younger.

DESIGN AND SETTING

Retrospective review of autopsy reports at the Department of Forensic Medicine, Sydney, New South Wales, 1 January 1994-31 December 2006.

MAIN OUTCOME MEASURE

Causes of mortality in people with type 1 diabetes aged <40 years.

RESULTS

Of the 26 682 autopsy reports, 1914 were for individuals with diabetes (type 1, 400; type 2, 1514). Cardiovascular disease accounted for 51% of deaths (169/333) in people with type 1 diabetes aged >40 years, versus 13% among those aged <or= 40 years (9/67; P=0.001). Acute complications of diabetes (27%; 18/67), unnatural deaths (28%; 19/67), and sudden unexpected deaths (22%; 15/67) were the predominant causes of death in young individuals with diabetes. Sudden unexpected death was more common in those with type 1 diabetes compared with a sex-matched control population in the same age range (22% v 5%; Xi(2) P<0.001). Of the sudden unexpected deaths, 10 people were found dead in an undisturbed bed with no cause of death found at autopsy ("dead-in-bed" syndrome; mean age [SD], 30.2 [9.4] years; males : females=4 :1).

CONCLUSIONS

In deceased young people with type 1 diabetes examined by the Coroner, acute diabetic complications, unnatural causes, and sudden unexpected deaths were the predominant causes of death. The relatively high frequency of sudden unexpected deaths, such as dead-in-bed syndrome, requires further investigation.

A cohort analysis of type 1 diabetes mortality in Havana and Allegheny County, Pittsburgh, PA

OBJECTIVE

To examine the mortality of type 1 diabetes (T1D) in two countries with very different health care systems using two population-based registries of childhood-onset T1D one in Havana (HA), Cuba, and the other in Allegheny County (AC), USA.

RESEARCH DESIGN AND METHODS

Cases diagnosed with T1D between 1965 and 1980 in HA and between 1965 and 1979 in AC were included. Follow-up started with diagnosis in each individual and ended as of 1 January 1991, or with death. Life-table analyses were used to examine the mortality rates in both populations by duration of diabetes.

RESULTS

Cumulative mortality by January 1991 in HA (14% in males and females, respectively) was higher than in AC (7% in males and 9% in females) for both genders (males, p=0.0005; females, p=0.0491). Mortality rates were considerably higher in HA for both men and women than in AC however, among females confidence intervals overlapped. Overall mortality rate for Caucasians (AC) was significantly lower than that for African-Americans (AC) or Hispanics (HR). An analysis of causes of death showed a greater proportion of deaths attributed to nephropathy (48.6%) in HA while acute complications (36%) and infections (27%) were more frequent in AC.

CONCLUSIONS

This study shows a two-fold greater mortality among people with childhood-onset T1D in Havana, Cuba, than in Allegheny, USA. Different strategies may be needed to increase survival among those with type 1 diabetes in the USA and Cuba.

All-cause mortality rates in patients with type 1 diabetes mellitus compared with a non-diabetic population from the UK general practice research database, 1992-1999

AIMS/HYPOTHESIS

We compiled up to date estimates of the absolute and relative risk of all-cause mortality in patients with type 1 diabetes in the UK.

MATERIALS AND METHODS

We selected patients with type 1 diabetes (n=7,713), and for each of these diabetic subjects five age- and sex-matched control subjects without diabetes (n=38,518) from the General Practice Research Database (GPRD). Baseline was 1 January 1992; subjects were followed until 1999. The GPRD is a large primary-care database containing morbidity and mortality data of a large sample representative of the UK population. Deaths occurring in the follow-up period were identified.

RESULTS

The study comprised 208,178 person-years of follow-up. The prevalence of type 1 diabetes was 2.15/1,000 subjects in 1992 (mean age 33 years, SD 15). Annual mortality rates were 8.0 per 1,000 person-years (95% CI 7.2-8.9) in type 1 diabetic subjects compared with 2.4 per 1,000 person-years (95% CI 2.2-2.6) in those without diabetes (hazard ratio [HR]=3.7, 95% CI 3.2-4.3). The increased mortality rates in patients with type 1 diabetes were apparent across all age-bands. The HR was higher in women (HR=4.5, 95% CI 3.5-5.6 compared with non-diabetic women) than men (HR=3.3, 95% CI 2.7-4.0), such that the sex difference (p<0.0001) in mortality in the non-diabetic population was abolished (p=0.3) in the type 1 diabetic patients. The predominant cause of death in patients with type 1 diabetes was cardiovascular disease.

CONCLUSIONS/INTERPRETATION

Despite advances in care, UK mortality rates in the past decade continue to be much greater in patients with type 1 diabetes than in those without diabetes.

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.

Mortality in childhood-onset type 1 diabetes: a population-based study

OBJECTIVE

To describe the age- and sex-specific mortality in a cohort of young type 1 diabetic patients and to analyze the causes of death with special focus on suicide, accidents, and unexplained deaths.

RESEARCH DESIGN AND METHODS

A population-based incident childhood diabetes register, covering onset cases since 1 July 1977, was linked to the Swedish Cause of Death Register up to 31 December 2000. The official Swedish population register was used to calculate age- and sex-standardized mortality rates (SMRs), excluding neonatal deaths. To analyze excess risks for specific diagnoses, case subjects were compared with five nondiabetic control subjects, matched by age, sex, and year of death. Death certificates were collected for all case and control subjects. For case subjects with an unclear diagnosis, hospital records and/or forensic autopsy reports were obtained.

RESULTS

Mean age- and sex-SMR was 2.15 (95% CI 1.70-2.68) and tended to be higher among females (2.65 vs. 1.93, P = 0.045). Mean age at death was 15.2 years (range 1.2-27.3) and mean duration 8.2 years (0-20.7). Twenty-three deaths were clearly related to diabetes; 20 died of diabetic ketoacidosis. Only two case subjects died with late diabetes complications (acute coronary infarction). Thirty-three case subjects died with a diagnosis not directly related to diabetes; 7 of them committed suicide, and 14 died from accidents. There was no significant difference in traffic accidents (odds ratio 1.02 [95% CI 0.40-2.37]). Obvious suicide tended to be increased but not statistically significantly so (1.55 [0.54-3.89]). Seventeen diabetic case subjects were found deceased in bed without any cause of death found at forensic autopsy. Only two of the control subjects died of similar unexplained deaths.

CONCLUSIONS

In a well-developed health care system, there is still a significant excess mortality in young type 1 diabetic patients. We confirm a very large proportion of unexplained deaths in bed, which should be further studied. There is no clear excess death rate caused by suicide or traffic accidents among young diabetic subjects.

Cardiovascular disease morbidity and mortality in patients with type 1 diabetes mellitus : management strategies

There is an increased risk of cardiovascular disease (CVD) mortality and morbidity in patients with type 1 diabetes mellitus compared with the general population as shown by epidemiologic studies measuring cardiovascular endpoints, as well as by autopsy, angiographic, and coronary calcification studies. Most of the excess CVD risk associated with type 1 diabetes is concentrated in the subset of approximately 35% of patients who develop diabetic nephropathy (after 20 years of diabetes duration), who also typically have dyslipidemias, elevated blood pressure, and hyperglycemia, factors contributing to CVD. For reasons that remain speculative, the relative risks from CVD are higher in women than in men with type 1 diabetes compared with the general population, which effectively eliminates the gender differences in CVD. As in the general population and in patients with type 2 diabetes, education and lifestyle changes, interventions to reduce hyperglycemia, blood pressure, micro-albuminuria, lipid control, and the use of aspirin are important management areas in order to reduce the increased risk of CVD. Whether management with aspirin and statins should be started in type 1 diabetic patients at a younger age or at a lower risk score than in the general population is still under investigation. There is a need for a better understanding of the pathophysiology of vascular complications in type 1 diabetes, more specific risk engines in type 1 diabetes, and accurate estimations of the absolute and relative risk for CVD in order to improve management of CVD in these high-risk patients.

Bayesian approach to study the temporal trend and the geographical variation in the risk of type 1 diabetes. The Sardinian Conscript Type 1 Diabetes Registry

BACKGROUND

A previous analysis of the Sardinian Conscript Type 1 Diabetes Registry indicated an abrupt increase in the risk for type 1 diabetes (T1D) among Sardinian male cohorts starting from the 1946 one.

OBJECTIVE

The aim of this study was to update the point prevalence of T1D among Sardinian male army conscripts aged 18 yr from 1992 to 1997 described in the previous survey and to update its secular trend. It also looked at the geographical distribution of prevalence.

SUBJECTS AND METHODS

All male Italian citizens must appear before the Conscript Board for a clinical examination prior to military service. T1D patients are rejected with T1D listed as the reason. We examined, retrospectively, a total of 83807 Sardinian males aged 18, born between 1 January 1974 and 31 December 1979. They virtually represent the whole Sardinian population of that age and sex.

RESULTS

A total of 307 subjects with T1D were identified. T1D point prevalence for the birth cohorts 1974-1979 was 3.66/1000 (95% CI 3.28-4.09). Bayesian analysis of the geographical distribution of prevalence shows the highest rate in the Southern part of the island (Cagliari province) and the lowest in the north-western part (Sassari province). A similar picture was produced by data from the Eurodiab Registry in Sardinia (1989 ongoing). No significant temporal trend of prevalence was seen in the 6 yr examined in the current study; pooling these recent birth cohorts with the previous ones, the increasing trend of prevalence was confirmed.

CONCLUSIONS

Our data confirmed the South to North gradient of T1D and the progressive increase of T1D risk among males in Sardinia.

Long-term mortality in nationwide cohorts of childhood-onset type 1 diabetes in Japan and Finland

OBJECTIVE

This study compares mortality from type 1 diabetes in Japan and Finland and examines the effects of sex, age at diagnosis, and calendar time period of diagnosis on mortality.

RESEARCH DESIGN AND METHODS

Patients with type 1 diabetes from Japan (n = 1,408) and Finland (n = 5,126), diagnosed from 1965 through 1979, at age <18 years, were followed until 1994. Mortality was estimated with and without adjustment for that of the general population to assess absolute and relative mortality using Cox proportional hazard models.

RESULTS

Overall mortality rates in Japan and Finland were 607 (95% CI 510-718) and 352 (315-393), respectively, per 100,000 person-years; standardized mortality ratios were 12.9 (10.8-15.3) and 3.7 (3.3-4.1), respectively. Absolute mortality was higher for men than for women in Finland, but relative mortality was higher for women than for men in both cohorts. Absolute mortality was higher in both cohorts among those whose diabetes was diagnosed during puberty, but relative mortality did not show any significant difference by age at diagnosis in either cohort. In Japan, both absolute and relative mortality were higher among those whose diagnosis was in the 1960s rather than the 1970s.

CONCLUSIONS

Mortality from type 1 diabetes was higher in Japan compared with Finland. The increased risk of death from type 1 diabetes seems to vary by sex, age at diagnosis, and calendar time period of diagnosis. Further investigation, especially on cause-specific mortality, is warranted in the two countries.

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.

Incidence, prevalence, and mortality of insulin-dependent (type 1) diabetes mellitus in Lithuanian children during 1983-98

AIMS/HYPOTHESIS

Our purpose is to analyze interrelations of the incidence, prevalence and mortality of childhood-onset insulin-dependent diabetes mellitus (type 1) in Lithuania.

METHODS

Incidence and prevalence rates were based on the national type 1 diabetes register during 1983-98. The cohort study was performed to evaluate the standardized mortality ratios.

RESULTS

The average incidence of type 1 diabetes during the 16-yr study period was 7.36 per 100,000/yr. For both males and females the highest incidence of type 1 diabetes was recorded in the 10-14 yr age group. The regression-based linear trends of the increase in incidence in various age groups and the annual percentage change for both genders was 2.05 (p = 0.0039) and the greatest regression slope is observed for both genders in the 10-14 yr age group. Regression-based linear trends in type 1 diabetes prevalence indicate an even growth in all age groups (3.47; p = 0.001), although the annual percentage change is most prominent in the 5-9 yr age group for girls (4.95%/yr) and in the 10-14 yr age group for boys (4.06%/yr). The standardized mortality ratio of all-cause mortality in people with diabetes is higher than in the common population 7.71 (p < 0.0001). The standard mortality ratio for all causes increases with longer diabetes duration.

CONCLUSION/INTERPRETATION

The significant increasing trend of incidence and prevalence during 1983-98 is observed. The annual percentage change is similar. The young patients with type 1 diabetes have a higher mortality risk.

Mortality trends in type 1 diabetes. The Allegheny County (Pennsylvania) Registry 1965-1999

OBJECTIVES

To investigate long-term mortality and its temporal trends as of 1 January 1999 among the 1,075 patients with type 1 diabetes (onset age <18 years, diagnosed between 1965 and 1979) who comprise the Allegheny County population-based registry.

RESEARCH DESIGN AND METHODS

Overall, sex- and race-specific mortality rates per person-year of follow-up were determined. Standardized mortality ratios were also calculated. Survival analyses and Cox proportional hazard model were also used. Temporal trends were examined by dividing the cohort into three groups by year of diagnosis (1965-1969, 1970-1974, and 1975-1979).

RESULTS

Living status of 972 cases was ascertained as of January 1, 1999 (ascertainment rate 90.4%). The mean duration of diabetes was 25.2 +/- 5.8 (SD) years. Overall, 170 deaths were observed. The crude mortality rate was 627 per 100,000 person-years (95% CI 532-728) and standardized mortality ratio was 519 (440-602). Life-table analyses by the Kaplan-Meier method indicated cumulative survival rates of 98.0% at 10 years, 92.1% at 20 years, and 79.6% at 30 years duration of diabetes. There was a significant improvement in the survival rate between the cohort diagnosed during 1965-1969 and that diagnosed during 1975-1979 by the log-rank test (P = 0.03). Mortality was higher in African-Americans than in Caucasians, but there were no differences seen by sex. The improvement in recent years was seen in both ethnic groups and sexes.

CONCLUSIONS

An improvement in long-term survival was observed in the more recently diagnosed cohort. This improvement is consistent with the introduction of HbA1 testing, home blood glucose monitoring, and improved blood pressure therapy in the 1980s.

Increased mortality in diabetes during the first 10 years of the disease. A population-based study (DISS) in Swedish adults 15-34 years old at diagnosis

OBJECTIVES

To study, prospectively, in young adult patients, the mortality during the first years after the diagnosis of diabetes.

DESIGN

The Diabetes Incidence Study in Sweden (DISS) aims to register all incident cases aged 15-34 years. During a 10-year period all deaths were identified by record linkage to the national Cause of Death Registry.

SUBJECTS

During the period, 4097 new cases were registered and classified as type 1 diabetes (73%), type 2 (16%), secondary (2%) and unclassified (9%). The median follow-up was 5 years (21 001 person-years).

MAIN OUTCOME MEASURES

Calculation of the standardized mortality ratio (SMR) and 95% confidence interval (CI). Evaluation of all deceased by scrutiny of clinical records, death certificates and autopsy protocols.

RESULTS

Fifty-eight patients died, corresponding to an SMR of 3.5 (CI=2.7-4.5), which increased from 1.5 at 15-19 years to 4.1 at 30-34 years. SMR was 2.7 in primary diabetes: 2.3 (1.6-3.3) in type 1 and 4.1 (2.6-6.7) in type 2. In secondary diabetes, alcohol-associated pancreatitis a common cause, SMR was 32 (CI=24-45). Evidence of alcohol or drug misuse, mental dysfunction or suicide was found in 40 of all 58 deceased cases. Less often, hypoglycaemia (n=7) or hyperglycaemia-ketoacidosis (n=11) was present at death. Unexplained 'dead in bed' was found once.

CONCLUSIONS

In the investigated population-based cohort the early mortality was about threefold increased. Hypoglycaemia and ketoacidosis per se played a relatively small role compared with a heavy impact from social and mental dysfunction, and from careless use of alcohol or drugs.

All-cause mortality in the Canterbury (New Zealand) insulin-treated Diabetic Registry population

OBJECTIVE

To establish all-cause death rates and life expectancies of and risk factors for mortality in insulin-treated diabetic individuals living in Canterbury, New Zealand.

RESEARCH DESIGN AND METHODS

Insulin-treated diabetic subjects (n = 1,008) on the Canterbury Diabetes Registry were tracked over 9 years, and their vital status was determined. Death rates were standardized using direct and indirect methods. Cox proportional hazard regression was used to model the effects of demographic and clinical covariates on survival time.

RESULTS

At study entry, age ranged from 2.9 to 92.7 years, with mean 48.7 +/- 20.4 years; age at diagnosis was 0.2-88.9 years, mean 34.5 +/- 20.0 years; and duration of diabetes was 0.1-58.5 years, mean 14.0 +/- 10.6 years. There were 303 deaths in 7,372 person-years of follow-up with a standardized mortality ratio (SMR) of 2.6 (95% CI 2.4-3.0). Relative mortality was greatest for those aged 30-39 years (SMR 9.2 [4.8-16.2]). The death rate for the diabetic cohort standardized against the Segi world standard population was 16.2 per 1,000. Attained age, sex, and clinical subtype were significant predictors of mortality The SMR for subjects with type 1 diabetes and age at onset <30 years was 3.7 (CI 2.7-5.0), 2.2 (1.8-2.6) for those with onset > or =30 years, and 3.1 (2.5-3.7) for subjects suspected of having latent autoimmune diabetes in adulthood or insulin-treated type 2 diabetes. Life expectancy was reduced for both sexes at all ages.

CONCLUSIONS

Mortality rates for insulin-treated diabetic individuals remain high, resulting in shortened life spans relative to the general population. Marked differences in mortality exist between clinical groups of subjects. Further research is needed to improve diabetes classification and to clarify differences in health outcomes.

Causes of death in children with insulin dependent diabetes 1990-96

BACKGROUND

Mortality rates in children with insulin dependent diabetes (IDDM) in the UK are unknown and the causes of death not well documented.

AIM

To determine the mortality rate and causes of death in children with IDDM.

METHODS

The Office of National Statistics (England and Wales) and the General Register Office (Scotland) notified all deaths under 20 years of age from 1990 to 1996 with diabetes on the certificate. Further details were provided by coroners, pathologists, and clinicians.

RESULTS

116 deaths were notified and 83 were caused by diabetes. The standardised mortality ratio was 2.3 (95% confidence interval (CI), 1.9 to 2.9), being highest in the age group 1-4 years, at 9.2 (95% CI, 5.4 to 14.7). Of the 83 diabetic deaths, hyperglycaemia/diabetic ketoacidosis (DKA) was implicated in 69 and hypoglycaemia in 7. Cerebral oedema was the most common cause of death in young children (25 of 36 diabetes related deaths in children under 12 years of age). 34 young people (10-19 years; 24 male) were either found dead at home (n = 26) or moribund on arrival at hospital (n = 8). In 24 of these, it appeared that DKA was the cause of death, in four hypoglycaemia was likely. Nine of these were found "dead in bed".

CONCLUSIONS

Children with IDDM have a higher mortality than the general population. Cerebral oedema accounts for most hospital deaths in young children. There are a large number of young men dying at home from neglected IDDM. Early diagnosis of IDDM in children and closer supervision of young people might prevent some of these deaths.

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.

[Severe ketoacidosis because of delayed diagnosis of diabetes in children. 4 cases to alert physicians]

BACKGROUND

In France, 48% of children with insulin-dependent diabetes mellitus (IDDM) are seen for the first time at the stage of keto-acidosis (DKA), a figure far higher than in other countries. The four consecutive cases reported in this paper suggest that severity at presentation is directly related to the delay of diagnosis.

CASE REPORTS

All children, aged 6 to 11, presented with severe clinical and metabolic conditions: coma, hemodynamic failure, severe dehydration and acidosis (pH = 6.86 to 7.06). However, clinical symptoms were a present from 2 to 4 months, parents did not worry about them. Family practitioners visited 2-21 days before admission failed to immediately make the diagnosis of IDDM. True DKA was however present in all cases 48 hours prior to admission.

CONCLUSIONS

Earlier diagnosis of IDDM in children is necessary to reduce morbidity and mortality of DKA. General practitioners, pediatricians and emergency care practitioners must be made fully aware to consider diabetes in children and to use more extensively glucose-tests based on urine and blood strips.

Simulation of diabetic eye disease to compare screening policies

AIMS/BACKGROUND

The purpose of the project was to develop a technique for evaluating screening policies in the treatment of insulin dependent diabetic retinopathy. The study was concerned with patients who contracted the disease, aged under 35 years. Simulation was used to describe the progress of a cohort of patients through disease and treatment.

METHOD

Data, derived from a literature survey of European and American population and clinic studies, were used to model as closely as possible the development of retinopathy in all its stages, together with the effects of screening and treatment. The model output was validated against published data.

RESULTS

The results showed that where screening sensitivities are high, the frequency of screening makes little difference to the years of sight saved, but it does make a difference if screening sensitivities are close to 50%.

CONCLUSIONS

Although annual screening is normally desirable, biannual screening could be considered where patient compliance and screening sensitivities are both high.

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.

The 1984 Tasmanian insulin treated diabetes mellitus prevalence cohort: an eight and a half year mortality follow-up investigation

Total mortality and underlying cause of death were examined in a population-based prevalence cohort (n = 1232) of Tasmanians with insulin-treated diabetes mellitus. Eight and a half years after the establishment of the registry, the cause of death based on death certificate information was determined for the overall cohort and for three classification groups of insulin-treated diabetes: Group A--childhood-onset IDDM cases; Group B--adult-onset IDDM cases; and Group C--adult-onset insulin-treated NIDDM cases. A total of 378 deaths occurred, providing an overall SMR of 2.2 (95% CI 2.0-2.4) compared to the Tasmanian population. Diabetic females experienced a higher SMR (2.6, 95% CI 2.3-3.0) than diabetic males (1.9, 95% CI 1.6-2.2). The all-cause SMRs for the diabetic classification groups were 4.6 (95% CI 3.4-6.1) in Group A, 1.8 (95% CI 1.5-2.1) in Group B, and 2.2 (95% CI 1.9-2.6) in Group C. After adjusting for age, gender and duration of diabetes, the mortality in Group C was significantly higher compared to Group B (odds ratio 1.6, 95% CI 1.2-2.3). This study indicates that people with childhood-onset IDDM experience 4.6 times the death rate compared to the Tasmanian population and that the excess mortality is most pronounced in females.

Short-term mortality in childhood onset insulin-dependent diabetes mellitus: a high frequency of unexpected deaths in bed

Mortality and the causes of death have been studied in a population-based cohort of 4919 childhood onset IDDM cases. Enrolment began in 1977 and at the time of study there had been a maximum duration of disease of 13.5 years, with a total of 33,721 person years at risk. Survival status was ascertained by linkage to the Swedish Cause-of-Death register. Death certificates, autopsy protocols, and hospital records were scrutinized for classification of causes of deaths. Twenty males and 13 females with IDDM died before the age of 28.5 years. This corresponds to a Standardized Mortality Rate for age of 262% (95% confidence limits, 172-400) for the boys and 384% (95% confidence limits, 232-635) for girls. Seven patients died of ketoacidosis, four at onset of diabetes. Nine cases were found 'dead in bed', having been seen apparently healthy 1-2 days before death. One of these cases had signs of cerebral haemorrhages at autopsy and another one had signs of bite marks in the mouth, but otherwise all autopsies were normal and no evidence of alcohol or other intoxication was found. In a well-educated population with good access to inexpensive diabetes care, there is still a two- to threefold excess mortality among young onset insulin-dependent diabetic individuals including a high frequency of unexplained deaths in bed.

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.