Recent trends in life expectancy for people with type 1 diabetes in Sweden

The epidemiology of type 1 diabetes mellitus in older adults

Although type 1 diabetes mellitus (T1DM) is traditionally viewed as a youth-onset disorder, the number of older adults being diagnosed with this disease is growing. Improvements in the average life expectancy of people with T1DM have also contributed to the growing number of older people living with this disease. We summarize the evidence regarding the epidemiology (incidence, prevalence and excess mortality) of T1DM in older adults (ages ≥60 years) as well as the genetics, immunology and diagnostic challenges. Several studies report an incidence peak of T1DM in older adults of a similar size to or exceeding that in children, and population prevalence generally increases with increasing age. Glutamic acid decarboxylase antibody positivity is frequently observed in adult-onset T1DM. Guidelines for differentiating T1DM from type 2 diabetes mellitus in older adults recommend measuring levels of C-peptide and autoantibodies, including glutamic acid decarboxylase antibodies. However, there is no gold standard for differentiating T1DM from type 2 diabetes mellitus in people aged 60 years and over. As such, the global variation observed in T1DM epidemiology might be in part explained by misclassification, which increases with increasing age of diabetes mellitus onset. With a growing global population of older adults with T1DM, improved genetic and immunological evidence is needed to differentiate diabetes mellitus type at older ages so that a clear epidemiological picture can emerge.

Glycemic and Psychosocial Outcomes of Advanced Hybrid Closed-Loop Therapy in Youth With High HbA1c: A Randomized Clinical Trial

OBJECTIVE

To determine the efficacy of advanced hybrid closed-loop (AHCL) therapy in a high-risk cohort of youth on continuous subcutaneous insulin infusion (CSII) with or without continuous glucose monitoring (CGM) with suboptimal glycemia.

RESEARCH DESIGN AND METHODS

In a 6-month multicenter clinical trial, youth with type 1 diabetes with mean and most recent HbA1c >8.5% (65 mmol/mol) were randomly assigned 1:1 to AHCL or treatment as usual (CSII ± CGM). The primary outcome was the 24-week between-group difference in HbA1c. Secondary outcomes included CGM metrics from masked CGM and psychological measures (youth-reported problem areas in diabetes [PAID], quality of life, anxiety, depression, and hypoglycemia fear) assessed using validated questionnaires.

RESULTS

A total of 42 participants were randomized (mean [SD] age 16.2 [2.5] years, HbA1c 9.8 [1.1]% or 84 [12] mmol/mol, PAID score 50.3 [19.8]). At study end, the mean (SD) HbA1c was 8.8 (1.1)% or 73 (12) mmol/mol with AHCL and 9.9 (1.2)% or 85 (13.1) mmol/mol with CSII ± CGM, with mean adjusted group difference of -0.77% (95% CI -1.45 to -0.09) or -8.4 mmol/mol (-15.8 to -1.0); P = 0.027. AHCL increased time in range 70-180 mg/dL (difference 19.1%; 95% CI 11.1 to 27.1), reduced time >180 mg/dL (difference -17.7%; 95% CI -26.6 to -8.8), with no increase in time spent <70 mg/dL (difference -0.8%; 95% CI -2.7 to 0.6). There was no evidence for difference in psychosocial outcomes between the two groups at study end.

CONCLUSIONS

AHCL should be encouraged in youth with suboptimal glycemia, as AHCL improves glycemia. However, psychological support remains vital, as technology alone may not be able to reduce the burden of diabetes care in this subgroup.

β-Cell Deletion of Hypoxia-Inducible Factor 1α (HIF-1α) Increases Pancreatic β-Cell Susceptibility to Streptozotocin

Type 1 diabetes (T1D) is caused by the immune-mediated loss of pancreatic β-cells. Hypoxia-inducible factor 1α (HIF-1α) is a transcription factor which is crucial for cellular responses to low oxygen. Here, we investigate the role of β-cell HIF-1α in β-cell death and diabetes after exposure to multiple low-dose streptozotocin (MLDS). MDLS triggers auto-immunity in susceptible animal models, such as non-obese diabetic (NOD) mice. These experiments used a novel mouse model with β-cell-specific deletion of HIF-1α on a NOD background (BIN mice). Mice were given 20 mg/kg MLDS for 5 consecutive days. Following MLDS, 100% of BIN mice developed frank diabetes versus 33% of floxed-control (FC) littermates and 17% of NOD controls (p < 0.001). BIN mice had obvious loss of β-cell mass (p < 0.0001) and increased necrotic areas within islets (p < 0.001). To confirm that diabetes was T1D, adoptive transfers of splenocytes from diabetic BIN and FC mice were performed on NOD-SCID (Severe Combined ImmunoDeficiency) recipients. All mice receiving BIN-splenocytes developed frank diabetes, confirming that MLDS induced true T1D. Interestingly, diabetes developed significantly faster in BIN-adoptive transfer mice compared to mice which developed diabetes after receiving an FC-adoptive transfer. These studies demonstrate the importance of β-cell HIF-1α in the preservation of β-cell mass and avoidance of auto-immunity.

All-cause mortality and factors associated with it in Finnish patients with type 1 diabetes

AIMS

To assess the effect of comorbidities, risk classification for chronic kidney disease (CKD) according to albuminuria and eGFR, HbA1c and LDL-cholesterol levels on all-cause mortality in patients with type 1 diabetes (DM1).

METHODS

The study included all 45,801 DM1 patients from the Finnish Diabetes Registry during 2018-2022. Mortality of patients with DM1 was compared with mortality in non-diabetic population in Finland by estimating standardized mortality rates (SMRs). Poisson regression model was used to estimate the effect of risk factors on the SMR.

RESULTS

A total of 2469 patients died during follow-up. SMR for the total cohort was 1.84 (95 % CI 1.77-1.92) peaking at the age of 30-49 years. The coverage of HbA1c values was 98 %, that of LDL-cholesterol 94 %, and U-ACR and eGFR 80 %. In a multivariate analysis, assessing the effect on mortality, the rate ratio for end-stage renal disease was 2.66, cardiovascular diseases 1.92, mental and behavioural disorders 1.64, foot complications 1.51, high or very high risk for CKD 3.64, LDL-cholesterol ≥2.6 mmol/l 1.33, and HbA1c ≥8 % (64 mmol/mol) 1.27.

CONCLUSIONS

There's substantial excess mortality due to DM1 in Finland. Interventions should focus on addressing both renal and cardiovascular risk factors but also pay more attention to mental health.

Transplant of fecal microbiota from healthy young mice relieves cognitive defects in late-stage diabetic mice by reducing metabolic disorders and neuroinflammation

Fecal microbiota transplant (FMT) is becoming as a promising area of interest for treating refractory diseases. In this study, we investigated the effects of FMT on diabetes-associated cognitive defects in mice as well as the underlying mechanisms. Fecal microbiota was prepared from 8-week-aged healthy mice. Late-stage type 1 diabetics (T1D) mice with a 30-week history of streptozotocin-induced diabetics were treated with antibiotics for 7 days, and then were transplanted with bacterial suspension (100 μL, i.g.) once a day for 14 days. We found that FMT from healthy young mice significantly alleviated cognitive defects of late-stage T1D mice assessed in Morris water maze test. We revealed that FMT significantly reduced the relative abundance of Gram-negative bacteria in the gut microbiota and enhanced intestinal barrier integrity, mitigating LPS translocation into the bloodstream and NLRP3 inflammasome activation in the hippocampus, thereby reducing T1D-induced neuronal loss and astrocytic proliferation. FMT also reshaped the metabolic phenotypes in the hippocampus of T1D mice especially for alanine, aspartate and glutamate metabolism. Moreover, we showed that application of aspartate (0.1 mM) significantly inhibited NLRP3 inflammasome activation and IL-1β production in BV2 cells under a HG/LPS condition. We conclude that FMT can effectively relieve T1D-associated cognitive decline via reducing the gut-brain metabolic disorders and neuroinflammation, providing a potential therapeutic approach for diabetes-related brain disorders in clinic.

Cognitive Disorders in Type 1 Diabetes: Role of Brain Glucose Variation, Insulin Activity, and Glucocorticoid Exposure

BACKGROUND

The number of patients with type 2 diabetes (T2D) and type 1 diabetes (T1D) is on the rise, partly due to a global increase in new T1D cases among children. Beyond the well-documented microvascular and macrovascular complications, there is now substantial evidence indicating that diabetes also impacts the brain, leading to neuropsychological impairments. The risk of developing neuropsychiatric symptoms is notably higher in childhood due to the ongoing maturation of the brain, which makes it more susceptible to damage. Despite this awareness, the specific effects of diabetes on cognitive function remain poorly understood.

SUMMARY

This review synthesizes literature on the impact of diabetes on cognition and its relationship with brain structural changes. It presents data and hypotheses to explain how T1D contributes to cognitive dysfunction, with a particular focus on children and adolescents. The emphasis on the pediatric population is intentional, as young diabetic patients typically have fewer comorbidities, reducing confounding factors and simplifying the investigation of cognitive alterations.

KEY MESSAGE

We examine the roles of hypo- and hyperglycemia, as well as the emerging role of glucocorticoids in the development of neuropsychological disorders. When specific mechanisms related to T1D are available, they are highlighted; otherwise, data and hypotheses applicable to both T1D and T2D are discussed.

Adherence to cardio-protective medications and cardiovascular disease in adults with type 1 diabetes

AIMS

We estimated overall refill adherence to all antihypertensive [AHT] and/or lipid-lowering drugs in the treatment regimen and its association with cardiovascular disease (CVD) in adults with type 1 diabetes, taking kidney disease into account.

METHODS

This Finnish Diabetic Nephropathy Study involved 1,558 adults with type 1 diabetes who had purchased AHT and/or lipid-lowering drugs within ± 0.5 year from baseline and were followed until their first CVD event, death, or end of 2015. Proportion of days covered (PDC) method was used to calculate adherence. The adherence was classified as good (≥80 %), intermediate (≥50 and <80%) or poor (<50%).

RESULTS

Median adherence rate was 74% (IQR 63-84 %). Both good (OR 0.55 [95% CI 0.33, 0.92], P=0.02) and intermediate (0.47 [0.29, 0.77], P=0.003) adherence were associated with lower odds of CVD, compared to poor adherence. Moreover, the higher the adherence percentage point in those with moderate albuminuria, the lower was the odds for CVD (0.81 [0.67, 0.98], P=0.03, per 10 unit increase in adherence).

CONCLUSIONS

In adults with type 1 diabetes, refill adherence of 50% or more to cardio-protective medications is associated with lower odds of incident CVD. Our findings highlight the relevance of going beyond prescribing protective CVD drugs, ensuring, and improving medication adherence matters.

Global cognition and executive functions of older adults with type 1 diabetes mellitus without dementia

AIMS/INTRODUCTION

This study aimed to characterize the global cognition and executive functions of older adults with type 1 diabetes mellitus in comparison with type 2 diabetes mellitus.

MATERIALS AND METHODS

This study included 37 patients with type 1 diabetes mellitus aged ≥65 years and 37 age- and sex-matched patients with type 2 diabetes mellitus. Patients with dementia scoring <24 on the Mini-Mental State Examination were excluded. General cognition, memory, classic, and practical executive function were investigated.

RESULTS

Patients with type 1 diabetes mellitus demonstrated lower psychomotor speed scores on Trail Making Tests A and B (P < 0.001, P < 0.013) than those with type 2 diabetes mellitus. The dysexecutive syndrome behavioral assessment revealed similar results in patients with types 1 and 2 diabetes mellitus. The Wechsler Memory Scale-Revised verbal episodic memory and Montreal Cognitive Assessment Japanese version were similar in terms of general cognition, but worse delayed recall subset on the latter was associated with type 2 diabetes mellitus (P = 0.038). A worse Trail Making Test-A performance was associated with type 1 diabetes mellitus and age (P < 0.004, P < 0.029).

CONCLUSIONS

Executive function of psychomotor speed was worse in older outpatient adults without dementia with type 1 diabetes mellitus than in those with type 2 diabetes mellitus but with no significant differences in the comprehensive and practical behavioral assessment of dysexecutive syndrome. Patients with type 1 diabetes had more severely impaired executive function, whereas those with type 2 had greater impaired memory than executive function.

Harnessing the Synergy of SGLT2 Inhibitors and Continuous Ketone Monitoring (CKM) in Managing Heart Failure among Patients with Type 1 Diabetes

Heart failure (HF) management in type 1 diabetes (T1D) is particularly challenging due to its increased prevalence and the associated risks of hospitalization and mortality, driven by diabetic cardiomyopathy. Sodium-glucose cotransporter-2 inhibitors (SGLT2-is) offer a promising avenue for treating HF, specifically the preserved ejection fraction variant most common in T1D, but their utility is hampered by the risk of euglycemic diabetic ketoacidosis (DKA). This review investigates the potential of SGLT2-is in T1D HF management alongside emergent Continuous Ketone Monitoring (CKM) technology as a means to mitigate DKA risk through a comprehensive analysis of clinical trials, observational studies, and reviews. The evidence suggests that SGLT2-is significantly reduce HF hospitalization and enhance cardiovascular outcomes. However, their application in T1D patients remains limited due to DKA concerns. CKM technology emerges as a crucial tool in this context, offering real-time monitoring of ketone levels, which enables the safe incorporation of SGLT2-is into treatment regimes by allowing for early detection and intervention in the development of ketosis. The synergy between SGLT2-is and CKM has the potential to revolutionize HF treatment in T1D, promising improved patient safety, quality of life, and reduced HF-related morbidity and mortality. Future research should aim to employ clinical trials directly assessing this integrated approach, potentially guiding new management protocols for HF in T1D.

Exploring the Impact of Glycemic Control on Diabetic Retinopathy: Emerging Models and Prognostic Implications

This review addresses the complexities of type 1 diabetes (T1D) and its associated complications, with a particular focus on diabetic retinopathy (DR). This review outlines the progression from non-proliferative to proliferative diabetic retinopathy and diabetic macular edema, highlighting the role of dysglycemia in the pathogenesis of these conditions. A significant portion of this review is devoted to technological advances in diabetes management, particularly the use of hybrid closed-loop systems (HCLSs) and to the potential of open-source HCLSs, which could be easily adapted to different patients' needs using big data analytics and machine learning. Personalized HCLS algorithms that integrate factors such as patient lifestyle, dietary habits, and hormonal variations are highlighted as critical to reducing the incidence of diabetes-related complications and improving patient outcomes.

Progression and regression of kidney disease in type 1 diabetes

Diabetic kidney disease is distinguished by the presence of albuminuria, hypertension, declining kidney function, and a markedly elevated cardiovascular disease risk. This constellation of clinical features drives the premature mortality associated with type 1 diabetes. The first epidemiological investigations concerning type 1 diabetes-related albuminuria date back to the 1980s. The early studies found that proteinuria - largely equivalent to severe albuminuria - developed in 35 to 45% of individuals with type 1 diabetes, with the diabetes duration-specific incidence rate pattern portraying one or two peaks. Furthermore, moderate albuminuria, the first detectable sign of diabetic kidney disease, was found to nearly inexorably progress to overt kidney disease within a short span of time. Since the early reports, studies presenting more updated incidence rates have appeared, although significant limitations such as study populations that lack broad generalizability, study designs vulnerable to substantive selection bias, and constrained follow-up times have been encountered by many. Nevertheless, the most recent reports estimate that in modern times, moderate - instead of severe - albuminuria develops in one-third of individuals with type 1 diabetes; yet, a considerable part (up to 40% during the first ten years after the initial albuminuria diagnosis) progresses to more advanced stages of the disease over time. An alternative pathway to albuminuria progression is its regression, which affects up to 60% of the individuals, but notably, the relapse rate to a more advanced disease stage is high. Whether albuminuria regression translates into a decline in cardiovascular disease and premature mortality risk is an area of debate, warranting more detailed research in the future. Another unclear but alarming feature is that although the incidence of severe albuminuria has fallen since the 1930s, the decline seems to have reached a plateau after the 1980s. This stagnation may be due to the lack of kidney-protective medicines since the early 1980s, as the recent breakthroughs in type 2 diabetes have not been applicable to type 1 diabetes. Therefore, novel treatment strategies are at high priority within this patient population.

Allo Beta Cell transplantation: specific features, unanswered questions, and immunological challenge

Type 1 diabetes (T1D) presents a persistent medical challenge, demanding innovative strategies for sustained glycemic control and enhanced patient well-being. Beta cells are specialized cells in the pancreas that produce insulin, a hormone that regulates blood sugar levels. When beta cells are damaged or destroyed, insulin production decreases, which leads to T1D. Allo Beta Cell Transplantation has emerged as a promising therapeutic avenue, with the goal of reinstating glucose regulation and insulin production in T1D patients. However, the path to success in this approach is fraught with complex immunological hurdles that demand rigorous exploration and resolution for enduring therapeutic efficacy. This exploration focuses on the distinct immunological characteristics inherent to Allo Beta Cell Transplantation. An understanding of these unique challenges is pivotal for the development of effective therapeutic interventions. The critical role of glucose regulation and insulin in immune activation is emphasized, with an emphasis on the intricate interplay between beta cells and immune cells. The transplantation site, particularly the liver, is examined in depth, highlighting its relevance in the context of complex immunological issues. Scrutiny extends to recipient and donor matching, including the utilization of multiple islet donors, while also considering the potential risk of autoimmune recurrence. Moreover, unanswered questions and persistent gaps in knowledge within the field are identified. These include the absence of robust evidence supporting immunosuppression treatments, the need for reliable methods to assess rejection and treatment protocols, the lack of validated biomarkers for monitoring beta cell loss, and the imperative need for improved beta cell imaging techniques. In addition, attention is drawn to emerging directions and transformative strategies in the field. This encompasses alternative immunosuppressive regimens and calcineurin-free immunoprotocols, as well as a reevaluation of induction therapy and recipient preconditioning methods. Innovative approaches targeting autoimmune recurrence, such as CAR Tregs and TCR Tregs, are explored, along with the potential of stem stealth cells, tissue engineering, and encapsulation to overcome the risk of graft rejection. In summary, this review provides a comprehensive overview of the inherent immunological obstacles associated with Allo Beta Cell Transplantation. It offers valuable insights into emerging strategies and directions that hold great promise for advancing the field and ultimately improving outcomes for individuals living with diabetes.

Lifespan variation among people with a given disease or condition

In addition to fundamental mortality metrics such as mortality rates and mortality rate ratios, life expectancy is also commonly used to investigate excess mortality among a group of individuals diagnosed with specific diseases or conditions. However, as an average measure, life expectancy ignores the heterogeneity in lifespan. Interestingly, the variation in lifespan-a measure commonly used in the field of demography-has not been estimated for people with a specific condition. Based on recent advances in methodology in research within epidemiology and demography, we discuss two metrics, namely, the average life disparity and average lifetable entropy after diagnosis, which estimate the variation in lifespan for time-varying conditions in both absolute and relative aspects. These metrics are further decomposed into early and late components, separated by their threshold ages. We use mortality data for women with mental disorders from Danish registers to design a population-based study and measure such metrics. Compared with women from the general population, women with a mental disorder had a shorter average remaining life expectancy after diagnosis (37.6 years vs. 44.9 years). In addition, women with mental disorders also experienced a larger average lifespan variation, illustrated by larger average life disparity (9.5 years vs 9.1 years) and larger average lifetable entropy (0.33 vs 0.27). More specifically, we found that women with a mental disorder had a larger early average life disparity but a smaller late average life disparity. Unlike the average life disparity, both early and late average lifetable entropy were higher for women with mental disorders compared to the general population. In conclusion, the metric proposed in our study complements the current research focusing merely on life expectancy and further provides a new perspective into the assessment of people's health associated with time-varying conditions.

Diabetes burden, trends, and inequalities in western pacific region, 1990-2019: A population-based study

AIMS

The aim was to describe the diabetes regional burden, trends, and inequalities in the Western Pacific region.

METHODS

The Global Burden of Disease 2019 study was used to evaluate the prevalence, incidence, mortality, disability-adjusted life year (DALY) rates and average annual percentage changes (AAPCs) in diabetes in the Western Pacific region from 1990 to 2019. Cross-country inequalities in the DALY rates of diabetes were estimated between 1990 and 2019.

RESULTS

The age-standardized incidence of type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) in the Western Pacific region increased from 2.6 to 3.8 per 100,000 population (AAPC, 0.97 [95% CI 0.84 to 1.1]) and from 174.8 to 207.3 per 100,000 population (AAPC, 0.63 [95% CI 0.48 to 0.77]) between 1990 and 2019, respectively. The most substantial increase in the incidence of T1DM and T2DM was found in the groups aged 70 years and older (AAPC, 2.38 [95% CI 2.19 to 2.58]) and 15-49 years (AAPC, 1.58 [95% CI 1.43 to 1.72]) from 1990 to 2019, respectively. Age-standardized DALYs for T1DM decreased but those for T2DM increased between 1990 and 2019. The relative concentration index of DALYs in T1DM and T2DM changed from 0.11 in 1990 to -0.08 in 2019 and from 0.03 in 1990 to -0.04 in 2019, respectively.

CONCLUSIONS

Over three decades, diabetes incidence in the Western Pacific region rose substantially, with inequalities among countries. The burden shifted from higher to lower sociodemographic index countries. Diabetes remains a public health challenge, especially among young populations. Urgent interventions for prevention and early detection are crucial.

Using Continuous Glucose Monitoring and Data Sharing to Encourage Collaboration Among Older Adults With Type 1 Diabetes and Their Care Partners: Qualitative Descriptive Study

BACKGROUND

Persons with diabetes use continuous glucose monitoring (CGM) to self-manage their diabetes. Care partners (CPs) frequently become involved in supporting persons with diabetes in the management of their diabetes. However, persons with diabetes and CP dyads may require more communication and problem-solving skills regarding how to share and respond to CGM data.

OBJECTIVE

The purpose of this study was to describe the experiences of persons with diabetes and CPs who participated in the Share "plus" intervention, which addresses dyadic communication strategies, problem-solving, and action planning to promote sharing of CGM data among the dyad.

METHODS

Ten dyads participated in the Share "plus" telehealth intervention. Participants were interviewed during and after the Share "plus" intervention. Thematic analysis was used to analyze interview data.

RESULTS

During postsession interviews, dyads described feeling a sense of shared responsibility yet viewed the persons with diabetes as ultimately responsible for the disease. Additionally, dyads shared that communication patterns improved and were able to recognize the negative aspects of previously established communication patterns. Dyads reported communication focused on hypoglycemia episodes while also differing in the frequency they reviewed CGM data and set alerts. Overall, dyads expressed positive reactions to the Share "plus" intervention.

CONCLUSIONS

Share "plus" was helpful in promoting positive CGM-related communication among dyads and encouraged more CP support. CPs play an important role in supporting older adults with type 1 diabetes. Communication strategies help support dyad involvement in CGM data sharing and self-management among persons with diabetes.

Comparison of coronary artery calcium score and cardiovascular risk-stratification by European Society of Cardiology Guidelines and Steno Type 1 Risk Engine in statin-naïve adults with type 1 diabetes

BACKGROUND

Coronary artery calcium (CAC) is a marker of atherosclerotic cardiovascular disease (CVD). However, for patients with type 1 diabetes (T1D), its relationship with T1D-specific cardiovascular (CV) risk-stratification tools is unknown.

AIMS

Assess prevalence of CAC and evaluate relationship between CAC and T1D-specific CV risk-stratification methods in T1D.

METHODS

Cross-sectional study of adults with T1D age 20-60 years, statin-naïve and no history of CVD. Data was obtained from electronic medical records and by interview. Presence of CAC was assessed using non-contrast cardiac computed tomography and quantified by Agatston Units (AU). CV risk-stratification was assessed using the 2019 European Society of Cardiology (ESC) Guidelines and the Steno T1 Risk Engine (ST1RE).

RESULTS

85 patients were included with mean age 35.4 ± 10.3 years, HbA1c 8.3 ± 1.5 % and T1D duration 17.0 ± 10.1 years. 67 patients (78.9 %) had a CAC score of 0 AU, 17 (20.0 %) >0-100 AU, and one (1.2 %) >100 AU. Duration of T1D (p = 0.009), body mass index (p = 0.029), neuropathy (p = 0.016) and low-density lipoprotein cholesterol levels (p = 0.016) were independently associated with a positive CAC score on multivariate analysis. Positive predictive value for a positive CAC score was 85.7 % for the ST1RE high risk category and 31.3 % for the 2019 ESC Guidelines very high risk category.

CONCLUSIONS

One-fifth of this T1D cohort had a positive CAC score. The ST1RE was superior in identifying positive CAC compared to the 2019 ESC Guidelines. Further studies are required to elucidate the role of CAC in personalising CV risk-stratification and statin initiation in T1D.

Life Years Lost in Children with Kidney Failure: A Binational Cohort Study with Multistate Probabilities of Death and Life Expectancy

SIGNIFICANCE STATEMENT

In children with kidney failure, little is known about their treatment trajectories or the effects of kidney failure on lifetime survival and years of life lost, which are arguably more relevant measures for children. In this population-based cohort study of 2013 children who developed kidney failure in Australia and New Zealand, most children were either transplanted after initiating dialysis (74%) or had a preemptive kidney transplant (14%). Life expectancy increased with older age at kidney failure, but more life years were spent on dialysis than with a functioning transplant. The expected (compared with the general population) number of life years lost ranged from 16 to 32 years, with female patients and those who developed kidney failure at a younger age experiencing the greatest loss of life years.

BACKGROUND

Of the consequences of kidney failure in childhood, those rated as most important by children and their caregivers are its effects on long-term survival. From a life course perspective, little is known about the experience of kidney failure treatment or long-term survival.

METHODS

To determine expected years of life lost (YLL) and treatment trajectory for kidney failure in childhood, we conducted a population-based cohort study of all children aged 18 years or younger with treated kidney failure in Australia (1980-2019) and New Zealand (1988-2019).We used patient data from the CELESTIAL study, which linked the Australian and New Zealand Dialysis and Transplant registry with national death registers. We estimated standardized mortality ratios and used multistate modeling to understand treatment transitions and life expectancy.

RESULTS

A total of 394 (20%) of 2013 individuals died over 30,082 person-years of follow-up (median follow-up, 13.1 years). Most children (74%) were transplanted after initiating dialysis; 14% (18% of male patients and 10% of female patients) underwent preemptive kidney transplantation. Excess deaths (compared with the general population) decreased dramatically from 1980 to 1999 (from 41 to 22 times expected) and declined more modestly (to 17 times expected) by 2019. Life expectancy increased with older age at kidney failure, but more life years were spent on dialysis than with a functioning transplant. The number of YLL ranged from 16 to 32 years, with the greatest loss among female patients and those who developed kidney failure at a younger age.

CONCLUSIONS

Children with kidney failure lose a substantial number of their potential life years. Female patients and those who develop kidney failure at younger ages experience the greatest burden.

Long-term and recent trends in survival and life expectancy for people with type 1 diabetes in Finland

AIMS

Type 1 diabetes has been associated with a significant reduction in life expectancy. Major advances in treatment of type 1 diabetes have been associated with improved survival. However, life expectancy for type 1 diabetes under contemporary care is not known.

METHODS

Health care registers were used to obtain data on all people with type 1 diabetes in Finland in 1964-2017 and their mortality in 1972-2017. Survival analyses were used to study long-term trends in survival and abridged period life table methods to calculate life expectancy estimates. Causes of death were examined to consider development.

RESULTS

Study data included 42,936 persons with type 1 diabetes and 6,771 deaths. Kaplan-Meier curves showed improved survival during the study period. In 2017, the remaining life expectancy at the age of 20 for a person diagnosed for type 1 diabetes was estimated to be 51.64 (95% CI: 51.51, 51.78) years which was 9.88 (9.74, 10.01) years lower than for the general Finnish population.

CONCLUSIONS

We found improved survival among persons with type 1 diabetes during the last decades. However, their life expectancy remained significantly below that of the general Finnish population. Our results call for further innovations and improvements in diabetes care.

Furcation involvement and tooth loss: A registry-based retrospective cohort study

AIM

This registry-based retrospective cohort study aimed to evaluate the impact of furcation status on the risk for molar loss.

MATERIALS AND METHODS

Subjects with and without furcation involvement (FI) in 2010/2011 were identified in a nationwide registry in Sweden (age- and gender-matched sample: 381,450 subjects; 2,374,883 molars). Data on dental and periodontal status were extracted for the subsequent 10-year period. Impact of FI (at baseline or detected during follow-up) on molar loss (i.e., tooth extraction) was evaluated through multilevel logistic regression and survival analyses.

RESULTS

FI had a significant impact on molar loss. FI degrees 2 and 3 resulted in adjusted risk ratios of 1.67 (95% confidence interval [CI] 1.63-1.71) and 3.30 (95% CI 3.18-3.43), respectively. Following the first detection of deep FI (degrees 2-3), estimated survival decreased by 4% at 5 years and 8% at 10 years. In addition to FI, endodontic status and probing depth were relevant risk factors for molar loss.

CONCLUSIONS

Furcation status had a clinically relevant impact on the risk for molar loss. Following first detection of deep FI, however, the decline in molar survival was minor.

Pancreatic transplant surgery and stem cell therapy: Finding the balance between therapeutic advances and ethical principles

The latest achievements in the field of pancreas transplantation and stem cell therapy require an effort by the scientific community to clarify the ethical implications of pioneering treatments, often characterized by high complexity from a surgical point of view, due to transplantation of multiple organs at the same time or at different times, and from an immunological point of view for stem cell therapy. The fundamental value in the field of organ transplants is, of course, a solidarity principle, namely that of protecting the health and life of people for whom transplantation is a condition of functional recovery, or even of survival. The nature of this value is that of a concept to which the legal discipline of transplants entrusts its own ethical dignity and for which it has ensured a constitutional recognition in different systems. The general principle of respect for human life, both of the donor and of the recipient, evokes the need not to put oneself and one's neighbor in dangerous conditions. The present ethical reflection aims to find a balance between the latest therapeutic advances and several concepts including the idea of the person, the respect due to the dead, the voluntary nature of the donation and the consent to the same, the gratuitousness of the donation, the scientific progress and the development of surgical techniques, and the policies of health promotion.

Large socioeconomic gap in period life expectancy and life years spent with complications of diabetes in the Scottish population with type 1 diabetes, 2013-2018

BACKGROUND

We report the first study to estimate the socioeconomic gap in period life expectancy (LE) and life years spent with and without complications in a national cohort of individuals with type 1 diabetes.

METHODS

This retrospective cohort study used linked healthcare records from SCI-Diabetes, the population-based diabetes register of Scotland. We studied all individuals aged 50 and older with a diagnosis of type 1 diabetes who were alive and residing in Scotland on 1 January 2013 (N = 8591). We used the Scottish Index of Multiple Deprivation (SIMD) 2016 as an area-based measure of socioeconomic deprivation. For each individual, we constructed a history of transitions by capturing whether individuals developed retinopathy/maculopathy, cardiovascular disease, chronic kidney disease, and diabetic foot, or died throughout the study period, which lasted until 31 December 2018. Using parametric multistate survival models, we estimated total and state-specific LE at an attained age of 50.

RESULTS

At age 50, remaining LE was 22.2 years (95% confidence interval (95% CI): 21.6 - 22.8) for males and 25.1 years (95% CI: 24.4 - 25.9) for females. Remaining LE at age 50 was around 8 years lower among the most deprived SIMD quintile when compared with the least deprived SIMD quintile: 18.7 years (95% CI: 17.5 - 19.9) vs. 26.3 years (95% CI: 24.5 - 28.1) among males, and 21.2 years (95% CI: 19.7 - 22.7) vs. 29.3 years (95% CI: 27.5 - 31.1) among females. The gap in life years spent without complications was around 5 years between the most and the least deprived SIMD quintile: 4.9 years (95% CI: 3.6 - 6.1) vs. 9.3 years (95% CI: 7.5 - 11.1) among males, and 5.3 years (95% CI: 3.7 - 6.9) vs. 10.3 years (95% CI: 8.3 - 12.3) among females. SIMD differences in transition rates decreased marginally when controlling for time-updated information on risk factors such as HbA1c, blood pressure, BMI, or smoking.

CONCLUSIONS

In addition to societal interventions, tailored support to reduce the impact of diabetes is needed for individuals from low socioeconomic backgrounds, including access to innovations in management of diabetes and the prevention of complications.

Performance of 2019 ESC risk classification and the Steno type 1 risk engine in predicting cardiovascular events in adults with type 1 diabetes: A retrospective study

AIMS

The study compares the performance of the European Society of Cardiology (ESC) risk criteria and the Steno Type 1 Risk Engine (ST1RE) in the prediction of cardiovascular (CV) events.

METHODS

456 adults with type 1 diabetes (T1D) were retrospectively studied. During 8.5 ± 5.5 years of observation, twenty-four patients (5.2%) experienced a CV event. The predictive performance of the two risk models was evaluated by classical metrics and the event-free survival analysis.

RESULTS

The ESC criteria show excellent sensitivity (91.7%) and suboptimal specificity (64.4 %) in predicting CV events in the very high CV risk group, but a poor performance in the high/moderate risk groups. The ST1RE algorithm shows a good predictive performance in all CV risk categories. Using ESC classification, the event-free survival analysis shows a significantly higher event rate in the very high CV risk group compared to the high/moderate risk group (p < 0.0019). Using the ST1RE algorithm, a significant difference in the event-free survival curve was found between the three CV risk categories (p < 0.0001).

CONCLUSIONS

In T1D the ESC classification has a good performance in predicting CV events only in those at very high CV risk, whereas the ST1RE algorithm has a good performance in all risk categories.

Incidence rate patterns, cumulative incidence, and time trends for moderate and severe albuminuria in individuals diagnosed with type 1 diabetes aged 0-14 years: a population-based retrospective cohort study

BACKGROUND

The incidence and temporal trends of moderate and severe albuminuria during recent decades are poorly described in type 1 diabetes. We aimed to assess diabetes duration-specific incidence rates, cumulative incidence, and secular trends of albuminuria in type 1 diabetes in Finland.

METHODS

We conducted a population-based, retrospective cohort study of a stratified random sample (n=1500) of all individuals diagnosed with type 1 diabetes before age 15 years during 1970-99 in Finland. The sampling frame was the database of the Finnish Institute for Health and Welfare. Individuals with an atypical clinical course, presentation of non-diabetic kidney disease, insufficient albumin excretion rate measurements, or unavailable medical records were excluded (final sample n=1430). Study participants were followed up until death, the event of interest (moderate or severe albuminuria or kidney failure), or the most recent event-free date. Medical records retrieved up to Dec 31, 2020 were systematically reviewed for albuminuria determinations. Moderate and severe albuminuria were categorised on the basis of international reference limits (two of three consecutive urine samples). Kidney failure was defined as dialysis treatment or kidney transplant. Cohorts defined by calendar year of diabetes diagnosis (1970-79, 1980-89, and 1990-99) were assessed. Patterns of duration-specific incidences were evaluated by fitting generalised additive models to the data, which were split into multiple observations of half-year duration. Cumulative incidences were calculated with Kaplan-Meier analysis. In analyses with kidney failure as the endpoint, competing risk for mortality was incorporated.

FINDINGS

In our stratified random sample, 462 individuals were diagnosed with diabetes in 1970-79, 481 were diagnosed in 1980-89, and 487 were diagnosed in 1990-99. The incidence rate pattern of severe albuminuria changed over time; a peak at 15-19 years since diabetes onset in the 1970-79 cohort was not replicated in those diagnosed later. In the combined 1980-99 diagnosis-year cohorts, the incidence rate rose during the first 14 years after diabetes onset, after which it levelled off to a plateau. Between the 1970-79 and 1980-89 diabetes diagnosis cohorts, the cumulative incidence of severe albuminuria had approximately halved (hazard ratio [HR] 0·55 [95% CI 0·42-0·72] with the 1970-79 cohort as reference, p<0·0001), whereas, between the 1980-89 and 1990-99 cohorts, no further decrease was observed (HR 0·83 [0·54-1·26] with the 1980-89 cohort as reference, p=0·38). The 25-year cumulative incidence for severe albuminuria was 26·8% (22·6-30·8) in the 1970-79 diagnosis cohort, 12·0% (9·0-15·0) in the 1980-89 cohort, and 10·8% (6·7-14·6) in the 1990-99 cohort. 15 years after onset of severe albuminuria, cumulative progression rate from severe albuminuria to kidney failure was 35·2% (27·4-43·0) in the 1970-79 cohort and 35·6% (24·3-47·0) in the 1980-99 cohorts combined (Gray's test p=0·37). In the cohorts with data on moderate albuminuria (1980-89 and 1990-99), cumulative incidence of moderate albuminuria showed no calendar effect between the earlier and later cohorts (HR 0·99 [0·78-1·28] with the 1980-89 cohort as reference, p=0·97). The incidence rate of moderate albuminuria increased until 10 years after diabetes onset, then remained mostly stable until starting to decrease at around 25 years after diabetes onset.

INTERPRETATION

Our analyses show that the cumulative incidence of severe albuminuria has decreased between 1970-79 and 1980-99; however, whether this decrease solely denotes a delay in albuminuria, or also a true prevention of albuminuria, needs to be investigated further. Nevertheless, diabetic kidney disease remains a significant complication of type 1 diabetes. Due to the robust association of diabetic kidney disease with premature mortality, novel therapies to improve prognosis are needed.

FUNDING

Folkhälsan Research Foundation, Medical Society of Finland, Wilhelm and Else Stockmann Foundation, Finnish Diabetes Research Foundation, Waldemar von Frenckell Foundation, Liv och Hälsa Society, Academy of Finland, and Novo Nordisk Foundation.

TRANSLATIONS

For the Finnish and Swedish translations of the abstract see Supplementary Materials section.

Burden of type 1 diabetes mellitus in the North Africa and Middle East Region, 1990-2019; findings from the global burden of disease study

AIMS

We aimed to report the burden of type 1 diabetes mellitus (T1DM) in the North Africa and Middle East region and its 21 countries from 1990 to 2019.

METHODS

Information related to incidence, prevalence, mortality, disability-adjusted life-years (DALYs), and years lived with disability (YLDs) of T1DM was acquired from the 2019 Global Burden of Disease study. The burden was estimated by sex, age groups, and socio-demographic index (SDI) in 21 countries.

RESULTS

Over the past 30 years, regional incidence, prevalence, mortality, and DALYs of T1DM increase by 188.7%, 304.8%, 43.7%, and 71.6%, respectively. While the age-standardized incidence and prevalence rates increased by 84% and 91%, the mortality and DALYs rates decreased by 34% and 13%. During these years, the contribution of YLDs to total DALYs increased considerably (from 17% to 42%). The highest increase in the incidence and prevalence rates occurred in high SDI countries. Moreover, the Mortality to Incidence Ratio (MIR) decreased in the region countries.

CONCLUSIONS

Despite progress made in diabetes care, there is a persistently increasing burden of T1DM in the region countries. This indicates that T1DM is still one of the major health challenges in the region countries, especially in high SDI Arab countries.

Glucose-Lowering Therapy beyond Insulin in Type 1 Diabetes: A Narrative Review on Existing Evidence from Randomized Controlled Trials and Clinical Perspective

Background: In Type 1 diabetes (T1D), according to the most recent guidelines, the everyday glucose-lowering treatment is still restricted to the use of subcutaneous insulin, while multiple therapeutic options exist for Type 2 diabetes (T2D). Methods: For this narrative review we unsystematically screened PubMed and Embase to identify clinical trials which investigated glucose-lowering agents as an adjunct to insulin treatment in people with T1D. Published studies up to March 2022 were included. We discuss the safety and efficacy in modifying cardiovascular risk factors for each drug, the current status of research, and provide a clinical perspective. Results: For several adjunct agents, in T1D, the scientific evidence demonstrates improvements in HbA1c, reductions in the risk of hypoglycemia, and achievements of lower insulin requirements, as well as positive effects on cardiovascular risk factors, such as blood lipids, blood pressure, and weight. As the prevalence of obesity, the major driver for double diabetes, is rising, weight and cardiovascular risk factor management is becoming increasingly important in people with T1D. Conclusions: Adjunct glucose-lowering agents, intended to be used in T2D, bear the potential to beneficially impact on cardiovascular risk factors when investigated in the T1D population and are suggested to be more extensively considered as potentially disease-modifying drugs in the future and should be investigated for hard cardiovascular endpoints.

Genetic Risk Score Enhances Coronary Artery Disease Risk Prediction in Individuals With Type 1 Diabetes

OBJECTIVE

Individuals with type 1 diabetes are at a high lifetime risk of coronary artery disease (CAD), calling for early interventions. This study explores the use of a genetic risk score (GRS) for CAD risk prediction, compares it to established clinical markers, and investigates its performance according to the age and pharmacological treatment.

RESEARCH DESIGN AND METHODS

This study in 3,295 individuals with type 1 diabetes from the Finnish Diabetic Nephropathy Study (467 incident CAD, 14.8 years follow-up) used three risk scores: a GRS, a validated clinical score, and their combined score. Hazard ratios (HR) were calculated with Cox regression, and model performances were compared with the Harrell C-index (C-index).

RESULTS

A HR of 6.7 for CAD was observed between the highest and the lowest 5th percentile of the GRS (P = 1.8 × 10-6). The performance of GRS (C-index = 0.562) was similar to HbA1c (C-index = 0.563, P = 0.96 for difference), HDL (C-index = 0.571, P = 0.6), and total cholesterol (C-index = 0.594, P = 0.1). The GRS was not correlated with the clinical score (r = -0.013, P = 0.5). The combined score outperformed the clinical score (C-index = 0.813 vs. C-index = 0.820, P = 0.003). The GRS performed better in individuals below the median age (38.6 years) compared with those above (C-index = 0.637 vs. C-index = 0.546).

CONCLUSIONS

A GRS identified individuals at high risk of CAD and worked better in younger individuals. GRS was also an independent risk factor for CAD, with a predictive power comparable to that of HbA1c and HDL and total cholesterol, and when incorporated into a clinical model, modestly improved the predictions. The GRS promises early risk stratification in clinical practice by enhancing the prediction of CAD.

Comparison of cognitive function in older adults with type 1 diabetes, type 2 diabetes, and no diabetes: results from the Study of Longevity in Diabetes (SOLID)

INTRODUCTION

The incidence of both type 1 diabetes (T1D) and type 2 diabetes (T2D) is increasing. Life expectancy is improving in T1D, resulting in a growing population of elderly adults with diabetes. While it is well established that older adults with T2D are at increased risk of cognitive impairment, little is known regarding cognitive aging in T1D and how their cognitive profiles may differ from T2D.

RESEARCH DESIGN AND METHODS

We compared baseline cognitive function and low cognitive function by diabetes status (n=734 T1D, n=232 T2D, n=247 without diabetes) among individuals from the Study of Longevity in Diabetes (mean age=68). We used factor analysis to group cognition into five domains and a composite measure of total cognition. Using linear and logistic regression models, we examined the associations between diabetes type and cognitive function, adjusting for demographics, comorbidities, depression, and sleep quality.

RESULTS

T1D was associated with lower scores on total cognition, language, executive function/psychomotor processing speed, and verbal episodic memory, and greater odds of low executive function/psychomotor processing speed (OR=2.99, 95% CI 1.66 to 5.37) and verbal episodic memory (OR=1.92, 95% CI 1.07 to 3.46), compared with those without diabetes. T2D was associated with lower scores on visual episodic memory. Compared with T2D, T1D was associated with lower scores on verbal episodic memory and executive function/psychomotor processing speed and greater odds of low executive function/psychomotor processing speed (OR=1.74, 95% CI 1.03 to 2.92).

CONCLUSIONS

Older adults with T1D had significantly poorer cognition compared with those with T2D and those without diabetes even after accounting for a range of comorbidities. Future studies should delineate how to reduce risk in this vulnerable population who are newly surviving to old age.

SHARE plus: Delivering a Telehealth CGM Data-Sharing Intervention to Older Adults and Their Care Partners

Care partners of older adults with type 1 diabetes often become part of the diabetes care team but lack knowledge of how to become involved with glucose management. This article describes a study confirming the feasibility of SHARE plus, a telehealth intervention involving continuous glucose monitoring and data-sharing to assist these individuals in working together on diabetes management. The intervention provides a strategy for increasing remote patient monitoring and facilitating care partner involvement in diabetes management.

Randomised controlled trial of Advanced Hybrid Closed Loop in an Adult Population with Type 1 Diabetes (ADAPT): study protocol and rationale

INTRODUCTION

For many people with type 1 diabetes who struggle to achieve glycaemic control with multiple daily injections of insulin (MDI) plus self-monitoring of blood glucose, MDI plus intermittently scanned continuous glucose monitoring (IS-CGM) or real-time continuous glucose monitoring (RT-CGM), or insulin administration using insulin pump therapy represent optimised care in many regions. Through technological advances an advanced hybrid closed loop (AHCL) system has been developed; studies of incremental effects relative to MDI plus IS-CGM are lacking.

METHODS AND ANALYSIS

The Advanced Hybrid Closed Loop study in Adult Population with Type 1 Diabetes (ADAPT) study is a multinational, prospective, open-label, confirmatory and exploratory randomised controlled trial to examine outcomes with the MiniMed 670G version 4.0 AHCL system (with an equivalent algorithm and commercialised as the MiniMed 780G system, referred to as AHCL) relative to MDI plus IS-CGM in adults with baseline HbA1c≥8.0%. An exploratory cohort will compare AHCL with MDI plus RT-CGM. The study will be conducted in approximately 124 adults on MDI plus either IS-CGM or RT-CGM for at least 3 months prior to screening. The primary endpoint will be the difference in mean HbA1c change from baseline to 6 months between the AHCL and the MDI plus IS-CGM arms. Secondary endpoints will include proportion of time spent in hypoglycaemic, euglycaemic and hyperglycaemic ranges.

ETHICS AND DISSEMINATION

The ADAPT study will be conducted in accordance with the requirements of the Declaration of Helsinki and local laws and regulations, and has been approved by ethics committees. The trial will provide valuable information on the incremental benefits that may be provided by AHCL for patients failing to achieve glycaemic targets on MDI plus IS-CGM or RT-CGM and form a basis for health economic evaluations to support market access.

TRIAL REGISTRATION NUMBER

NCT04235504; Pre-results.

Experience of living with type 1 diabetes in a low-income country: a qualitative study from Liberia

INTRODUCTION

While epidemiological data for type 1 diabetes (T1D) in low/middle-income countries, and particularly low-income countries (LICs) including Liberia is lacking, prevalence in LICs is thought to be increasing. T1D care in LICs is often impacted by challenges in diagnosis and management. These challenges, including misdiagnosis and access to insulin, can affect T1D outcomes and frequency of severe complications. Despite the severe nature of T1D and growing burden in sub-Saharan Africa, little is currently known about the impact of T1D on patients and caregivers in the region.

METHODS

We conducted a qualitative study consisting of interviews with patients with T1D, caregivers, providers, civil society members and a policy-maker in Liberia to better understand the psychosocial and economic impact of living with T1D, knowledge of T1D and self-management, and barriers and facilitators for accessing T1D care.

RESULTS

This study found T1D to have a major psychosocial and economic impact on patients and caregivers, who reported stigma, diabetes distress and food insecurity. Patients, caregivers and providers possessed the knowledge necessary to effectively manage T1D but insufficient community awareness leads to delayed diagnosis, often in an emergency department. Most patients reported receiving free services and materials, though the cost of transportation to clinic visits and recommended foods is a barrier to disease management. Many providers noted the lack of national T1D-specific guidelines and registries. Policy-makers reported a lack of prioritisation of and resources for T1D. These barriers, combined with scarcity and expense of appropriate foods, pose severe barriers for self-management of T1D.

CONCLUSION

T1D was found to have a significant impact on patients and caregivers, and informants identified several key individual and systems-level barriers to effective T1D care in Liberia. Addressing these concerns is vital for designing sustainable and effective programmes for treating patients living with T1D.

Felix dies natalis, insulin… ceterum autem censeo "beta is better"

One hundred years after its discovery, insulin remains the life-saving therapy for many patients with diabetes. It has been a 100-years-old success story thanks to the fact that insulin therapy has continuously integrated the knowledge developed over a century. In 1982, insulin becomes the first therapeutic protein to be produced using recombinant DNA technology. The first "mini" insulin pump and the first insulin pen become available in 1983 and 1985, respectively. In 1996, the first generation of insulin analogues were produced. In 1999, the first continuous glucose-monitoring device for reading interstitial glucose was approved by the FDA. In 2010s, the ultra-long action insulins were introduced. An equally exciting story developed in parallel. In 1966. Kelly et al. performed the first clinical pancreas transplant at the University of Minnesota, and now it is a well-established clinical option. First successful islet transplantations in humans were obtained in the late 1980s and 1990s. Their ability to consistently re-establish the endogenous insulin secretion was obtained in 2000s. More recently, the possibility to generate large numbers of functional human β cells from pluripotent stem cells was demonstrated, and the first clinical trial using stem cell-derived insulin producing cell was started in 2014. This year, the discovery of this life-saving hormone turns 100 years. This provides a unique opportunity not only to celebrate this extraordinary success story, but also to reflect on the limits of insulin therapy and renew the commitment of the scientific community to an insulin free world for our patients.

Development of a life expectancy table for individuals with type 1 diabetes

AIMS/HYPOTHESIS

Tables reporting life expectancies by common risk factors are available for individuals with type 2 diabetes; however, there is currently no published equivalent for individuals with type 1 diabetes. We aimed to develop a life expectancy table using a recently published simulation model for individuals with type 1 diabetes.

METHODS

The simulation model was developed using data from a real-world population of patients with type 1 diabetes selected from the Swedish National Diabetes Register. The following six important risk factors were included in the life table: sex; age; current smoking status; BMI; eGFR; and HbA_1c. For each of 1024 cells in the life expectancy table, a synthetic cohort containing 1000 individuals was created, with other risk factors assigned values representative of the real-world population. The simulations were executed for all synthetic cohorts and life expectancy for each cell was calculated as mean survival time of the individuals in the respective cohort.

RESULTS

There was a substantial variation in life expectancy across patients with different risk factor levels. Life expectancy of 20-year-old men varied from 29.3 years to 50.6 years, constituting a gap of 21.3 years between those with worst and best risk factor levels. In 20-year-old women, this gap was 18.9 years (life expectancy range 35.0-53.9 years). The variation in life expectancy was a function of the combination of risk factor values, with HbA_1c and eGFR consistently showing a negative and positive correlation, respectively, with life expectancy at any level combination of other risk factors. Individuals with the lowest level (20 kg/m²) and highest level of BMI (35 kg/m²) had a lower life expectancy compared with those with a BMI of 25 kg/m². Non-smokers and women had a higher life expectancy than smokers and men, respectively, with the difference in life expectancy ranging from 0.4 years to 2.7 years between non-smokers and smokers, and from 1.9 years to 5.9 years between women and men, depending on levels of other risk factors.

CONCLUSIONS/INTERPRETATION

The life expectancy table generated in this study shows a substantial variation in life expectancy across individuals with different modifiable risk factors. The table allows for rapid communications of risk in an easily understood format between healthcare professionals, health economists, researchers, policy makers and patients. Particularly, it supports clinicians in their discussion with patients about the benefits of improving risk factors.

The association of polypharmacy and high-risk drug classes with adverse health outcomes in the Scottish population with type 1 diabetes

AIMS/HYPOTHESIS

The aim of this work was to map the number of prescribed drugs over age, sex and area-based socioeconomic deprivation, and to examine the association between the number of drugs and particular high-risk drug classes with adverse health outcomes among a national cohort of individuals with type 1 diabetes.

METHODS

Utilising linked healthcare records from the population-based diabetes register of Scotland, we identified 28,245 individuals with a diagnosis of type 1 diabetes on 1 January 2017. For this population, we obtained information on health status, predominantly reflecting diabetes-related complications, and information on the total number of drugs and particular high-risk drug classes prescribed. We then studied the association of these baseline-level features with hospital admissions for falls, diabetic ketoacidosis (DKA), and hypoglycaemia or death within the subsequent year using multivariate Cox proportional hazards models.

RESULTS

Not considering insulin and treatment for hypoglycaemia, the mean number of prescribed drugs was 4.00 (SD 4.35). The proportion of individuals being prescribed five or more drugs at baseline consistently increased with age (proportion [95% CI]: 0-19 years 2.04% [1.60, 2.49]; 40-49 years 28.50% [27.08, 29.93]; 80+ years 76.04% [67.73, 84.84]). Controlling for age, sex, area-based socioeconomic deprivation and health status, each additional drug at baseline was associated with an increase in the hazard for hospitalisation for falls, hypoglycaemia and death but not for DKA admissions (HR [95% CI]: falls 1.03 [1.01, 1.06]; DKA 1.01 [1.00, 1.03]; hypoglycaemia 1.05 [1.02, 1.07]; death 1.04 [1.02, 1.06]). We found a number of drug classes to be associated with an increased hazard of one or more of these adverse health outcomes, including antithrombotic/anticoagulant agents, corticosteroids, opioids, antiepileptics, antipsychotics, hypnotics and sedatives, and antidepressants.

CONCLUSIONS

Polypharmacy is common among the Scottish population with type 1 diabetes and is strongly patterned by sociodemographic factors. The number of prescribed drugs and the prescription of particular high-risk drug classes are strong markers of an increased risk of adverse health outcomes, including acute complications of diabetes.

The rise in the number of long-term survivors from different diseases can slow the increase in life expectancy of the total population

Background

Recent improvements in life expectancy in many countries stem from reduced mortality from cardiovascular disease and cancer above the age of 60. This is the combined result of decreased incidence and improved survival among those with disease. The latter has led to a higher proportion in the population of people with a past history of disease. This is a group with higher mortality than the general population. How growing shares of persons with past history of disease and improved survival with disease have affected changes in life expectancy of the total population is the objective of this paper.

Methods

Using register data for the total Swedish population, we stratified the population based on whether individuals have been diagnosed with myocardial infarction, stroke, hip fracture, colon cancer, or breast cancer. Using a novel decomposition approach, we decomposed the changes in life expectancy at age 60 between 1994 and 2016 into contributions from improved survival with disease and from changes in proportion of people with past history of disease.

Results

Improvements in survival from disease resulted in gains of life expectancy for the total population. However, while the contributions to life expectancy improvements from myocardial infarction, stroke and breast cancer were substantial, the contributions from the other diseases were minor. These gains were counteracted, to various degrees, by the increasing proportion of people with raised mortality due to a past history of disease. For instance, the impact on life expectancy by improved survival from breast cancer was almost halved by the increasing share of females with a past history of breast cancer.

Conclusion

Rising numbers of survivors of different diseases can slow the increase in life expectancy. This dynamic may represent the costs associated with successful treatment of diseases, and thus, a potential “failure of success.” This dynamic should be considered when assessing mortality and life expectancy trends. As populations are aging and disease survival continues to improve, this issue is likely to become even more important in the future.

Type 1 diabetes management and outcomes: A multicenter study in Thailand

Aims/Introduction

The Thai Type 1 Diabetes and Diabetes Diagnosed Before Age 30 Years Registry, Care and Network was established in 2014 and involved 31 hospitals. The objective of the registry was to evaluate glycemic control and complications of patients with type 1 diabetes.

Materials and Methods

Patients’ demographics, clinical data, frequencies of daily self‐monitoring of blood glucose (SMBG), glycemic control and complications were collected.

Results

Among the 1,907 type 1 diabetes patients, the mean age was 21.2 ± 11.3 years. The mean glycated hemoglobin level was 9.35 ± 2.41%, with significant variations among age groups (P < 0.001). Conventional insulin treatment and intensive insulin treatment were used in 43 and 57% of patients, respectively. Mean glycated hemoglobin levels were significantly higher in patients treated with conventional insulin treatment compared to those treated with intensive insulin treatment (9.63 ± 2.34 vs 9.17 ± 2.46%, P = 0.002). Compared to the conventional insulin treatment group, significantly more patients in the intensive insulin treatment group achieved good glycemic control (P < 0.001), and fewer had diabetic retinopathy (P = 0.031). The prevalence of microvascular complications increased significantly with age (P < 0.001). Multivariate analysis showed good glycemic control to be associated with age 25 to <45 years, intensive insulin treatment with SMBG three or more times daily and diabetes duration of 1 to <5 years.

Conclusions

Most Thai type 1 diabetes patients were not meeting the recommended glycemic target. As a result of this study, the national program to improve the quality of diabetes treatment and education has been implemented, and the results are ongoing.

Evaluation of cardiovascular risk in adults with type 1 diabetes: poor concordance between the 2019 ESC risk classification and 10-year cardiovascular risk prediction according to the Steno Type 1 Risk Engine

BACKGROUND

Patients with type 1 diabetes (T1D) have higher mortality risk compared to the general population; this is largely due to increased rates of cardiovascular disease (CVD). As accurate CVD risk stratification is essential for an appropriate preventive strategy, we aimed to evaluate the concordance between 2019 European Society of Cardiology (ESC) CVD risk classification and the 10-year CVD risk prediction according to the Steno Type 1 Risk Engine (ST1RE) in adults with T1D.

METHODS

A cohort of 575 adults with T1D (272F/303M, mean age 36 ± 12 years) were studied. Patients were stratified in different CVD risk categories according to ESC criteria and the 10-year CVD risk prediction was estimated with ST1RE within each category.

RESULTS

Men had higher BMI, WC, SBP than women, while no difference was found in HbA1c levels between genders. According to the ESC classification, 92.5% of patients aged < 35 years and 100% of patients ≥ 35 years were at very high/high risk. Conversely, using ST1RE to predict the 10-year CVD risk within each ESC category, among patients at very high risk according to ESC, almost all (99%) had a moderate CVD risk according to ST1RE if age < 35 years; among patients aged ≥35 years, the majority (59.1%) was at moderate risk and only 12% had a predicted very high risk by ST1RE. The presence of target organ damage or three o more CV risk factors, or early onset T1D of long duration (> 20 years) alone identified few patients (< 30%) among those aged ≥35 years, who were at very high risk according to ESC, in whom this condition was confirmed by ST1RE; conversely, the coexistence of two or more of these criteria identified about half of the patients at high/very high risk also according to this predicting algorithm. When only patients aged ≥ 50 years were considered, there was greater concordance between ESC classification and ST1RE prediction, since as many as 78% of those at high/very high risk according to ESC were confirmed as such also by ST1RE.

CONCLUSIONS

Using ESC criteria, a large proportion (45%) of T1D patients without CVD are classified at very high CVD risk; however, among them, none of those < 35 years and only 12% of those ≥ 35 years could be confirmed at very high CVD risk by the ST1RE predicting algorithm. More studies are needed to characterize the clinical and metabolic features of T1D patients that identify those at very high CVD risk, in whom a very aggressive cardioprotective treatment would be justified.

Global, regional, and national burden and trend of diabetes in 195 countries and territories: an analysis from 1990 to 2025

Diabetes mellitus is a leading cause of mortality and reduced life expectancy. We aim to estimate the burden of diabetes by type, year, regions, and socioeconomic status in 195 countries and territories over the past 28 years, which provide information to achieve the goal of World Health Organization Global Action Plan for the Prevention and Control of Noncommunicable Diseases in 2025. Data were obtained from the Global Burden of Disease Study 2017. Overall, the global burden of diabetes had increased significantly since 1990. Both the trend and magnitude of diabetes related diseases burden varied substantially across regions and countries. In 2017, global incidence, prevalence, death, and disability-adjusted life-years (DALYs) associated with diabetes were 22.9 million, 476.0 million, 1.37 million, and 67.9 million, with a projection to 26.6 million, 570.9 million, 1.59 million, and 79.3 million in 2025, respectively. The trend of global type 2 diabetes burden was similar to that of total diabetes (including type 1 diabetes and type 2 diabetes), while global age-standardized rate of mortality and DALYs for type 1 diabetes declined. Globally, metabolic risks (high BMI) and behavioral factors (inappropriate diet, smoking, and low physical activity) contributed the most attributable death and DALYs of diabetes. These estimations could be useful in policy-making, priority setting, and resource allocation in diabetes prevention and treatment.

Time trends in deaths before age 50 years in people with type 1 diabetes: a nationwide analysis from Scotland 2004-2017

AIMS/HYPOTHESIS

We aimed to examine whether crude mortality and mortality relative to the general population below 50 years of age have improved in recent years in those with type 1 diabetes.

METHODS

Individuals with type 1 diabetes aged below 50 and at least 1 year old at any time between 2004 and 2017 in Scotland were identified using the national register. Death data were obtained by linkage to Scottish national death registrations. Indirect age standardisation was used to calculate sex-specific standardised mortality ratios (SMRs). Poisson regression was used to test for calendar-time effects as incidence rate ratios (IRRs).

RESULTS

There were 1138 deaths in 251,143 person-years among 27,935 people with type 1 diabetes. There was a significant decline in mortality rate over time (IRR for calendar year 0.983 [95% CI 0.967, 0.998], p = 0.03), but the SMR remained approximately stable at 3.1 and 3.6 in men and 4.09 and 4.16 in women for 2004 and 2017, respectively. Diabetic ketoacidosis or coma (DKAoC) accounted for 22% of deaths and the rate did not decline significantly (IRR 0.975 [95% CI 0.94, 1.011], p = 0.168); 79.3% of DKAoC deaths occurred out of hospital. Circulatory diseases accounted for 27% of deaths and did decline significantly (IRR 0.946 [95% CI 0.914, 0.979], p = 0.002).

CONCLUSIONS/INTERPRETATION

Absolute mortality has fallen, but the relative impact of type 1 diabetes on mortality below 50 years has not improved. There is scope to improve prevention of premature circulatory diseases and DKAoC and to develop more effective strategies for enabling people with type 1 diabetes to avoid clinically significant hyper- or hypoglycaemia. Graphical abstract.

A Patient-Level Model to Estimate Lifetime Health Outcomes of Patients With Type 1 Diabetes

OBJECTIVE

To develop a patient-level simulation model for predicting lifetime health outcomes of patients with type 1 diabetes and as a tool for economic evaluation of type 1 diabetes treatment based on data from a large, longitudinal cohort.

RESEARCH DESIGN AND METHODS

Data for model development were obtained from the Swedish National Diabetes Register. We derived parametric proportional hazards models predicting the absolute risk of diabetes complications and death based on a wide range of clinical variables and history of complications. We used linear regression models to predict risk factor progression. Internal validation was performed, estimates of life expectancies for different age-sex strata were computed, and the impact of key risk factors on life expectancy was assessed.

RESULTS

The study population consisted of 27,841 patients with type 1 diabetes with a mean duration of follow-up of 7 years. Internal validation showed good agreement between the predicted and observed cumulative incidence of death and 10 complications. Simulated life expectancy was ∼13 years lower than that of the sex- and age-matched general population, and patients with type 1 diabetes could expect to live with one or more complications for ∼40% of their remaining life. Sensitivity analysis showed the importance of preventing renal dysfunction, hypoglycemia, and hyperglycemia as well as lowering HbA_1c in reducing the risk of complications and death.

CONCLUSIONS

Our model was able to simulate risk factor progression and event histories that closely match the observed outcomes and to project events occurring over patients' lifetimes. The model can serve as a tool to estimate the impact of changing clinical risk factors on health outcomes to inform economic evaluations of interventions in type 1 diabetes.

Lipid Biomarkers as Predictors of Diastolic Dysfunction in Diabetes with Poor Glycemic Control

Uncontrolled type-1 diabetes (T1DM) can lead to dyslipidaemia and albuminuria, which may promote cardiovascular injuries. However, some lipidemic factors could be useful in predicting cardiac dysfunction. Seventy-eight adolescents under insulin treatment due to a 6-year history of T1DM and were retrospectively examined. Glycemia, lipidemia, and albuminuria were measured in addition to development of cardiovascular abnormalities Both girls and boys showed higher HbA1c and fasting blood glucose and 27.1% females and 33.3% males exhibited microalbuminuria though their plasma levels of total cholesterol (TC), triglycerides (TG), and low-density lipoproteins (LDL) and high-density lipoproteins (HDL lipoproteins were in the normal range. They exhibited a preserved systolic function, but 50% of females and 66.6% of males had developed diastolic failures. Interestingly, girls with diastolic dysfunction showed significantly lower concentrations of HDL and higher TC/HDL and TG/HDL ratios. In fact, low HDL levels (OR 0.93; 95% CI 0.88-0.99; p = 0.029) and high TC/HDL (OR 2.55; 95% CI 1.9-5.45; p = 0.016) and TG/HDL (OR 2.74; 95% CI 1.12-6.71; p = 0.028) ratios associated with the development of diastolic complications. The cut-off values for HDL, TC/HDL, and TG/HDL were 49 mg/dL, 3.0 and 1.85, respectively. HDL and TC/HDL and TG/HDL ratios may be useful for predicting diastolic dysfunction in girls with uncontrolled T1DM.

Tau, Diabetes and Insulin

Tau protein which was discovered in 1975 [310] became of great interest when it was identified as the main component of neurofibrillary tangles (NFT), a pathological feature in the brain of patients with Alzheimer's disease (AD) [39, 110, 232]. Tau protein is expressed mainly in the brain as six isoforms generated by alternative splicing [46, 97]. Tau is a microtubule associated proteins (MAPs) and plays a role in microtubules assembly and stability, as well as diverse cellular processes such as cell morphogenesis, cell division, and intracellular trafficking [49]. Additionally, Tau is involved in much larger neuronal functions particularly at the level of synapses and nuclei [11, 133, 280]. Tau is also physiologically released by neurons [233] even if the natural function of extracellular Tau remains to be uncovered (see other chapters of the present book).

lillies: An R package for the estimation of excess Life Years Lost among patients with a given disease or condition

Life expectancy at a given age is a summary measure of mortality rates present in a population (estimated as the area under the survival curve), and represents the average number of years an individual at that age is expected to live if current age-specific mortality rates apply now and in the future. A complementary metric is the number of Life Years Lost, which is used to measure the reduction in life expectancy for a specific group of persons, for example those diagnosed with a specific disease or condition (e.g. smoking). However, calculation of life expectancy among those with a specific disease is not straightforward for diseases that are not present at birth, and previous studies have considered a fixed age at onset of the disease, e.g. at age 15 or 20 years. In this paper, we present the R package lillies (freely available through the Comprehensive R Archive Network; CRAN) to guide the reader on how to implement a recently-introduced method to estimate excess Life Years Lost associated with a disease or condition that overcomes these limitations. In addition, we show how to decompose the total number of Life Years Lost into specific causes of death through a competing risks model, and how to calculate confidence intervals for the estimates using non-parametric bootstrap. We provide a description on how to use the method when the researcher has access to individual-level data (e.g. electronic healthcare and mortality records) and when only aggregated-level data are available.

Acute Responses to Low and High Intensity Exercise in Type 1 Diabetic Adolescents in Relation to Their Level of Serum 25(OH)D

The main purpose of this study was to investigate the differences in glycaemic reaction in response to various physical activities in 20 young boys (14.4 ± 1.6 years) with type 1 diabetes mellitus (T1DM) and with either vitamin D deficiency or with suboptimal levels of vitamin D. Participants were divided into two groups (deficiency group-DG, n = 10; suboptimal group-SG, n = 10) according to their vitamin D levels. All patients performed aerobic and mixed (aerobic-anaerobic) physical efforts. During the exercise, the respiratory responses and glucose levels were monitored. Biochemical blood analyses were performed before each physical effort. The oxygen consumption was not significantly lower in SG during both aerobic and mixed effort (4.0% and 5.6%, respectively). The glycated haemoglobin (HbA1c) level was higher by 6.1% and the total daily dose of insulin (DDI) was higher by 18.4% in the DG. The differences were not statistically significant. Patients with lower vitamin D levels demonstrated an insignificantly higher glycaemic variability during days with both aerobic and mixed exercises. An appropriate vitamin D concentration in T1DM patients' blood may constitute a prophylactic factor for hyperglycaemia during anaerobic training and hypoglycaemia during aerobic training.

Standard mortality rates and years of life lost for serologically defined adult-onset type 1 and type 2 diabetes - A fifteen year follow-up

AIMS

The Diabetes Incidence in Kronoberg (DIK) study of adult-onset diabetes used serological classification. Standard Mortality Rates (SMR) and Years of Life Lost (YLL) 15 years after adult-onset (18-100 years) of diabetes were compared to the population of Kronoberg.

METHODS

Of 1609/1660 (97%) patients, 112 (7%) had type 1 (T1D) (GADA⁺ and/or ICA⁺, and/or C-peptide < 0.25 nmol/l), and 1497 (93%) had type 2 diabetes (T2D) (antibody^- and C-peptide ≥ 0.25 nmol/l). The National Swedish Mortality Register provided time of death.

RESULTS

For T1D SMR did not differ from the Kronoberg population in any age group. In T2D SMR was 1.20 (1.12-1.29). After 15 years 26% (29/112) T1D and 52% (785/1497) T2D patients had died, p < 0.0001. In T2D SMR was 5.6 (30-39 years), 2 (40-59 years), 1.4 (60-69 years), and thereafter no difference. There were no significant sex differences in mortality, and no YLL to adult-onset T1D, but five YLL to T2D for onset at ages 20-60 years.

CONCLUSIONS

For adult-onset T1D SMR did not differ from the general population, in contrast to previous findings in childhood-onset (< 30 years of age) T1D. The difference in mortality between persons with diabetes and the general population was due to higher mortality in T2D.

Investigation of early signs of systolic and diastolic dysfunction among persons with type 1 diabetes

Background

Persons with type 1 diabetes have a higher risk to develop heart failure than the general population, and the mechanism behind the increased risk is unclear. In epidemiological studies with hospitalisation for heart failure as endpoint HbA1c, body mass index and decreased kidney function are significant risk factors, but it is unclear how these risk factors influence the development of heart failure.

Methods

In this study, we investigated early signs of systolic and diastolic dysfunction with transthoracic echocardiography. Statistical analysis on correlation of risk factors and early signs of diastolic and systolic dysfunction was made.

Results

In this study population of 287 persons with type 1 diabetes, 160 were men and 127 were women with a mean age of 53.8 (SD 11.6) years and a mean diabetes duration of 36.2 (SD 13.5) years. There were 23 (8.2%) persons who fulfilled the definition of systolic dysfunction (ejection fraction <50% or regional wall motion abnormalities) and 24 persons (9%) the definition for diastolic dysfunction. When comparing the groups with either systolic or diastolic dysfunction to the rest of the population, the only significant risk factor was age in both groups and previous myocardial infarction in the systolic group.

Conclusion

In our study population with type 1 diabetes, we found signs of diastolic dysfunction in 9% and systolic dysfunction in 8.2%. Compared with published data from the general population, this rate is somewhat higher in a younger population. Only age was a significant risk factor in the study.

The Challenges of Identifying Environmental Determinants of Type 1 Diabetes: In Search of the Holy Grail

Type 1 diabetes is the result of autoimmune-mediated destruction and inflammation of the insulin-producing β-cells of the pancreas. The excess morbidity and mortality from its complications coupled with its increasing incidence emphasize the importance to better understand the etiology of this condition. It has a strong genetic component, but a genetic predisposition is not the sole contributor to disease development as only 30% to 50% of identical twins both develop the disease. In addition, there are multiple lines of evidence to support that environmental factors contribute to the pathogenesis of type 1 diabetes. Environmental risk factors that have been proposed include infections, dietary factors, air pollution, vaccines, location of residence, childhood obesity, family environment and stress. Researchers have conducted many observational studies to identify and characterize these potential environmental factors, but findings have been inconsistent or inconclusive. Many studies have had inherent methodological issues in recruitment, participation, defining cases and exposures, and/or data analysis which may limit the interpretability of findings. Identifying and addressing these limitations may allow for greatly needed advances in our understanding of type 1 diabetes. As such, the purpose of this article is to review and discuss the limitations of observational studies that aim to determine environmental risk factors for type 1 diabetes and propose recommendations to overcome them.

Cognitive dysfunction in diabetes: how to implement emerging guidelines

Cognitive dysfunction, including mild cognitive impairment and dementia, is increasingly recognised as an important comorbidity and complication of diabetes that affects an individual's well-being and diabetes management, and is associated with diabetes treatment-related complications. Recent guidelines therefore recommend screening for cognitive impairment in older individuals with diabetes. In addition, these guidelines suggest that glucose-lowering treatment should be tailored in those diagnosed with cognitive impairment, to reduce the risk of hypoglycaemia and improve treatment adherence. This review gives an overview of cognitive dysfunction in people with diabetes, briefly describing the clinical features of different stages of cognitive dysfunction and their epidemiology. In particular, it addresses essential additional steps that need to be taken to fully implement the emerging guidelines on screening and management of cognitive dysfunction in diabetes into daily practice.

Locus of Control and Cognition in Older Adults With Type 1 Diabetes: Evidence For Sex Differences From the Study of Longevity in Diabetes (SOLID)

OBJECTIVE

Life expectancy for individuals with type 1 diabetes mellitus (T1DM) has increased recently; however, it is unknown how diabetes care attitudes affect late-life brain health.

RESEARCH DESIGN AND METHODS

The Study of Longevity in Diabetes (SOLID) consists of 734 older adults with T1DM, reporting diabetes locus of control (dLOC), age of diabetes diagnosis and other demographics, history of hypoglycemic episodes, and depressive symptoms. Global and domain-specific (language, executive function, episodic memory, simple attention) cognitive functioning was assessed at in-person interviews. Cross-sectional associations between dLOC and cognition were estimated using covariate-adjusted linear regression models in pooled and sex-stratified models.

RESULTS

In pooled analyses, a 1-point increase in dLOC (more internal) was positively associated with global cognition [β=0.05, 95% confidence interval (CI): 0.02, 0.07], language (β=0.04, 95% CI: 0.01, 0.07), and executive function (β=0.04, 95% CI: 0.01, 0.07), but not episodic memory or simple attention. However, in sex-stratified analyses, this effect was seen only in males and not females.

CONCLUSIONS

In elderly individuals with T1DM, we found associations between dLOC and cognition overall and in men but not women. Underlying sex differences should be considered in future research or interventions on psychosocial characteristics for cognition.