Burden of diabetes in Australia: life expectancy and disability-free life expectancy in adults with diabetes

Sodium-glucose cotransporter 2 inhibitors and renin-angiotensin-aldosterone system, possible cellular interactions and benefits

Sodium glucose cotransporter 2 inhibitors (SGLT2is) are a newly developed class of anti-diabetics which exert potent hypoglycemic effects in the diabetic milieu. However, the evidence suggests that they also have extra-glycemic effects. The renin-angiotensin-aldosterone system (RAAS) is a hormonal system widely distributed in the body that is important for water and electrolyte homeostasis as well as renal and cardiovascular function. Therefore, modulating RAAS activity is a main goal in patients, notably diabetic patients, which are at higher risk of complications involving these organ systems. Some studies have suggested that SGLT2is have modulatory effects on RAAS activity in addition to their hypoglycemic effects and, thus, these drugs can be considered as promising therapeutic agents for renal and cardiovascular disorders. However, the exact molecular interactions between SGLT2 inhibition and RAAS activity are not clearly understood. Therefore, in the current study we surveyed the literature for possible molecular mechanisms by which SGLT2is modulate RAAS activity.

Systematic review of the effectiveness of nurse-led care in reducing glycated haemoglobin in adults with Type 1 or 2 diabetes

BACKGROUND

Type 1 and 2 diabetes care, especially within primary health-care settings, has traditionally involved doctor-led clinics. However, with increasing chronic disease burden, there is scope for nurses to expand their role in assisting diabetes self-management.

AIMS

This study aimed to determine the effectiveness of nurse-led care in reducing glycated haemoglobin in adults with Type 1 or 2 diabetes.

METHODS

Methodology from the Joanna Briggs Institute Method for Systematic Review Research and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, including identifying publications, assessing study quality, summarizing evidence and interpreting findings. The search strategy involved using the Medical Subject Headings and keyword variations when searching MEDLINE (Ovid), Scopus, PubMed and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Inclusion criteria were samples with Type 1 or 2 diabetes, mean age of ≥18 years, English language studies and publication date of January 2011-December 2021.

RESULTS

Overall, 34 articles from 16 countries met inclusion criteria. Though not always clinically significant, results indicated that nurse-led care had beneficial impacts on glycated haemoglobin values, with reductions from 0.03% to 2.0%. This was evident when nurses received formal training, used treatment algorithms, had limited medical support, utilized technology and offered defined culturally sensitive and appropriate diabetes care.

CONCLUSIONS

Findings support nurse-led Type 1 and 2 diabetes care. Although further research is required, changes may necessitate increased recognition of nurse-led care and funding. Nurse-led care models should differ according to health-care settings.

Prediabetes, diabetes and loss of disability-free survival in a community-based older cohort: a post-hoc analysis of the ASPirin in Reducing Events in the Elderly trial

BACKGROUND

Evidence for the prognostic implications of hyperglycaemia in older adults is inconsistent.

OBJECTIVE

To evaluate disability-free survival (DFS) in older individuals by glycaemic status.

METHODS

This analysis used data from a randomised trial recruiting 19,114 community-based participants aged ≥70 years, who had no prior cardiovascular events, dementia and physical disability. Participants with sufficient information to ascertain their baseline diabetes status were categorised as having normoglycaemia (fasting plasma glucose [FPG] < 5.6 mmol/l, 64%), prediabetes (FPG 5.6 to <7.0 mmol/l, 26%) and diabetes (self-report or FPG ≥ 7.0 mmol/l or use of glucose-lowering agents, 11%). The primary outcome was loss of disability-free survival (DFS), a composite of all-cause mortality, persistent physical disability or dementia. Other outcomes included the three individual components of the DFS loss, as well as cognitive impairment-no dementia (CIND), major adverse cardiovascular events (MACE) and any cardiovascular event. Cox models were used for outcome analyses, with covariate adjustment using inverse-probability weighting.

RESULTS

We included 18,816 participants (median follow-up: 6.9 years). Compared to normoglycaemia, participants with diabetes had greater risks of DFS loss (weighted HR: 1.39, 95% CI 1.21-1.60), all-cause mortality (1.45, 1.23-1.72), persistent physical disability (1.73, 1.35-2.22), CIND (1.22, 1.08-1.38), MACE (1.30, 1.04-1.63) and cardiovascular events (1.25, 1.02-1.54) but not dementia (1.13, 0.87-1.47). The prediabetes group did not have an excess risk for DFS loss (1.02, 0.93-1.12) or other outcomes.

CONCLUSIONS

Among older people, diabetes was associated with reduced DFS, and higher risk of CIND and cardiovascular outcomes, whereas prediabetes was not. The impact of preventing or treating diabetes in this age group deserves closer attention.

Impact of diabetes on longevity and disability-free life expectancy among older South African adults: A prospective longitudinal analysis

AIMS

We seek to understand the coexisting effects of population aging and a rising burden of diabetes on healthy longevity in South Africa.

METHODS

We used longitudinal data from the 2015 and 2018 waves of the "Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa" (HAALSI) study to explore life expectancy (LE) and disability-free life expectancy (DFLE) of adults aged 45 and older with and without diabetes in rural South Africa. We estimated LE and DFLE by diabetes status using Markov-based microsimulation.

RESULTS

We find a clear gradient in remaining LE and DFLE based on diabetes status. At age 45, a man without diabetes could expect to live 7.4 [95% CI 3.4 - 11.7] more years than a man with diabetes, and a woman without diabetes could expect to live 3.9 [95% CI: 0.8 - 6.9] more years than a woman with diabetes. Individuals with diabetes lived proportionately more years subject to disability than individuals without diabetes.

CONCLUSIONS

We find large and important decrements in disability-free aging for people with diabetes in South Africa. This finding should motivate efforts to strengthen prevention and treatment efforts for diabetes and its complications for older adults in this setting.

[Diabetes mellitus, coronary artery disease and heart disease (Update 2023)]

Diabetes mellitus, cardiovascular disease and heart failure are interacting dynamically. Patients being diagnosed with cardiovascular disease should be screened for diabetes mellitus. Enhanced cardiovascular risk stratification based on biomarkers, symptoms and classical risk factors should be performed in patients with preexisting diabetes mellitus. In patients with previously diagnosed arterosclerotic cardiovascular disease an agent proven to reduce major adverse cardiovascular events or cardiovascular mortality is recommended.

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.

Effect of diabetes and prediabetes on the development of disability and mortality among middle-aged adult Japanese: a 22-year follow-up of NIPPON DATA90

Aims/Introduction

To examine the association between diabetes and prediabetes at baseline, and disability, mortality over a 22‐year period among middle‐aged Japanese adults.

Materials and Methods

Participants consisted of 1,788 adults aged 45–64 years at baseline from the cohort study National Integrated Project for Prospective Observation of Non‐communicable Disease and its Trends in the Aged 1990 (NIPPON DATA90). Disability, defined as having a decline in activities of daily living (ADL), was assessed by a modified Katz questionnaire at four time points. Disability and death without disability for 22‐year follow up were used as outcomes to test the association with a diagnosis of diabetes or prediabetes at baseline, using multinomial logistic regression. Adjusted odds ratios (ORs) were obtained from four models that contained appropriate adjustment factors, such as age, sex, smoking status, drinking status, body mass index and cardiovascular risk factors (hypertension, hypercholesterolemia, triglycerides, low serum high‐density lipoprotein), at baseline.

Results

In the present study, 334 participants (18.7%) reported at least one disability, and 350 (19.6%) were reported dead without observation of disability during follow up. Adjusting sex and other risk factors, participants with diabetes and prediabetes had a higher risk for disability (OR 1.43, 95% confidence interval [CI] 1.07–1.91 and OR 1.66, 95% CI 1.10–2.50, respectively) and for mortality (OR 1.56, 95% CI 1.16–2.08 and OR 1.77, 95% CI 1.18–2.65, respectively) than individuals with normal glucose tolerance.

Conclusions

In middle‐aged Japanese adults, individuals with diabetes and prediabetes were more likely to be associated with disability and mortality. Our findings suggest that prediabetes and diabetes in middle‐aged adults should be paid more attention, and requires more intervention to prevent disability and mortality in later life.

Biochemical mechanism underlying the pathogenesis of diabetic retinopathy and other diabetic complications in humans: the methanol-formaldehyde-formic acid hypothesis

Hyperglycemia in diabetic patients is associated with abnormally-elevated cellular glucose levels. It is hypothesized that increased cellular glucose will lead to increased formation of endogenous methanol and/or formaldehyde, both of which are then metabolically converted to formic acid. These one-carbon metabolites are known to be present naturally in humans, and their levels are increased under diabetic conditions. Mechanistically, while formaldehyde is a cross-linking agent capable of causing extensive cytotoxicity, formic acid is an inhibitor of mitochondrial cytochrome oxidase, capable of inducing histotoxic hypoxia, ATP deficiency and cytotoxicity. Chronic increase in the production and accumulation of these toxic one-carbon metabolites in diabetic patients can drive the pathogenesis of ocular as well as other diabetic complications. This hypothesis is supported by a large body of experimental and clinical observations scattered in the literature. For instance, methanol is known to have organ- and species-selective toxicities, including the characteristic ocular lesions commonly seen in humans and non-human primates, but not in rodents. Similarly, some of the diabetic complications (such as ocular lesions) also have a characteristic species-selective pattern, closely resembling methanol intoxication. Moreover, while alcohol consumption or combined use of folic acid plus vitamin B is beneficial for mitigating acute methanol toxicity in humans, their use also improves the outcomes of diabetic complications. In addition, there is also a large body of evidence from biochemical and cellular studies. Together, there is considerable experimental support for the proposed hypothesis that increased metabolic formation of toxic one-carbon metabolites in diabetic patients contributes importantly to the development of various clinical complications.

Healthy behaviours, leisure activities, and social network prolong disability-free survival in older adults with diabetes

Background

Diabetes has been related to disability and excess mortality. We estimated the extent to which diabetes shortens disability-free survival and identified modifiable factors that may prolong disability-free survival in older adults with diabetes.

Methods

Disability-free older adults (n = 2 216, mean age: 71 years, female: 61%) were followed for up to 15 years. Diabetes was ascertained through medical examinations, medication use, or glycated hemoglobin ≥6.5% (48 mmol/mol). Disability-free survival was defined as survival until the occurrence of disability. A favorable (vs unfavorable) lifestyle profile was defined as the presence of at least 1 of the following: healthy (vs unhealthy) behaviors, active (vs inactive) engagement in leisure activities, or moderate-to-rich (vs poor) social network. Data were analyzed using Cox regression and Laplace regression.

Results

During the follow-up, 1 345 (60.7%) participants developed disability or died. Diabetes, but not prediabetes, was related to the outcome (hazard ratio [HR] 1.29, 95% CI 1.06–1.57), and 2.15 (1.02–3.27) years shorter median disability-free survival. In joint exposure analysis, disability-free survival was shortened by 3.29 (1.21–5.36), 3.92 (2.08–5.76), and 1.66 (0.06–3.28) years for participants with diabetes plus unhealthy behaviors, inactive engagement in leisure activities, or poor social network. Among participants with diabetes, a favorable profile led to a nonsignificant HR of 1.19 (0.93–1.56) for disability/death and prolonged disability-free survival by 3.26 (2.33–4.18) years compared to those with an unfavorable profile.

Conclusions

A healthy and socially active lifestyle may attenuate the risk of diabetes on disability or death and prolong disability-free survival among people with diabetes.

A century past the discovery of insulin: global progress and challenges for type 1 diabetes among children and adolescents in low-income and middle-income countries

Type 1 diabetes is on the rise globally; however, the burden of mortality remains disproportionate in low-income and middle-income countries (LMICs). As 2021 marks 100 years since the discovery of insulin, we revisit progress, global burden of type 1 diabetes trends, and understanding of the pathogenesis and management practices related to the disease. Despite much progress, inequities in access and availability of insulin formulations persist and are reflected in differences in survival and morbidity patterns related to the disease. Some of these inequities have also been exacerbated by health-system challenges during the COVID-19 pandemic. There is a clear opportunity to improve access to insulin and related essential technologies for improved management of type 1 diabetes in LMICs, especially as a part of universal health coverage. These improvements will require concerted action and investments in human resources, community engagement, and education for the timely diagnosis and management of type 1 diabetes, as well as adequate health-care financing. Further research in LMICs, especially those in Africa, is needed to improve our understanding of the burden, risk factors, and implementation strategies for managing type 1 diabetes.

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.

Disability trajectories prior to death for ten leading causes of death among middle-aged and older adults in Taiwan

BACKGROUND

Prolonged life expectancy is associated with increased prevalence of chronic diseases. The aim of this study was to determine the different disability trajectories for the top ten leading causes of death in Taiwan .

METHODS

A total of 2,431 participants aged 50-96 in 1996 from the Taiwan longitudinal study on aging (TLSA) who died from 1996 to 2016 were analyzed. Integration of Cause of Death Data and TLSA helped sort out participants who had died from the ten leading causes of death. The level of physical disability was evaluated with the Activities of Daily Living Scale (ADLs), ranging from 0 to 6 points, in 1996, 1999, 2003, 2007, and 2011. A multilevel model was used to investigate the levels and rates of change in disability development before death.

RESULTS

The outcome of the research showed that the earliest group to experience physical limitation was individuals living with diabetes. The groups with the highest ADL scores were participants with diabetes, cerebrovascular disease, and hypertension-related diseases. Most groups reach ADL scores ≥ 1 (mild-level) during 4-6 years before death except chronic hepatitis and cirrhosis and injury.

CONCLUSIONS

People who had died from the ten leading causes of death experienced different disability trajectories before death. The trajectory of the participants who had died from diabetes showed a unique pattern with the earliest occurrence and more severe deterioration in terms of development of disabilities. Disability trajectories provide a prediction of survival status for middle-aged and older adults associated with the ten leading causes of death.

Associations with sight-threatening diabetic macular oedema among Indigenous adults with type 2 diabetes attending an Indigenous primary care clinic in remote Australia: a Centre of Research Excellence in Diabetic Retinopathy and Telehealth Eye and Associated Medical Services Network study

Objective

To identify factors associated with sight-threatening diabetic macular oedema (STDM) in Indigenous Australians attending an Indigenous primary care clinic in remote Australia.

Methods and analysis

A cross-sectional study design of retinopathy screening data and routinely-collected clinical data among 236 adult Indigenous participants with type 2 diabetes (35.6% men) set in one Indigenous primary care clinic in remote Australia. The primary outcome variable was STDM assessed from retinal images.

Results

Age (median (range)) was 48 (21–86) years, and known diabetes duration (median (range)) was 8.0 (0–24) years. Prevalence of STDM was high (14.8%) and similar in men and women. STDM was associated with longer diabetes duration (11.7 vs 7.9 years, respectively; p<0.001) and markers of renal impairment: abnormal estimated Glomerular Filtration Rate (eGFR) (62.9 vs 38.3%, respectively; p=0.007), severe macroalbuminuria (>300 mg/mmol) (20.6 vs 5.7%, respectively; p=0.014) and chronic kidney disease (25.7 vs 12.2%, respectively; p=0.035). Some clinical factors differed by sex: anaemia was more prevalent in women. A higher proportion of men were smokers, prescribed statins and had increased albuminuria. Men had higher blood pressure, but lower glycated Haemoglobin A1c (HbA1c) levels and body mass index, than women.

Conclusion

STDM prevalence was high and similar in men and women. Markers of renal impairment and longer diabetes duration were associated with STDM in this Indigenous primary care population. Embedded teleretinal screening, known diabetes duration-based risk stratification and targeted interventions may lower the prevalence of STDM in remote Indigenous primary care services.

Trial registration number

Australia and New Zealand Clinical Trials Register: ACTRN 12616000370404.

Impact of Diabetes on Life and Healthy Life Expectancy Among Older Women

BACKGROUND

Diabetes is a major chronic condition with ever-increasing health and economic burden. This study aimed to measure the impact of diabetes on total life expectancy (TLE) and healthy life expectancy (HLE) at ages 70 and 80 and to assess how educational level, obesity, and comorbidity affected the expectancies.

METHODS

The study involved 9849 population-representative women born between 1921 and 1926 from the Australian Longitudinal Study on Women's Health (ALSWH). Self-rated health was obtained from the ALSWH surveys. Diabetes diagnosis was ascertained using survey and health care administrative data. Total life expectancy and HLE were estimated for women with and without diabetes using multistate modeling.

RESULTS

Diabetes was associated with an increased risk of poor health (adjusted risk ratio: 1.63, 95% confidence interval: 1.49-1.79). Diabetes was also associated with a reduction of 0.9 years in HLE and 2.6 years in TLE at age 70 and 0.4 years in HLE and 1.3 years in TLE at age 80. If a woman had low education, obesity, and more than 2 comorbidities in addition to diabetes, these reductions increased to 3.0 years in TLE and 7.9 years in HLE at age 70 and 1.5 years in TLE and 3.8 years in HLE at age 80.

CONCLUSIONS

Diabetes substantially reduced older women's quantity and quality of life, with further reductions for those with lower education, obesity, and comorbidities. These findings underscore the importance of optimally managing diabetes by maintaining a healthy weight and delaying the onset of comorbidities, to promote healthy aging for older women with diabetes.

Effects of Body Mass Index and Pay-for-Performance Program on Risk of Death in Patients with Type 2 Diabetes: A Nationwide Cohort Study

Background: The diabetes patients enrolled in the pay-for-performance (P4P) program demonstrate reduced risk of death. Body mass index (BMI) is a risk factor of all-cause death. This study investigates the effects of BMI and P4P on the risk of death in type 2 diabetes patients. Methods: This is a retrospective cohort study. The study population includes the 3-wave National Health Interview Survey in Taiwan. A total of 6354 patients with diabetes aged ≥ 20 years were enrolled and followed up until the end of 2014. Results: The highest mortality rate per 1000 person-years was 61.05 in the underweight patients with diabetes. A lower crude death rate was observed in the P4P participants than non-P4P participants. The risk of death was 1.86 times higher in the underweight patients with diabetes than that in the normal weight group (95% CI: 1.37–2.53) and was lower in the P4P participants, as compared to the non-participants (HR: 0.55, 95% CI: 0.44–0.69). The most significant effect of joining the P4P program in reducing death risk was found in the underweight patients with diabetes (HR: 0.11, 95% CI: 0.04–0.38), followed by the obesity group (HR: 0.30, 95% CI: 0.17–0.52). Conclusions: Different effects of joining the P4P program on reducing death risk were observed in the underweight and obesity groups. We strongly recommend that patients with diabetes and without healthy BMIs participate in the P4P program.

Diabetes after pregnancy: a study protocol for the derivation and validation of a risk prediction model for 5-year risk of diabetes following pregnancy

BACKGROUND

Pregnancy offers a unique opportunity to identify women at higher future risk of type 2 diabetes mellitus (DM). In pregnancy, a woman has greater engagement with the healthcare system, and certain conditions are more apt to manifest, such as gestational DM (GDM) that are important markers for future DM risk. This study protocol describes the development and validation of a risk prediction model (RPM) for estimating a woman's 5-year risk of developing type 2 DM after pregnancy.

METHODS

Data will be obtained from existing Ontario population-based administrative datasets. The derivation cohort will consist of all women who gave birth in Ontario, Canada between April 2006 and March 2014. Pre-specified predictors will include socio-demographic factors (age at delivery, ethnicity), maternal clinical factors (e.g., body mass index), pregnancy-related events (gestational DM, hypertensive disorders of pregnancy), and newborn factors (birthweight percentile). Incident type 2 DM will be identified by linkage to the Ontario Diabetes Database. Weibull accelerated failure time models will be developed to predict 5-year risk of type 2 DM. Measures of predictive accuracy (Nagelkerke's R2), discrimination (C-statistics), and calibration plots will be generated. Internal validation will be conducted using a bootstrapping approach in 500 samples with replacement, and an optimism-corrected C-statistic will be calculated. External validation of the RPM will be conducted by applying the model in a large population-based pregnancy cohort in Alberta, and estimating the above measures of model performance. The model will be re-calibrated by adjusting baseline hazards and coefficients where appropriate.

DISCUSSION

The derived RPM may help identify women at high risk of developing DM in a 5-year period after pregnancy, thus facilitate lifestyle changes for women at higher risk, as well as more frequent screening for type 2 DM after pregnancy.

Cardiac Function is Preserved in Adolescents With Well-Controlled Type 1 Diabetes and a Normal Physical Fitness: A Cross-sectional Study

OBJECTIVES

Cardiovascular diseases and exercise intolerance elevate mortality in type 1 diabetes (T1D). Left ventricular systolic and diastolic function are already affected in T1DM adolescents, displaying poor glycemic control (glycated hemoglobin [A1C]>7.5%) and exercise intolerance. We investigated to the extent to which left ventricular function is affected by disease severity/duration and whether this is related to exercise capacity.

METHODS

Transthoracic echocardiography was performed in 19 T1DM adolescents (14.8±1.9 years old, A1C 7.4±0.9%) and 19 controls (14.4±1.3 years old, A1C 5.3±0.2%), matched for age and Tanner stage. Diastolic and systolic (ejection fraction [EF]) function were assessed. Cardiopulmonary exercise testing was used to evaluate exercise capacity, as measured by peak oxygen uptake (VO_2peak).

RESULTS

VO_2peak and left ventricular systolic and diastolic function were similar in both groups. Within the T1D group, EF was negatively associated with disease duration (r=-0.79 corrected for age, standardized body mass index, glucose variability and VO_2peak; p=0.011). Regression analyses revealed that 37.6% of the variance in EF could be attributed to disease duration.

CONCLUSIONS

Although left ventricular systolic and diastolic function are preserved in T1D with adequate exercise capacity, disease duration negatively affects EF. The detrimental effects of T1D seem to be driven by disease duration, rather than by disease severity, at least during adolescence. Young T1D patients may, therefore, benefit from cardiovascular evaluation in order to detect cardiovascular abnormalities early in the disease course, and therefore, improve long-term cardiovascular health.

The Significant Association between Health Examination Results and Population Health: A Cross-Sectional Ecological Study Using a Nation-Wide Health Checkup Database in Japan

In Japan, population health with life expectancy (LE) and healthy life expectancy (HALE) as indicators varies across the 47 prefectures (administrative regions). This study investigates how health examination results, including attitude toward improving life habits, are associated with population health. The association between health checkup variables and summary population health outcomes (i.e., life expectancy and healthy life expectancy) was investigated using a cross-sectional ecological design with prefectures as the unit of analysis. The medical records, aggregated by prefecture, gender, and age in the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) Open Data Japan, were used as health checkup variables. Body weight, blood pressure, liver enzymes, drinking habits, smoking habits, diabetes, serum lipids, and answers to questions regarding attitude toward improving health habits were significantly correlated to population health outcomes. Multiple regression analysis also revealed significant influence of these variables on population health. This study highlights that health examination results, including attitude toward improving health habits, are positively associated with population health. Consequently, implementing measures to improve health habits in response to the examination results could help the population maintain a healthy life.

Developing a prototype for integrated dental and diabetes care: understanding needs and priorities

BACKGROUND

Periodontal treatment may be a useful adjunct to medical management of diabetes; however, oral health has not been integrated into multidisciplinary diabetes care in Australia. This study aimed to understand the needs of patients and staff at a diabetes clinic to inform a prototype of integrated dental and diabetes care.

METHODS

Quantitative and qualitative data were collected from patients and staff at West Moreton Diabetes Clinic (WMDC) between September-October 2019. Clinical information, survey responses and dental screening results were analysed for 41 patients. Semi-structured interviews were held with six patients and a focus group with seven staff.

RESULTS

Most patients (83%) had not seen a dentist in the previous year. Of the 37 patients with remaining natural teeth, 84% required periodontal assessment and 46% had multiple carious lesions. Unmet treatment needs and rates of access were similar for private and public dental patients. Staff and patients reported high levels of support for incorporation of dental care at WMDC.

CONCLUSIONS

Integrating oral health into diabetes management is well-supported by patients and staff to address significant unmet dental needs for both public and private dental patients. Incorporating dental screening/services within diabetes clinics may increase uptake and improve awareness of its importance in diabetes management.

Patient decision aids in clinical practice for people with diabetes: a scoping review

BACKGROUND

People with diabetes need to make regular choices that influence their long-term morbidity and mortality. Patient decision aids are validated tools and when used collaboratively between healthcare professionals, patients and carers, can help guide value-based discussions which encourage choices that are well informed and personally relevant.

OBJECTIVE

To explore the use and effect of patient decision aids in the management of diabetes.

METHOD

A scoping review design was used. Medline, ProQuest, PsycINFO, Scopus, and Cumulative Index to Nursing and Allied Health Literature databases were searched for peer-reviewed articles published between January 1998 and December 2018.

RESULTS

Patient decision aids are not commonly or widely used in diabetes management. They offer a suitable adjunct to practice within the domains of healthcare knowledge, active participation, and communication, and shared decision-making between patients and healthcare professionals.

CONCLUSION

Patient decision aids can offer a simple and easy-to-use method to potentially improve diabetes health literacy, through the process of shared decision-making and two-way conversations. However, there are current limitations on using them to positively influence clinical outcomes or long-term changes in self-care behaviors within the management of diabetes. Further research to explore the validity of using patient decision aids long term in these areas is required.

Predicting the Development of Type 2 Diabetes in a Large Australian Cohort Using Machine-Learning Techniques: Longitudinal Survey Study

BACKGROUND

Previous conventional models for the prediction of diabetes could be updated by incorporating the increasing amount of health data available and new risk prediction methodology.

OBJECTIVE

We aimed to develop a substantially improved diabetes risk prediction model using sophisticated machine-learning algorithms based on a large retrospective population cohort of over 230,000 people who were enrolled in the study during 2006-2017.

METHODS

We collected demographic, medical, behavioral, and incidence data for type 2 diabetes mellitus (T2DM) in over 236,684 diabetes-free participants recruited from the 45 and Up Study. We predicted and compared the risk of diabetes onset in these participants at 3, 5, 7, and 10 years based on three machine-learning approaches and the conventional regression model.

RESULTS

Overall, 6.05% (14,313/236,684) of the participants developed T2DM during an average 8.8-year follow-up period. The 10-year diabetes incidence in men was 8.30% (8.08%-8.49%), which was significantly higher (odds ratio 1.37, 95% CI 1.32-1.41) than that in women at 6.20% (6.00%-6.40%). The incidence of T2DM was doubled in individuals with obesity (men: 17.78% [17.05%-18.43%]; women: 14.59% [13.99%-15.17%]) compared with that of nonobese individuals. The gradient boosting machine model showed the best performance among the four models (area under the curve of 79% in 3-year prediction and 75% in 10-year prediction). All machine-learning models predicted BMI as the most significant factor contributing to diabetes onset, which explained 12%-50% of the variance in the prediction of diabetes. The model predicted that if BMI in obese and overweight participants could be hypothetically reduced to a healthy range, the 10-year probability of diabetes onset would be significantly reduced from 8.3% to 2.8% (P<.001).

CONCLUSIONS

A one-time self-reported survey can accurately predict the risk of diabetes using a machine-learning approach. Achieving a healthy BMI can significantly reduce the risk of developing T2DM.

Assessing guideline adherence in the management of type 1 diabetes mellitus in Australian children: a population-based sample survey

INTRODUCTION

To estimate adherence to clinical practice guidelines in selected settings at a population level for Australian children with type 1 diabetes mellitus.

RESEARCH DESIGN AND METHODS

Medical records of children with type 1 diabetes mellitus aged 0-15 years in 2012-2013 were targeted for sampling across inpatient, emergency department and community visits with specialist pediatricians in regional and metropolitan areas and tertiary pediatric hospitals in three states where approximately 60% of Australian children reside. Clinical recommendations extracted from two clinical practice guidelines were used to audit adherence. Results were aggregated across types of care (diagnosis, routine care, emergency care).

RESULTS

Surveyors conducted 6346 indicator assessments from an audit of 539 healthcare visits by 251 children. Average adherence across all indicators was estimated at 79.9% (95% CI 69.5 to 88.0). Children with type 1 diabetes mellitus have higher rates of behavioral and psychological disorders, but only a third of children (37.9%; 95% CI 11.7 to 70.7) with suboptimal glycemic control (eg, hemoglobin A1c >10% or 86 mmol/mol) were screened for psychological disorders using a validated tool; this was the only indicator with <50% estimated adherence. Adherence by care type was: 86.1% for diagnosis (95% CI 76.7 to 92.7); 78.8% for routine care (95% CI 65.4 to 88.9) and 83.9% for emergency care (95% CI 78.4 to 88.5).

CONCLUSIONS

Most indicators for care of children with type 1 diabetes mellitus were adhered to. However, there remains room to improve adherence to guidelines for optimization of practice consistency and minimization of future disease burden.

Life expectancy and survival analysis of patients with diabetes compared to the non diabetic population in Bulgaria

Aims

To evaluate the expected life expectancy in patients with diabetes in Bulgaria and to compare it to the expected life expectancy of the non-diabetic population in the country.

Methods

It is a retrospective observational population study on individuals diagnosed with diabetes, compared to the non-diabetic population in Bulgaria for the period 2012–2015. Data from the national diabetes register and national statistical institute were used to construct life-tables with probability of survival with t-test and Chi Square test. Confounder analysis was done by age, sex, and type of diabetes. All-cause mortality and deaths in diabetic patients were analyzed. Kaplan-Meier survival curves were constructed for each age group and a log-rank analysis was conducted.

Results

Average life expectancy in the non-diabetic population, patients with Type 1 DM and with Type 2 DM is 74.8; 70.96 and 75.19 years, respectively. For 2012–2015 the mortality in the non-diabetic population remained constant and lower (average—1.48%) compared to type-1 DM (5.25%) and Type-2 (4.27%). Relative risk of death in diabetics was higher overall (12%), after the age of 70 before which the relative risk was higher for the non-diabetic population. This was observed as a trend in all analyzed years.

Conclusion

Patients with type 2 DM have a longer life-expectancy than patients with type-1 DM and overall Diabetics life expectancy equals that of the non-diabetic population, which could suggest improved disease control and its associated complications in Bulgaria. Male diabetics show slightly longer life expectancy than their counterparts in the non-diabetic population, by a marginal gain of 0.6 years for the entire observed period. Life expectancy in diabetic women increased by 1.3 years, which was not observed in the non-diabetic population. Prevalence of diabetes was higher for women. Improved diabetes control may explain this gain in life; however other studies are needed to confirm this.

Time protective effect of contact with a general practitioner and its association with diabetes-related hospitalisations: a cohort study using the 45 and Up Study data in Australia

OBJECTIVES

To evaluate the relationship between the proportion of time under the potentially protective effect of a general practitioner (GP) captured using the Cover Index and diabetes-related hospitalisation and length of stay (LOS).

DESIGN

An observational cohort study over two 3-year time periods (2009/2010-2011/2012 as the baseline and 2012/2013-2014/2015 as the follow-up).

SETTING

Linked self-report and administrative health service data at individual level from the 45 and Up Study in New South Wales, Australia.

PARTICIPANTS

A total of 21 965 individuals aged 45 years and older identified with diabetes before July 2009 were included in this study.

MAIN OUTCOME MEASURES

Diabetes-related hospitalisation, unplanned diabetes-related hospitalisation and LOS of diabetes-related hospitalisation and unplanned diabetes-related hospitalisation.

METHODS

The average annual GP cover index over a 3-year period was calculated using information obtained from Australian Medicare and hospitalisation. The effect of exposure to different levels of the cover on the main outcomes was estimated using negative binomial models weighted for inverse probability of treatment weight to control for observed covariate imbalance at the baseline period.

RESULTS

Perfect GP cover was observed among 53% of people with diabetes in the study cohort. Compared with perfect level of GP cover, having lower levels of GP cover including high (incidence rate ratio (IRR) 2.8, 95% CI 2.6 to 3.0), medium (IRR 3.2, 95% CI 2.7 to 3.8) and low (IRR 3.1, 95% CI 2.0 to 4.9) were significantly associated with higher number of diabetes-related hospitalisation. Similar association was observed between the different levels of GP cover and other outcomes including LOS for diabetes-related hospitalisation, unplanned diabetes-related hospitalisation and LOS for unplanned diabetes-related hospitalisation.

CONCLUSIONS

Measuring longitudinal continuity in terms of time under cover of GP care may offer opportunities to optimise the performance of primary healthcare and reduce secondary care costs in the management of diabetes.

Alterations in the Levels of Circulating and Endothelial Progenitor Cells Levels in Young Adults with Type 1 Diabetes: A 2-Year Follow-Up from the Observational METRO Study

PURPOSE

Type 1 diabetes is associated with high risk of cardiovascular disease (CVD). Reduced levels of circulating progenitor cells (CPCs) and endothelial progenitor cells (EPCs) have been indicated as a risk factor for adverse cardiovascular outcomes and death in people at high cardiovascular risk. The aim of the present study was to evaluate the change in CPCs and EPCs levels in a population of young type 1 diabetic patients treated with intensive insulin regimen over a period of 2 years.

PATIENTS AND METHODS

A total of 204 type 1 diabetic patients, of whom 84 treated with insulin pump (CSII) and 120 with multiple daily insulin injections (MDI), completed a 2-year follow-up. Clinical measurements, including the indices of glycemic control and glucose variability, were collected at baseline and after 2 years. Both CPC and EPC cell count were assessed by flow cytometry.

RESULTS

Mean age of participants was 24.5 years and mean diabetes duration was 13.6 years. After 2 years, we found a significant reduction of HbA1c (-0.3% versus baseline, P <0.001), associated with decrease in mean amplitude of glucose excursion (MAGE) (-0.5 mmol/L versus baseline, P<0.001), continuous overall net glycemic action (CONGA) (-0.2 mmol/L versus baseline, P=0.006), and blood glucose standard deviation (BGSD) (-0.2 mmol/L versus baseline, P<0.001). The number of all EPCs phenotypes, but not CPC cell count, significantly raised up in the entire population, with higher increase in CSII group. MAGE resulted as an independent predictor for increased levels of both CD34+ (P = 0.020) and CD34+KDR+ (P = 0.004) cell count in the whole population.

CONCLUSION

Over a 2-year follow-up, young type 1 diabetic patients showed an increase in circulating EPCs levels, which was higher in patients with CSII. Glucose variability resulted as an independent predictor of the raised levels of EPCs in this selected population.

Using patient reported outcomes in diabetes research and practice: Recommendations from a national workshop

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and the American Diabetes Association (ADA) Co-Sponsored the workshop, Using Patient Reported Outcomes in Diabetes Research and Practice. The goal of the workshop was to identify PRO research priorities for those living with type 1 or type 2 diabetes, discuss considerations for use of disease specific versus generic measures, as well as outline research priorities to meet key end-user needs for assessing PROs for diabetes researchers, clinicians/hospital systems, patients/caregivers, and regulators. Here, we summarize the conclusions and recommendations from the workshop.

[Diabetes mellitus, coronary artery disease und heart disease (Update 2019)]

Diabetes mellitus, cardiovascular disease and heart failure are interacting dynamically. Patients being diagnosed with cardiovascular disease should be screened for diabetes mellitus. Enhanced cardiovascular risk stratification based on biomarkers, symptoms and classical risk factors should be performed in patients with pre-existing diabetes mellitus. In patients with previously diagnosed arterosclerotic cardiovascular disease an agent proven to reduce major adverse cardiovascular events or cardiovascular mortality is recommended after therapy failure of metformin.

Potential gains in health-adjusted life expectancy from reducing four main non-communicable diseases among Chinese elderly

BACKGROUND

To estimate the potential gains in health-adjusted life expectancy (HALE) after hypothetical elimination of four non-communicable diseases (NCDs) among Chinese elderly from 1990 to 2016, including cardiovascular diseases (CVD), cancers, chronic respiratory diseases (CRD) and diabetes mellitus (DM).

METHODS

Based on data from Global Burden of Disease 2016, we generated life table by gender using Sullivan method to calculate HALE. Disease-deleted method was used to calculate cause-elimination HALE, after hypothetical elimination of specific diseases.

RESULTS

From 1990 to 2016, HALE increased for all age groups. After hypothetic eliminating the four main NCDs, potential gain in HALE by CVD, DM and cancers increased while by CRD decreased from 1990 to 2016 for both genders. Among four main NCDs, potential gain in HALE after eliminating CVD was largest and increased most for both genders. Although elimination of DM led to the smallest gain in HALE, the increasing speed of gain in HALE by DM was faster than that by CVD and cancers from 1990 to 2016.

CONCLUSIONS

This study highlights the potential gains in HALE of NCDs among Chinese elderly from 1990 to 2016. HALE of Chinese elderly could further increase from the reduction of NCDs. Control measures and targeted prevention should be carried out.

A cost analysis of intensified vs conventional multifactorial therapy in individuals with type 2 diabetes: a post hoc analysis of the Steno-2 study

AIMS/HYPOTHESIS

Long-term follow-up of the Steno-2 study demonstrated that intensified multifactorial intervention increased median lifespan by 7.9 years and delayed incident cardiovascular disease by a median of 8.1 years compared with conventional multifactorial intervention during 21.2 years of follow-up. In this post hoc analysis of data from the Steno-2 study, we aimed to study the difference in direct medical costs associated with conventional vs intensified treatment.

METHODS

In 1993, 160 Danish individuals with type 2 diabetes and microalbuminuria were randomised to conventional or intensified multifactorial target-driven intervention for 7.8 years. Information on direct healthcare costs was retrieved from health registries, and the costs in the two groups of participants were compared by bootstrap t test analysis.

RESULTS

Over 21.2 years of follow-up, there was no difference in total direct medical costs between the intensified treatment group, €12,126,900, and the conventional treatment group, €11,181,700 (p = 0.48). The mean cost per person-year during 1996-2014 was significantly lower in the intensified treatment group (€8725 in the intensive group and €10,091 in the conventional group, p = 0.045). The main driver of this difference was reduced costs associated with inpatient admissions related to cardiovascular disease (p = 0.0024).

CONCLUSIONS/INTERPRETATION

Over a follow-up period of 21.2 years, we found no difference in total costs and reduced cost per person-year associated with intensified multifactorial treatment for 7.8 years compared with conventional multifactorial treatment. Considering the substantial gain in life-years and health benefits achieved with intensified treatment, we conclude that intensified multifaceted intervention in high-risk individuals with type 2 diabetes seems to be highly feasible when balancing healthcare costs and treatment benefits in a Danish healthcare setting.

Risk factors for self-reported diabetes among Bhutanese adults: A nationally representative survey data analysis

Background

Bhutan, a small land-locked country in the eastern Himalayas has been undergoing an epidemiological and nutritional transition in the last two decades. The objective of this paper was to determine the prevalence and explore the risk factors of self-reported diabetes among Bhutanese adults.

Methods

We conducted a secondary data analysis among adults 18 years and older Bhutanese using the data from the National Health Survey 2012 (NHS, 2012) of Bhutan. The self-reported information on risk factors was obtained using standard protocols of the WHO STEPwise approach to Surveillance. The outcome of interest was self-reported diabetes on medication. Adjusted and unadjusted logistic regression analyses were performed to identify the risk factor of diabetes.

Results

A total of 31,066 participants aged 18 years and older were included for the analysis. The prevalence of self-reported hypertension was 1.8% (491). Risk factors for diabetes were: age groups: 35–44 years adjusted odds ratio (AOR) = 2.82 (95% CI, 1.07, 7.41), 45–54 years AOR = 6.02 (95% CI, 2.29, 15.83), 55–64 year AOR = 15.7 (95% CI 5.93, 41.55) and >65 years AOR = 19.60 (95% CI, 6.93, 55.71); high school and diploma/certificate education AOR = 2.57, (95% CI 1.62, 4.07) and AOR = 3.92 (95% CI 1.70, 9.07); and urban dwellers AOR = 2.37, (95% 1.58, 3.57); hypertension AOR = 3.3, (95% CI 2.47, 4.41); and fruit servings of 1–3 per week AOR = 1.63 (95% CI 1.15, 2.31).

Conclusion

The number of Bhutanese adults with diabetes and co-morbidities associated with it is likely to increase with the ageing of the population, nutrition transition, and high rural-urban migration in the near future. This calls for an urgent need to implement strategies to prevent diabetes in the Bhutanese population targeting risk factors including healthy lifestyle with increased physical activities and reduced smoking. At the same time treating other chronic morbidities including hypertension.

Macrovascular disease and risk factors in youth with type 1 diabetes: time to be more attentive to treatment?

Cardiovascular disease remains the leading cause of mortality in patients with type 1 diabetes. Although cardiovascular disease complications are rare until adulthood, pathology and early markers can manifest in adolescence. Whereas advances have been made in the management of microvascular complications of type 1 diabetes, similar progress in reducing macrovascular complications has not been made. The reasons for the absence of progress remain incompletely understood, but most likely relate to the long time needed for cardiovascular disease to manifest clinically and hence for risk factor management to show a clinical benefit, thus allowing inertia to prevail for diagnosis and particularly for targeting risk factors. In this Review, we summarise paediatric data on traditional and novel risk factors of cardiovascular disease, provide an overview of data from previous and current clinical trials, discuss future directions in cardiovascular disease research for paediatric patients with type 1 diabetes, and advocate for the early identification and treatment of cardiovascular disease risk factors as recommended in multiple guidelines.

Type 1 diabetes

Type 1 diabetes is a chronic autoimmune disease characterised by insulin deficiency and resultant hyperglycaemia. Knowledge of type 1 diabetes has rapidly increased over the past 25 years, resulting in a broad understanding about many aspects of the disease, including its genetics, epidemiology, immune and β-cell phenotypes, and disease burden. Interventions to preserve β cells have been tested, and several methods to improve clinical disease management have been assessed. However, wide gaps still exist in our understanding of type 1 diabetes and our ability to standardise clinical care and decrease disease-associated complications and burden. This Seminar gives an overview of the current understanding of the disease and potential future directions for research and care.

Diabetic retinopathy in patients with diabetic foot syndrome in South India

Purpose

The purpose was to study the retinopathy status in diabetic patients with a risk of diabetic foot (DF) syndrome visiting a tertiary care hospital in South India.

Methods

In this cross sectional study all patients with diabetes mellitus (DM) with a risk of DF syndrome, visiting a tertiary care hospital during the study period, underwent an ophthalmological evaluation for documentation of their retinopathy status.

Results

One hundred and eighty-two patients diagnosed to have a risk profile for DF syndrome were included in the study. Their mean age was 59.28 years and 75.27% were males. The mean duration of Type 1 and Type 2 variants of DM was 14.9 years and 10.9 years, respectively. Of the 182 patients, 67.58% had retinopathy changes. Proliferative diabetic retinopathy (DR) constituted 17.88% of the total patients with retinopathy. An increased presence of retinopathy in patients with an increased risk grade of DF was found significant by the Chi-square test (P < 0.001).

Conclusion

Our study found an increased presence of DR in a South Indian cohort with DF syndrome. The severity of retinopathy was greater in patients with higher grades of risk for DF. The establishment of an association between DR and DF syndrome will help in developing an integrated management strategy for these two debilitating consequences of diabetes.

Effect of 6 months of hybrid closed-loop insulin delivery in adults with type 1 diabetes: a randomised controlled trial protocol

INTRODUCTION

Manual determination of insulin dosing largely fails to optimise glucose control in type 1 diabetes. Automated insulin delivery via closed-loop systems has improved glucose control in short-term studies. The objective of the present study is to determine the effectiveness of 6 months' closed-loop compared with manually determined insulin dosing on time-in-target glucose range in adults with type 1 diabetes.

METHODS AND ANALYSIS

This open-label, seven-centre, randomised controlled parallel group clinical trial will compare home-based hybrid closed-loop versus standard diabetes therapy in Australia. Adults aged ≥25 years with type 1 diabetes using intensive insulin therapy (via multiple daily injections or insulin pump, total enrolment target n=120) will undertake a run-in period including diabetes and carbohydrate-counting education, clinical optimisation and baseline data collection. Participants will then be randomised 1:1 either to 26 weeks of MiniMed 670G hybrid closed-loop system therapy (Medtronic, Northridge, CA, USA) or continuation of their current diabetes therapy. The hybrid closed-loop system delivers insulin automatically to address basal requirements and correct to target glucose level, while bolus doses for meals require user initiation and carbohydrate estimation. Analysis will be intention to treat, with the primary outcome time in continuous glucose monitoring (CGM) target range (3.9-10.0 mmol/L) during the final 3 weeks of intervention. Secondary outcomes include: other CGM parameters, HbA_1c, severe hypoglycaemia, psychosocial well-being, sleep, cognition, electrocardiography, costs, quality of life, biomarkers of vascular health and hybrid closed-loop system performance. Semistructured interviews will assess the expectations and experiences of a subgroup of hybrid closed-loop users.

ETHICS AND DISSEMINATION

The study has Human Research Ethics Committee approval. The study will be conducted in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice. Results will be disseminated at scientific conferences and via peer-reviewed publications.

TRIAL REGISTRATION NUMBER

ACTRN12617000520336; Pre-results.

The Productivity Burden of Diabetes at a Population Level

OBJECTIVE

Recent studies suggest that diabetes may impact work productivity. In the current study, we sought to estimate the lifetime and population impact of diabetes on productivity using the novel measure of "productivity-adjusted life years" (PALYs).

RESEARCH DESIGN AND METHODS

Using age-specific mortality rates and a productivity index attributable to diabetes (akin to the quality of life index, but which adjusts for reduction in productivity) and life table modeling, we estimated years of life and PALYs lost to diabetes among Australians with diabetes currently aged 20-65 years, with follow-up until 69 years. Life tables were first constructed for the cohort with diabetes and then repeated for the same cohort but with the assumption that they no longer had diabetes. The "nondiabetic" cohort had lower mortality rates and improved productivity. The differences in total years of life lived and PALYs lived between the two cohorts reflected the impact of diabetes.

RESULTS

Overall, diabetes reduced total years of life lived by the cohort by 190,219 years or almost 3%. Diabetes reduced PALYs by 11.6% and 10.5% among men and women, respectively. For both sexes, the impact of diabetes on productivity was lowest in those aged 65-69 years and highest in those 20-24 years. Among the latter, PALYs were reduced by 12.2% and 11.0% for men and women, respectively.

CONCLUSIONS

Elimination of diabetes can prolong life years lived by the whole population and increase the amount of productive years lived. Employers and government should be aware that having diabetes affects work force productivity and implement prevention programs to reduce the impact of diabetes on the workforce.

Type 2 diabetes, socioeconomic status and life expectancy in Scotland (2012-2014): a population-based observational study

AIMS/HYPOTHESIS

The aim of this study was to assess the role of socioeconomic status (SES) in the associations between type 2 diabetes and life expectancy in a complete national population.

METHODS

An observational population-based cohort study was performed using the Scottish Care Information - Diabetes database. Age-specific life expectancy (stratified by SES) was calculated for all individuals with type 2 diabetes in the age range 40-89 during the period 2012-2014, and for the remaining population of Scotland aged 40-89 without type 2 diabetes. Differences in life expectancy between the two groups were calculated.

RESULTS

Results were based on 272,597 individuals with type 2 diabetes and 2.75 million people without type 2 diabetes (total for 2013, the middle calendar year of the study period). With the exception of deprived men aged 80-89, life expectancy in people with type 2 diabetes was significantly reduced (relative to the type 2 diabetes-free population) at all ages and levels of SES. Differences in life expectancy ranged from -5.5 years (95% CI -6.2, -4.8) for women aged 40-44 in the second most-deprived quintile of SES, to 0.1 years (95% CI -0.2, 0.4) for men aged 85-89 in the most-deprived quintile of SES. Observed life-expectancy deficits in those with type 2 diabetes were generally greater in women than in men.

CONCLUSIONS/INTERPRETATION

Type 2 diabetes is associated with reduced life expectancy at almost all ages and levels of SES. Elimination of life-expectancy deficits in individuals with type 2 diabetes will require prevention and management strategies targeted at all social strata (not just deprived groups).

The Use of Mobile Applications Among Adults with Type 1 and Type 2 Diabetes: Results from the Second MILES-Australia (MILES-2) Study

BACKGROUND

While the number of diabetes-specific mobile applications (apps) continues to grow, there is a lack of knowledge about their actual use.

METHODS

The second MILES (Management and Impact for Long-term Empowerment and Success)-Australia study was a national cross-sectional survey of the psychological, behavioral, and social aspects of diabetes for adults with type 1 diabetes (T1D) and type 2 diabetes (T2D). Associations between diabetes-specific app usage and demographic, clinical, and psychosocial variables were examined.

RESULTS

Of the 1589 respondents responding to the diabetes-specific app questions, 795 had T1D (mean ± standard deviation age 43 ± 14 years; 61% women; diabetes duration 19 ± 14 years) and 794 had T2D (age 60 ± 9 years; 40% women; diabetes duration 11 ± 7 years). Among adults with T1D, 24% (n = 188) reported using apps, with carbohydrate counting (74%; n = 139) as the most common cited purpose. App usage was significantly associated with shorter diabetes duration, more frequent glucose monitoring, and lower self-reported HbA1c. Among adults with T2D, 8% (n = 64) reported using apps, with glucose monitoring (62%; n = 39) as the most common purpose. For all respondents, the most commonly reported reason for not using apps was a belief that they could not help with diabetes self-management.

CONCLUSIONS

A minority of adults with T1D and T2D use apps to support their self-management. App use among adults with T1D is associated with a more recent T1D diagnosis, more frequent glucose monitoring, and lower self-reported HbA1c. Future efforts should focus on this association and determine the mechanisms by which app use is related to better clinical outcomes.

Bone health in subjects with type 1 diabetes for more than 50 years

AIMS

Few data regarding prevalence of and risk factors for poor bone health in aging individuals with long-standing T1D are available. In this study, we aim to describe the prevalence of bone fragility and to identify factors associated with low bone density in individuals with long-term T1D.

METHODS

We examined the prevalence of non-vertebral fractures in 985 subjects enrolled in the Joslin 50-Year Medalist Study and measured bone mineral density (BMD) by dual-energy X-ray absorptiometry at the femoral neck, lumbar spine and radius in a subset (65 subjects, mean age 62.6 years, duration 52.5 years, HbA1c 7.1%) with no significant clinical or demographic differences from the rest of the cohort.

RESULTS

Medalists have low prevalence of fractures (0.20% hip and 0.91% wrist) and normal Z-score values (spine +1.15, total hip +0.23, femoral neck -0.01, radius +0.26; p > 0.05 for differences vs. 0 at all sites). A significant relationship was found between lower BMD and higher total cholesterol, triglycerides and LDL levels, but not HbA1c. Low BMD at the femoral neck was associated with cardiovascular disease after adjustment for confounding factors: prevalence risk ratio of CVD [95% CI] 4.6 [1.2-18.1], p = 0.03. No other diabetic vascular complication was found to be associated with low BMD.

CONCLUSIONS

These are the first data regarding bone health in aging individuals who have had diabetes for 50 or more years. The low rates of non-vertebral fractures and the normal Z-score suggest the long T1D diabetes duration did not increase the risk of bone fractures in Medalists compared to non-diabetic peers. Additionally, the association with cardiovascular disease demonstrates the BMD differences in groups are likely not due to glycemic control alone.

Diabetes and disability in older Australians: The Australian Diabetes, Obesity and Lifestyle (AusDiab) study

AIMS

To examine the association between diabetes and disability in older Australians and to identify factors that explain this association.

METHODS

We analysed data from a subsample of the Australian Diabetes, Obesity and Lifestyle study (AusDiab) cohort. Disability was measured using the Katz questionnaire in those aged 60years or over and was defined as some difficulty in any of the Katz activities of daily living (ADL) questions.

RESULTS

Among 2373 study participants aged 60years or above who had a disability assessment at the third wave of follow-up (2011-12), 255 (11%) reported at least some disability. Participants with diabetes at baseline had higher odds of disability at 12years [odds ratio=2.41 (95% CI 1.60-3.64)] as compared to individuals with normal glucose tolerance; these patterns were similar for men and women. There was no association between baseline prediabetes and disability [OR=1.27 (95% CI 0.91-1.78)]. Baseline body mass index (BMI) and cardiometabolic factors (hypertension, prior cardiovascular disease, impaired glomerular filtration rate, triglycerides and high-density lipoproteins) were important in explaining the increased odds of disability. BMI and cardiometabolic factors together explained 65% of the diabetes-associated odds of disability at 12years.

CONCLUSIONS

In older Australians, we showed that baseline diabetes more than doubled the odds of reporting disability at 12years, with BMI and cardiometabolic factors accounting for much of this relationship. These findings suggest that interventions targeting weight control, and prevention and treatment of cardiometabolic factors may prevent disability associated with diabetes and promote healthy aging.

Compression of disability between two birth cohorts of US adults with diabetes, 1992-2012: a prospective longitudinal analysis

BACKGROUND

The life expectancy of the average American with diabetes has increased, but the quality of health and functioning during those extra years are unknown. We aimed to investigate the net effect of recent trends in diabetes incidence, disability, and mortality on the average age of disability onset and the number of healthy and disabled years lived by adults with and without diabetes in the USA. We assessed whether disability expanded or was compressed in the population with diabetes and compared the findings with those for the population without diabetes in two consecutive US birth cohorts aged 50-70 years.

METHODS

In this prospective longitudinal analysis, we analysed data for two cohorts of US adults aged 50-70 years from the Health and Retirement Study, including 1367 people with diabetes and 11 414 without diabetes. We assessed incident disability, remission from disability, and mortality between population-based cohort 1 (born 1931-41, follow-up 1992-2002) and cohort 2 (born 1942-47, follow up 2002-12). Disability was defined by mobility loss, difficulty with one or more instrumental activities of daily living, and difficulty with one or more activities of daily living. We entered age-specific probabilities representing the two birth cohorts into a five-state Markov model to estimate the number of years of disabled and disability-free life and life-years lost by age 70 years.

FINDINGS

In people with diabetes, compared with cohort 1 (n=1067), cohort 2 (n=300) had more disability-free and total years of life, later onset of disability, and fewer disabled years. Simulations of the Markov models suggest that in men with diabetes aged 50 years, this difference between cohorts amounted to a 0·8-2·3 year delay in disability across the three metrics (mobility, 63·0 [95% CI 62·3-63·6] to 64·8 [63·6-65·7], p=0·01; instrumental activities of daily living, 63·5 [63·0-64·0] to 64·3 [63·0-65·3], p=0·24; activities of daily living, 62·7 [62·1-63·3] to 65·0 [63·5-65·9], p<0·0001) and 1·3 fewer life-years lost (ie, fewer remaining life-years up to age 70 years; from 2·8 [2·5-3·2] to 1·5 [1·3-1·9]; p<0·0001 for all three measures of disability). Among women with diabetes aged 50 years, this difference between cohorts amounted to a 1·1-2·3 year delay in disability across the three metrics (mobility, 61·3 [95% CI 60·5-62·1] to 63·2 [61·5-64·5], p=0·0416; instrumental activities of daily living, 63·0 [62·4-63·7] to 64·1 [62·7-65·2], p=0·16; activities of daily living, 62·3 [61·6-63·0] to 64·6 [63·1-65·6], p<0·0001) and 0·8 fewer life-years lost by age 70 years (1·9 [1·7-2·2] to 1·1 [0·9-1·5]; p<0·0001 for all three measures of disability). Parallel improvements were gained between cohorts of adults without diabetes (cohort 1, n=8687; cohort 2, n=2727); within both cohorts, those without diabetes had significantly more disability-free years than those with diabetes (p<0·0001 for all comparisons).

INTERPRETATION

Irrespective of diabetes status, US adults saw a compression of disability and gains in disability-free life-years. The decrease in disability onset due to primary prevention of diabetes could play an important part in achieving longer disability-free life-years.

FUNDING

US Department of Health & Human Services and the US Centers for Disease Control and Prevention.