A follow-up study of diabetic Oklahoma Indians. Mortality and causes of death

Presentation and outcomes of indigenous Australians with peripheral artery disease

Background

The risk factors for peripheral artery disease (PAD) are more common in Indigenous than non-Indigenous Australians, however the presentation and outcome of PAD in Indigenous Australians has not been previously investigated. The aim of this prospective cohort study was to compare the presenting characteristics and clinical outcome of Indigenous and non-Indigenous Australians with PAD.

Methods

PAD patients were prospectively recruited and followed-up since 2003 from an outpatient vascular clinic in Townsville, Australia. Presenting symptoms and risk factors in Indigenous and non-Indigenous patients were compared using Pearson’s χ2 test and Mann Whitney U test. Kaplan Meier survival analysis and Cox proportional hazard analysis were used to compare the incidence of myocardial infarction (MI), stroke or death (major cardiovascular events) among Indigenous and non-Indigenous patients.

Results

Four hundred and one PAD patients were recruited, of which 16 were Indigenous and 385 were non-Indigenous Australians. Indigenous Australians were younger at entry (median age 63.3 [54.7–67.8] vs 69.6 [63.3–75.4]), more commonly current smokers (56.3% vs 31.4%), and more frequently had insulin-treated diabetes (18.8% vs 5.2%). During a median follow-up of 2.5 years, five and 45 major cardiovascular events were recorded amongst Indigenous and non-Indigenous Australians, respectively. Indigenous Australians were at ~ 5-fold greater risk of major cardiovascular events (adjusted hazard ratio 4.72 [95% confidence intervals 1.41–15.78], p = 0.012) compared to non-Indigenous Australians.

Conclusions

These findings suggest that Indigenous Australians with PAD present at a younger age, have higher rates of smoking and insulin-treated diabetes, and poorer clinical outcomes compared to non-Indigenous Australians.

Complications of the diabetic foot

The diabetic foot is at high risk for complications because of its role in ambulation. Peripheral neuropathy and peripheral vascular disease can lead to chronic foot ulcers, which are at high risk for infection, in part attributable to areas of high pressure caused by lack of tolerance of the soft tissue and bone and joint deformity. If left untreated, infection and ischemia lead to tissue death, culminating in amputation. Treatment strategies include antibiosis, topical therapies, offloading, debridement, and surgery. A multidisciplinary team approach is necessary in the prevention and treatment of complications of the diabetic foot.

Global complication rates of type 2 diabetes in Indigenous peoples: A comprehensive review

INTRODUCTION AND OBJECTIVE

The world's Indigenous peoples are experiencing an unprecedented epidemic of type 2 diabetes [T2DM] but little has been published describing the complications burden. The objective of this paper was to conduct a systematic review of T2DM complications in Indigenous populations worldwide.

METHODS

A literature review was conducted using PubMed and EMBASE to examine available complications data. Country, Indigenous population, authors, publication year, total sample size, Indigenous sample size, age, methodology, and prevalence of nephropathy, end-stage renal disease, retinopathy, neuropathy, lower extremity amputations, cardiovascular disease, hospitalizations and mortality due to diabetes were recorded.

RESULTS

One-hundred and eleven studies were selected. Results revealed a disproportionate burden of disease complications among all Indigenous peoples regardless of their geographic location. Complication rates were seen to vary widely across Indigenous groups.

DISCUSSION

Gaps were found in the published literature on complications among Indigenous populations, especially those living in underdeveloped countries. These gaps may be in part due to the challenges caused by varying operational practices, research methodologies, and definitions of the term Indigenous, making documentation of rates among these peoples problematic. Comprehensive surveillance applying standardized definitions and methodologies is needed to design targeted prevention and disease management strategies for Indigenous peoples with T2DM.

Racial differences in glycemic control in a well-functioning older diabetic population: findings from the Health, Aging and Body Composition Study

OBJECTIVE

To evaluate racial differences and factors associated with worse glycemic control in well-functioning older individuals with type 2 diabetes. Our hypothesis was that glycemic control would be worse among black than white diabetic individuals but that this association would be explained by differences in severity of diabetes, health status, health care indicators, and social, psychological, or behavioral factors. We further hypothesized that the association of race with poorer glycemic control would be limited to those with lower education or lower income.

RESEARCH DESIGN AND METHODS

Cross-sectional analysis of 468 diabetic participants among a cohort of 3,075 nondisabled blacks and whites aged 70-79 years living in the community enrolled in the Health, Aging and Body Composition Study. Glycemic control was measured by the level of HbA(1c).

RESULTS

A total of 58.5% of the diabetic individuals were black. Although control was poor in all diabetic participants (HbA(1c) > or =7% in 73.7%), blacks had worse glycemic control than whites (age- and sex-adjusted mean HbA(1c), 8.4% in blacks and 7.4% in whites; P < 0.01). Race differences in glycemic control remained significant, even after adjusting for current insulin therapy, cardiovascular disease, higher total cholesterol, and not receiving a flu shot in the previous year, all of which were associated with higher HbA(1c) concentrations. Controlling for these factors reduced the association by 27%. Race remained an important factor in glycemic control, even when results were stratified by education or income.

CONCLUSIONS

HbA(1c) concentrations were higher in older black diabetic individuals. Differences in glycemic control by race were associated with disease severity, health status, and poorer quality of care, but these factors did not fully explain the higher HbA(1c) levels in older black diabetic individuals.

Development and progression of nephropathy in type 2 diabetes: the United Kingdom Prospective Diabetes Study (UKPDS 64)

BACKGROUND

The progression of nephropathy from diagnosis of type 2 diabetes has not been well described from a single population. This study sought to describe the development and progression through the stages of microalbuminuria, macroalbuminuria, persistently elevated plasma creatinine or renal replacement therapy (RRT), and death.

METHODS

Using observed and modeled data from 5097 subjects in the UK Prospective Diabetes Study, we measured the annual probability of transition from stage to stage (incidence), prevalence, cumulative incidence, ten-year survival, median duration per stage, and risk of death from all-causes or cardiovascular disease.

RESULTS

From diagnosis of diabetes, progression to microalbuminuria occurred at 2.0% per year, from microalbuminuria to macroalbuminuria at 2.8% per year, and from macroalbuminuria to elevated plasma creatinine (>or=175 micromol/L) or renal replacement therapy at 2.3% per year. Ten years following diagnosis of diabetes, the prevalence of microalbuminuria was 24.9%, of macroalbuminuria was 5.3%, and of elevated plasma creatinine or RRT was 0.8%. Patients with elevated plasma creatinine or RRT had an annual death rate of 19.2% (95% confidence interval, CI, 14.0 to 24.4%). There was a trend for increasing risk of cardiovascular death with increasing nephropathy (P < 0.0001), with an annual rate of 0.7% for subjects in the stage of no nephropathy, 2.0% for those with microalbuminuria, 3.5% for those with macroalbuminuria, and 12.1% with elevated plasma creatinine or RRT. Individuals with macroalbuminuria were more likely to die in any year than to develop renal failure.

CONCLUSIONS

The proportion of patients with type 2 diabetes who develop microalbuminuria is substantial with one quarter affected by 10 years from diagnosis. Relatively fewer patients develop macroalbuminuria, but in those who do, the death rate exceeds the rate of progression to worse nephropathy.

Population-based estimates of mortality associated with diabetes: use of a death certificate check box in North Dakota

OBJECTIVES

Overall and cause-specific mortality among persons with diabetes in North Dakota was estimated and compared with estimates from previous population-based studies.

METHODS

Data were derived from North Dakota death certificate data, which included unique information on decedents' diabetes status and Behavioral Risk Factor Surveillance System estimates of the diabetic and nondiabetic adult populations of North Dakota.

RESULTS

The risk of death among adults with diabetes was 2.6 (2.2, 2.9) times that of adults without diabetes. Relative risks of death among adults with diabetes were at least twice as high for heart disease, cerebrovascular disease, accidents and adverse events, and kidney disease and 70% to 80% higher for pneumonia and influenza, malignant neoplasms, arterial disease, and other causes. Risks remained substantial in the oldest age group. These findings are comparable to results of other population-based studies.

CONCLUSIONS

Diabetes status information enhanced the usefulness of death certificate data in examining mortality associated with diabetes and confirms that the effect of diabetes on death is substantial.

[Increase in mortality associated with the presence of diabetes mellitus in Japanese-Brazilians]

OBJECTIVE

As part of a study involving Japanese migrants, living in a developed city in the state of S. Paulo, Southeastern Brazil, a four-year experience of mortality among diabetic and non-diabetic subjects is described and their respective death rates are compared. In 1993, a cohort of 530 Japanese-Brazilians (236 issei or 1st generation and 294 nisei or 2nd generation) of both sexes, aged 40 from to 79 years old, were identified.

RESEARCH DESIGN AND METHOD

At that time, 91 (17%) were classified as non-insulin-dependent diabetic subjects (NIDDM), 90 (17%) with impaired glucose tolerance (IGT) and 349 (66%) as normal, according to WHO criteria. In 1996, families were questioned with a view detecting the deaths which had occurred among the subjects previously studied. This information, in addition to that from death certificates was used to record the date and the causes of death. Mortality rates for all causes and for specific causes (circulatory and renal diseases) were obtained for the three groups of subjects, by glucose tolerance status. Proportional hazard regression models were used to compare the mortality rates, adjusted for several covariables (gender, age, generation, hypertension, dyslipidemia, obesity and serum creatinine).

RESULTS AND CONCLUSIONS

Crude mortality rate ratios for all causes and specific causes, for NIDDM, and normal subjects were 2.95 (95% CI: 1.10-7.62) and 4.57 (95% CI: 1.31-16.48), respectively. No difference was observed between the crude mortality rate ratio for IGT and normal subjects. After simultaneous adjustments for the covariates, higher mortality rates for specific causes were observed among NIDDM than in the normal subjects (mortality rates ratio: 3.86; 95% CI: 1.11-13.38). These results in Japanese-Brazilians are consistent with previous reports of increased mortality in other diabetic subjects, thus confirming the adverse effect of this metabolic disturbance on mortality among diabetic subjects.

A 15 year follow-up study of patients with non-insulin dependent diabetes mellitus (NIDDM) in Osaka, Japan. Long-term prognosis and causes of death

A 15 year follow-up study of diabetic patients was performed in Osaka, Japan. The subjects studied were 1939 patients with non-insulin dependent diabetes mellitus (NIDDM), of whom 1000 (51.5%) were alive, 880 (45.4%) had died and 59 (3.0%) were untraceable at the end of 1993. The mortality rate per 1000 person-years of the subjects increased from 28.94 in 1960-1984 to 35.74 in 1985-1993, but the ratio of numbers of observed to expected deaths (O/E ratio) declined from 1.77 to 1.52 for the corresponding periods, suggesting an improvement in the prognosis for diabetic patients, with the exception of patients 65 years or over at the time of entry. Cerebro-cardiovascular and renal diseases were major causes of death, accounting for 48.4% of all deaths. In particular, disease of the heart was the cause of death in 20.5% of all deaths, cerebrovascular disease in 14.5% and renal disease in 12.0%. The O/E ratio was 11.30 for renal disease, which was remarkably high. The O/E ratios were 1.48 for malignant neoplasms, 3.02 for cancer of the liver and 2.15 for cancer of the pancreas. In the subjects less than 65 years of age at entry, a significant decrease in the O/E ratio for overall deaths, malignant neoplasms, disease of the heart, cerebrovascular disease and renal disease was observed, but no notable difference in the O/E ratio for ischemic heart disease was found between the periods 1960-1984 and 1985-1993. By contrast, in the case of subjects 65 years or more at entry, the O/E ratios for overall deaths, malignant neoplasms, disease of the heart, ischemic heart disease and cerebrovascular disease increased markedly in the later period, while there was a considerable decline in renal disease indicated during this period. The analysis suggested a structural change in causes of death of Japanese diabetic patients in recent years, with a relative increase in ischemic heart disease and a relative decrease in renal disease.