COMMENTARY

Diabetes and Mortality: Good News and Bad News

Gregory A. Nichols, PhD

Disclosures

August 07, 2012

Trends in Death Rates Among U.S. Adults With and Without Diabetes Between 1997 and 2006: Findings From the National Health Interview Survey

Gregg EW, Cheng YJ, Saydah S, et al
Diabetes Care. 2012;35:1252-1257

Study Summary

This study examined all-cause mortality and deaths due to cardiovascular disease (CVD) in US adults with diabetes and compared the rates with those among US adults without diabetes. In addition, the investigators examined whether changes in mortality over time differed among various age, sex, race, and socioeconomic subgroups of patients with diabetes.

In the population with diagnosed diabetes, 3-year CVD death rates declined from 9.5 per 1000 person-years in 1997-1998 to 5.6 per 1000 person-years in 2003-2004. There was no significant decline in all-cause mortality among adults without diabetes.

CVD death rates declined among adults without diabetes as well, from 3.7 to 3.3 deaths per 1000 person-years. However, the magnitude of this decline was weaker than that observed for adults with diabetes. Thus, the excess CVD death rate associated with diabetes (compared with persons without diabetes) declined from 5.8 to 2.3 deaths per 1000 person-years, and the all-cause death rate difference between people with and without diabetes declined from 10.8 to 6.1 deaths per 1000 person-years. Reductions in all-cause and CVD mortality were relatively consistent across the population, according to stratified analyses.

Viewpoint

A recent report from the Framingham Heart Study suggested that all-cause and CVD mortality declined substantially between 1950 and 2005, but the relative risk associated with diabetes remained about twice as high as in persons who did not have diabetes.[1] In the study by Gregg and colleagues -- which, unlike the Framingham Heart Study, is nationally representative -- mortality rates declined much more among persons with diabetes, such that the excess CVD mortality rate associated with diabetes declined by 60% and the excess all-cause mortality rate declined by 44%.

These relative reductions were based on comparisons of the 1997-1998 and the 2003-2004 samples. However, it is important to note that the excess risk for CVD mortality in the 2001-2002 sample was nearly as high as in the 1997-1998 sample, and that the excess risk for all-cause mortality was actually higher in the 2001-2002 sample than in the 1997-1998 sample. It is not possible to determine whether the higher 2001-2002 rates or the lower 2003-2004 rates were aberrations. Nevertheless, assuming that the trends reported are not the result of an anomaly, they have ironic implications.

Increased survival among individuals with diabetes suggests that more people than ever before will be living with this disease. For the practicing clinician, this means that many more patients will require the sort of management that generated the decreasing mortality rates. Furthermore, while such management of hyperglycemia, hypertension, and other risk factors should decrease some complications of diabetes, other complications -- for example, nephropathy and heart failure -- are independently associated with duration of diabetes.[2,3] If patients are living longer with diabetes, we can expect that they will develop more comorbidities that need additional management, which will add to the already enormous economic burden of the disease.[4]

Abstract

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