People With Diabetes in Hong Kong Living Longer, Except the Young

Veronica Hackethal, MD

January 16, 2020

Overall death rates among people with diabetes in Hong Kong have plummeted by over 50% in recent years, according to a new study published online January 16 in Diabetologia.

However, the top-line figure hides the fact that younger people with diabetes were less likely to show improvements in survival compared with older people. Those aged 20-44 years with diabetes had death rates that were four to eight times higher than similarly aged counterparts without diabetes.

"In our study, the > 50% reduction in all-cause mortality rate in the Hong Kong Chinese cohort with diabetes during the 16-year study period is noteworthy and may be related to the many changes that have occurred in the social and healthcare system in Hong Kong during the last two decades," write Hongjiang Wu, MB, PhD, MPH, and colleagues.

In the 1990s, Hong Kong initiated major healthcare reforms. The region subsequently established multidisciplinary diabetes treatment centers to improve patient education and support, and diabetes risk assessment programs to improve earlier diagnosis and treatment. Rates of smoking and obesity have also declined in Hong Kong, which may have played a role.

But they note, "The less marked improvements in all-cause mortality rates among young people in Hong Kong and in other regions is concerning since these individuals are at the prime age of economic productivity and the high rates of premature mortality are expected to have major societal impacts."

As a result, Wu, of the Chinese University of Hong Kong, and coauthors call for "urgent action...more focused prevention and care strategies are needed for young people with diabetes in Hong Kong."

Findings Similar to Those in Other Developed Nations

The authors state that their results are roughly similar to what has been observed in studies in other developed countries like the UK, Australia, Canada, and the United States, where overall rates of death among people with diabetes have also declined in recent years.

However, few studies have evaluated the issue among people with diabetes in Asia.

The researchers therefore analyzed information in the Hong Kong Diabetes Surveillance Database, which covers the entire population of Hong Kong (over 7.3 million people, mostly of Chinese ethnicity) and captures over 90% of total medical services in the region.

The analysis spanned the years 2001 to 2016 and included people with diabetes who were aged 20 years and older (380,007 women and 390,071 men). Information about deaths came from the Hong Kong Death Registry.

The data did not distinguish between type 1 and type 2 diabetes, though 95% of people in Hong Kong with diabetes have type 2 diabetes.

Between 2001 and 2016 there were 88,437 deaths among women with diabetes and 96,645 deaths among men with diabetes. Overall, age-standardized mortality rates from any cause declined among all people with diabetes, and the percentage decline was similar for women (53.5%) and men (52.3%).

Compared to people without diabetes, women with diabetes were 3.3 times more likely to die from any cause in 2001 and 1.7 times more likely to die from any cause in 2016 (standardized mortality ratio [SMR], 3.28 and 1.67, respectively). 

Men with diabetes were 2.8 times more likely to die from any cause in 2001 and 1.5 times more likely to die from any cause in 2016 (SMR, 2.82 and 1.50, respectively).

"Data from our study showed that both A1c and LDL-cholesterol levels have improved significantly at the territory-wide level, indicating that people were benefiting from the diabetes care programs," Wu and colleagues indicate.

What's Happening Among Younger People With Diabetes?

Overall mortality rates declined at a slower rate among younger compared to older people with diabetes.

Among those aged 20-44 years, overall mortality rates only declined by 1.2% per year in women and 3.2% per year in men, a result that was not statistically significant.

In contrast, among those aged 45-59 years all-cause mortality rates significantly declined by 5.3% per year in women and 5.4% per year in men (P < .05 for both). Among those aged 60-74 years rates of all-cause mortality declined at an even higher rate at 7.6% per year in women and 6.4% per year in men (P < .05 for both).

Compared to people aged 20-44 years without diabetes, similarly aged women with diabetes were 6.1 times as likely to die from any cause in 2001 and 4.9 times as likely to die from any cause in 2016 (SMR, 6.10 and 4.92, respectively). 

Men with diabetes in this age group were 7.9 times more likely to die from any cause in 2001 and 4.95 times as likely to die from any cause in 2016 (SMR, 7.86 and 4.95, respectively).

"In our study, the improvements in the control of A1c and LDL-cholesterol were...generally less marked in the youngest age group than in other age groups," the authors write.

"There is now increasing evidence highlighting poor adherence to treatment and medical follow-up and high levels of psychosocial stress in young people with diabetes," they emphasize.

However, they also caution, "it is important to note that the nonstatistically significant changes in all-cause mortality rates and imprecise SMRs in young people may, in part, be due to the small number of deaths in this age group."

CVD and Cancer Deaths Declining Among Those With Diabetes

Death rates from cardiovascular disease and cancer declined overall (women: 78.5% and 59.6%, respectively; men: 72.2% and 65.1%, respectively).

However, cancer remained the leading cause of death among people with diabetes aged 45-74 years.

Results also showed an overall shift away from cardiovascular disease toward pneumonia as the leading cause of death in the oldest age group (over 75 years).

Because very few deaths occurred among those aged 20-44 years, researchers could not calculate cause-specific deaths in this age group.

Wu has reported receiving partial support by a research grant from the Asia Diabetes Foundation. The authors have reported no relevant financial relationships.

Diabetologia. Published online January 17, 2020. Abstract

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