medwireNews: Mortality in people with diabetes is declining in most high-income countries, in many cases faster than in people without diabetes, researchers report.
Dianna Magliano (Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia) and colleagues drew on 19 sources from 16 high-income countries that had mortality data available for part or all of the period 1995–2016.
They found that age- and sex-standardized all-cause mortality rates among people with diabetes significantly declined during this period in 17 of these data sources. The only exceptions were found in data from Norway, in which the decrease was not statistically significant; and from Catalonia, Spain, which recorded a significant increase.
The data sources used comprised nine administrative sources, five health insurance databases, four registries, and one nationally representative survey (the US National Health Interview Survey). Ten datasets were restricted to type 2 diabetes and the others covered all types. The standardized mortality rates ranged from 13.3 per 1000 person–years in Spain in 2011 to 42.1 per 1000 person–years in Latvia in 2000.
The largest declines in mortality occurred in the east and southeast Asian data sources, ranging from 3.5% in Taiwan to 4.2% in Hong Kong. In these countries, the annual changes in the standardized mortality ratio (SMR) versus people without diabetes were nonsignificant or significantly negative, indicating that the mortality reductions paralleled or even exceeded those seen in people without diabetes.
The researchers suggest this could be due to recent improvements in models of care and/or overall healthcare systems in these countries. These include the introduction of universal healthcare in Hong Kong, along with “major changes […] to integrate diabetes management into health care, expanding services across primary, secondary, and tertiary care.”
In Catalonia, the only region with increasing mortality among people with diabetes, the annual SMR change was negative, indicating that mortality had increased even more in people without diabetes.
“Increasing mortality in Spain has been attributed to increased influenza activity during this period and restrictions in the health-care system since the global financial crisis in 2008,” write the researchers in The Lancet Diabetes & Endocrinology.
Another seven data sources showed faster mortality declines for people with diabetes than those without. These data came from Hong Kong, Singapore, Denmark, Latvia, Canada, and the USA.
Five data sources showing overall declines in mortality had a positive annual change in SMR, indicating that the mortality declines were significantly slower in people with diabetes than in those without. These sources were from Israel, Italy, Scotland, Norway, and Hungary.
In a linked commentary, Jennifer Manne-Goehler (Harvard Medical School, Boston, Massachusetts, USA) and David Flood (University of Michigan, Ann Arbor, USA) caution that some of the data sources used only capture people who engage with the healthcare system, and that mortality trends could be different for disengaged individuals.
And they also stress these mortality reductions may not equate to a reduced overall burden of diabetes, which could continue to increase as a result of demographic changes.
The commentators also point out that nearly 80% of people with diabetes live in low- and middle-income countries, but “there is a paucity of data—particularly, longitudinal data—on all-cause mortality in people with diabetes in these regions.
They sat that data are urgently needed and conclude: “Further research to explore the mechanisms for decreasing mortality in high-income settings will be crucial to inform evidence-based strategies to extend these benefits to people living with diabetes globally.”
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Lancet Diabetes Endocrinol 2022; doi:10.1016/S2213-8587(21)00327-2
Lancet Diabetes Endocrinol 2022; doi:10.1016/S2213-8587(22)00001-8