medwireNews: Research using the Swedish National Diabetes Registry shows that diabetes confers a particularly high relative risk for mortality and multiple cardiovascular disease (CVD) outcomes in people who are young when diagnosed.
The risk increase for some outcomes, compared with people of the same age and sex without diabetes, was as high as four- to fivefold for people diagnosed by the age of 40 years, whereas people diagnosed with diabetes when they were older than 80 years had a reduced risk for most outcomes.
“The profile of an individual developing diabetes, say, in his 30s or 40s, is quite different – vastly different almost – from someone developing diabetes in their 80s, who tends to be leaner or less evidently obese,” study author Naveed Sattar (University of Glasgow, UK) told medwireNews.
He believes that the relative plasticity and good health of organs in young people means that “to develop diabetes at a younger age you have to have much more insulin resistance, much more fat gain, to overwhelm the pancreas’s ability to make insulin.”
This is quite different from, for example, a relatively lean 80-year-old in whom “the pancreas has now got so old that it just happens to trickle into diabetes,” he said, adding: “So it’s a different process and I don’t think people really understand that.”
In between these ages, the risk associated with diabetes “generally declined” with each 10-year increase in age at diabetes diagnosis, show the findings in Circulation.
The study included 241,278 people with type 2 diabetes who were initially free of CVD, matched with 1,363,612 people from the general population on age, sex, and county. The analysis accounted for diabetes duration, so the increased risk reflects “the excess risk that being diagnosed with diabetes at a particular age has upon an individual,” said Sattar.
Over a median follow-up of 2.52 years, people diagnosed with diabetes by the age of 40 years had a 2.05-fold increased mortality risk relative to their matched controls, composed of a 2.72-fold and 1.95-fold increased risk for CVD and non-CVD mortality, respectively.
The researchers also looked at risks for other CVD outcomes; the fold increases ranged from 1.95 for atrial fibrillation to 4.77 for heart failure. These risk increases remained in people diagnosed with diabetes in their 80s, but were “substantially attenuated,” with fold increases ranging from 1.09 to 1.42.
The team says these findings highlight the “need to reassess and discuss treatment goals and aggressiveness of interventions in people diagnosed after 80 years of age, particularly in asymptomatic individuals.”
But they also underline the need for intensive treatment of younger people with diabetes; Sattar noted that current CVD guidelines have a higher threshold for statin use in younger versus older people with hyperlipidemia.
“On the one hand you don’t want to over-medicate people, particularly younger people,” he said. But he stressed that this less intensive approach “ignores the point that if someone develops diabetes at the age of 35 years for example they’ve got a higher lifetime risk and they’ve got more life–years to lose, so actually we might want to think about giving more people who develop diabetes in their 30s statins than we are currently.”
He added: “It gets tricky, you know: what do you do with a 21-year-old who has developed type 2 diabetes? Do you want to put them on a statin straight away? But they’re going to lose a lot more life–years according to our paper than someone who develops diabetes at 72 and immediately gets put on a statin.”
Sattar said he would like to “get some guideline committees to start reflecting on this, and try to maybe be a bit more prescriptive for under 40-year-olds with type 2 [diabetes].”
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