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Risk Factors Associated with Mortality during Early Adulthood in Type 1 Diabetes

Better "bridge" care for patients transitioning from pediatric to adult health care is needed, say researchers, as the findings show a higher mortality rate especially among young women….

 

Researchers compared patients with type 1 diabetes with an age- and sex-matched cohort without diabetes to determine the association between pediatric clinical factors and the risk for mortality during early adulthood.

 

They found hazard ratios of 1.5 for a 1% increase in pediatric HbA1c level, 3.8 for four episodes of severe hypoglycemia, and 6.21 for a low-level socioeconomic background. The standardized mortality ratio was 1.7 for men and 10.1 for women.

 

Researchers suggest that more intensive management should be considered for patients with type 1 diabetes at higher risk for mortality during early adulthood.

 

To assess mortality rates and factors associated with early demise in those with type 1 diabetes, Cooper et al conducted an observational study in which they utilized data from the Western Australian Children’s Diabetes Database and identified a cohort of 1309 individuals with type 1 diabetes over the age of 18 years. An age- and sex-matched cohort was identified through the Western Australia Birth Register, with a case:control ratio of 1:5, providing 6451 controls. Use of the Western Australia Death Register allowed for calculation of mortality rates with comparison of the number of deaths that occurred prior to age 38 years.

 

The authors concluded that those with type 1 diabetes had a higher mortality rate compared with the control cohort, with a standardized mortality ratio of 3.3 (95% CI, 2.0–5.2). Interestingly, the ratio was found to be higher for females at 10.1 (95% CI, 5.2–17.7) vs males at 1.7 (95% CI, 0.7–3.3).

 

While previous studies have examined mortality rates, the present study extends these findings by utilizing a multitude of clinical factors during pediatric care such as potential risk factors related to higher mortality rates. Additionally, the study is further strengthened as the database used has been in existence for over 25 years and captures nearly all cases of diabetes in the region. Factors that contributed to higher mortality risk included 1% increase in mean pediatric HbA1c, over four episodes of hypoglycemia, and lower socioeconomic status. Importantly, the authors performed a multivariate analysis and confirmed that this did not drastically impact the magnitude of the mortality rates initially observed. Although these findings may not be surprising, identification of these characteristics as potential risk factors may allow for targeted education of individuals with these traits.

 

Recently, much attention has been paid to transition of care and ensuring that emerging adults are not lost to follow-up. The present study highlights that the highest mortality rate was seen in those between the ages of 25 and 29 years.

 

Further assessment of the disparate effects of diabetes diagnosis on the mortality rate in females is warranted. Cause of death was found to have a higher standardized mortality rate for both accidental poisoning by and exposure to noxious substances and suicide; this suggests that greater mental health screening and support may impact the higher mortality rates seen in young adults with diabetes. The clinical factors identified to be associated with a higher mortality rate in the present study could serve to inform the development of "bridge" programs, especially targeting those at highest risk, thereby allowing our adolescents to safely and successfully cross over to adult care.

 

Practice Pearls:
  • People with childhood-onset type 1 diabetes have higher mortality rates in early adulthood.
  • At particularly high risk are women, those with a history of poor HbA1c levels, those with recurrent severe hypoglycemia during pediatric management, and those from a low socio-economic background.
  • These groups may benefit from intensified management during transition from paediatric to adult care facilities.
Mortality During Early Adulthood in a Population-Based Cohort of Childhood-Onset Type 1 Diabetes
Diabet. Med. 2014 Dec 01;31(12)1550-1558, MN Cooper, NH de Klerk, TW Jones, EA Davis Abstract