Type 1 Diabetics Need More Than Tight Glucose Control

For the last 50 years we have seen declines in renal failure, neuropathy and premature deaths, but not a decline in coronary artery disease. More attention is needed for lipids and hypertension, much earlier in the disease.

Improvements in type 1 diabetes care over the past 50 years have led to declines in premature deaths, renal failure, and neuropathy, but not to significant changes in the rates of coronary artery disease, overt nephropathy, or retinopathy.

Those mixed results, described in a study published in the May 1 issue of Diabetes, came from a University of Pittsburgh team that looked at complications occurring over 20 to 30 years in patients diagnosed from 1950 to 1980. with type 1 disease.

They found that patients diagnosed in the 1950s had a fivefold higher rate of premature mortality after 25 years of follow-up than patients who were diagnosed in the 1970s. In addition, renal failure rates dropped from 31% at 30 years post-diagnosis among patients diagnosed in the 1950s, to 18% among those diagnosed from 1964 onwards.

Despite these improvements, there were no differences across the various time periods for rates of cardiovascular disease or cardiac interventions, even when they controlled for the increased frequency of revascularization procedures in the later decades of the study.

"Doctors have long considered type 1 diabetes a small blood vessel problem, so they have traditionally not focused on the potential large blood vessel complications, such as cardiovascular disease," said Georgia Pambianco, M.S., M.P.H., of the Pittsburgh Epidemiology of Diabetes Complications Study.

"However, our study suggests that doctors and their patients need to pay more attention to factors that affect the larger blood vessels, such as lipids and blood pressure," she added.

Ob the good news side, the authors saw a decreasing trend by diagnosis year for mortality, renal failure, and neuropathy across all time intervals (P <0.05). For example, patients diagnosed between 1950 and 1959 had a fivefold higher death rate at 25 years than did those diagnosed in the 1970s.

Renal failure rates also decreased over time, with people diagnosed from 1964-on having significantly better outcomes. At 20 years, only 4% of those diagnosed after 1964 had renal failure, compared with 16% of those who were diagnosed in the 1950s and followed for 20 years. After 30 years, renal failures rates were 31% for the 1950s cohort, compared with 18% for the 1965-69 cohort. Men overall were significantly more likely to have renal failure than women by 30 years (P<0.05).

Symptomatic autonomic neuropathy also showed a steady decline across all cohorts at 20 and 25 years (P < 0.05 and <0.06, respectively), and confirmed distal symmetric polyneuropathy trended even lower at both time periods.

On the grimmer side, despite the improvements in death rates, renal failure, and neuropathies, there were no significant differences across diagnosis cohorts at 30 years in the rates of coronary artery disease events or procedures.

"Because revascularization interventions may have increased with time, analyses were repeated, with coronary artery disease limited to myocardial infarction coronary artery disease death," the authors wrote. "No cohort differences were seen at either 20 or 30 years (pooled rates of 3.5% and 15%, respectively), whereas at 25 years (overall rate was 8%), the rates were marginally lower in the latter cohorts (P <0.30). Coronary artery disease rates were similar by sex within each cohort."

They also found that both proliferative retinopathy rates and overt nephropathy rates showed only non-significant declines at 20 years (P < 0.16 and P < 0.13, respectively) and no change at 25 years, suggesting that major change has been delay not prevention.

"We were, in fact, both surprised and disappointed that there were no improvements in cardiovascular and retinopathy disease rates, particularly because other complications improved so dramatically," said Trevor Orchard, M.D., a professor of epidemiology, medicine and pediatrics at the University of Pittsburgh Graduate School of Public Health.

"Our data show that focusing solely on blood-glucose control is only postponing, not preventing, some of the more significant complications of this disease," he added.
Dr. Orchard said that patients with type 1 diabetes appear to need more aggressive cardiovascular interventions, such as the use of statins for lipid control and antihypertensive agents for blood pressure control, adding that these interventions should probably be started at an earlier age than currently recommended.

"This childhood-onset group is at a higher risk for cardiovascular disease even at early middle age," he said. "Waiting until they are adults to treat their lipids is too late."

Pambianco G et al. "The 30-Year Natural History of Type 1 Diabetes Complications: The Pittsburgh Epidemiology of Diabetes Complications Study Experience." Diabetes 55:1463-1469, 2006

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