Multiple complications among people with diabetes from Finland: an 18-year follow-up in 1994-2011.

OBJECTIVE: In this study, we examined trends in severe diabetes-related complications (acute myocardial infarction, stroke, lower extremity amputation, and end-stage renal disease) and prevalence of multiple complications in a total population with diabetes in Finland during an 18-year period. RESEARCH DESIGN AND METHODS: The total population with diabetes aged 30 years or older in 1994-2011 was obtained from several Finnish health registers. Only the first episode of each end point was included in the analysis. We examined trends in the prevalence of these end points using age-standardization and changes in these end points were analyzed using repeated-measures Poisson regression models. RESULTS: The prevalence of single comorbidities decreased during the study period, especially for acute myocardial infarction and stroke. The age-adjusted and diabetes duration-adjusted risk of having one of these end points decreased throughout the study period among persons with type 2 diabetes. Among women, the risk ratio was 0.71 (0.63 to 0.79) in 2006-2011 compared to 1994-1999, and among men, the figure was 0.72 (0.66 to 0.78). In type 1 diabetes, the risk of multiple serious complications increased. We further found increased mortality risk among persons with any of these complications irrespective of diabetes type. CONCLUSIONS: Our results concerning the development of risk of complications suggest improvements in the management of diabetes. More attention needs to be paid to the prevention of complications among older persons and those with longer history of diabetes to prevent clustering of complications and to prevent the diabetes epidemic in the population to reduce the public health burden of diabetes.

Increased cancer mortality in diabetic people treated with insulin: a register-based follow-up study.

BACKGROUND: The national 10-year Development Programme for the Prevention and Care of Diabetes (DEHKO) was launched in Finland in 2000. The program focused on improving early diagnosis of type 2 diabetes and preventing diabetes-related complications. The FinDM database was established for epidemiological monitoring of diabetes and its complications. This study monitors mortality trends among people with diabetes during the DEHKO programme. METHODS: A database obtained from a compilation of several administrative national health registers was used to study mortality in people with diabetes in 1998-2007. Relative excess mortality between people with and without diabetes was analyzed using Poisson regression models. RESULTS: The number of diabetic people in Finland increased by 66% from 1997 reaching 284 832 in 2007. Like among non-diabetic people, all-cause mortality decreased in people with diabetes. Overall excess mortality remained high in people with diabetes; in 2003-2007 RRs in the non-insulin treated was 1.82 for men and 1.95 for women and in the insulin treated 3.45 and 4.29, and excess coronary heart disease mortality in the insulin treated: RR was 4.71 in men and 7.80 in women. A striking result was mortality from neoplasms; an increase in mortality emerged in almost every age group of insulin treated women. CONCLUSION: Compared to non-diabetic people our monitoring showed declining excess mortality in non-insulin treated diabetic people mainly due to a decrease in mortality from cardiovascular diseases. For insulin treated, relative overall excess mortality remained unchanged and mortality from neoplasms increased among women.

Socio-economic predictors of mortality among diabetic people.

BACKGROUND: The present study examines the role of six aspects of socio-economic status (income, occupational position, education, unemployment, living alone and type of residential area) in mortality among types 1 and 2 diabetic people in Finland. All-cause mortality and causes of deaths (for example, alcohol diseases) are assessed. METHODS: People with diabetes aged 30-79 years in 2000-03 were identified from national registers. The data comprised 528 734 person-years and 18 841 deaths. Relative mortality risks were obtained from Poisson regression models. RESULTS: Among type 1 diabetic men, mortality differences were largest for long-term unemployed (aged 30-64 years); RR 3.85 (3.00-4.94) compared with the employed, and for low (vs. high) income group; RR 1.96 (1.78-2.17). The findings were similar for type 2 men; RR 2.58 (2.16-3.09) for unemployment and 1.61 (1.53-1.69) for income. In type 1 diabetic women, largest differences were found according to unemployment; RR 3.32 (1.88-5.88) and education (lowest vs. highest education); RR 2.35 (1.84-3.00), but in type 2 diabetes, the strongest determinants were disposable income; RR 1.55 (1.44-1.66) and education; RR 1.50 (1.33-1.70). In most socio-economic determinants, relative differences were largest in deaths due to diabetes and alcohol diseases. CONCLUSIONS: Five aspects of socio-economic position were related to mortality among diabetic people in Finland. No systematic mortality differences were, however, found for type of municipality of residence. These findings together with the role of deaths from alcohol diseases and diabetes in mortality trends, indicate that different aspects of social disadvantage are important predictors of mortality among diabetic people.

Socioeconomic differences in mortality among diabetic people in Finland.

AIMS: A clear socioeconomic gradient in mortality emerged among diabetic people in Finland from the early 1980s to the early 1990s. The present study examines whether this development continued between 1991 and 2003. METHODS: People with diabetes aged 30-79 in 1991-2002 were identified in the national registers, and followed up for mortality until 31 December 2003. The data comprised 1,407,025 person years and 59,917 deaths. RESULTS: From 1991-1994 to 1995-1999, the all-cause mortality among diabetic people decreased 20% for men and 26% for women among non-manual workers compared with 14% and 19% respectively among manual workers. The socioeconomic differences increased particularly in mortality from coronary heart disease and causes related to smoking and excessive alcohol use. From 1995-1999 to 2000-2003 the socioeconomic mortality disparity remained stable except for emerging socioeconomic differences in neoplasm deaths among women. Persons with type 1 diabetes showed much larger socioeconomic differences in deaths from alcohol related diseases (RR: men 1.97, women 2.13) compared to persons with type 2 diabetes (RR: men 1.20, women 1.05). CONCLUSIONS: During the 1990s disparities in mortality between socioeconomic groups among diabetic people increased due to a more favourable trend among non-manual workers compared to manual workers in deaths from coronary heart disease and causes of death related to smoking and excessive alcohol use. From the late 1990s to 2000-2003, inequality in mortality remained stable except for emerging socioeconomic differences in neoplasm deaths among women.

Coronary heart disease among diabetic and nondiabetic people - socioeconomic differences in incidence, prognosis and mortality.

OBJECTIVE: To investigate coronary heart disease (CHD) morbidity and mortality and their patterning by socioeconomic status among diabetic and nondiabetic individuals in Finland. METHODS: All diabetic persons aged 35-74 years entitled to free anti-diabetic medication were drawn from the 1991-1996 national health insurance files along with nondiabetic referents. Outcome events for up to 6 years of follow-up, corresponding to 418,987 and 867,813 person-years in diabetic and nondiabetic people, respectively, were identified from national health insurance, hospital discharge and causes of death registers using personal identification codes. RESULTS: The annual CHD incidence for diabetic women and men was 2.7% and 3.7%, respectively, corresponding to relative risks of 3.55 (95% CI: 3.43-3.67) and 2.64 (95% CI: 2.56-2.72) compared to nondiabetic persons. The impact of diabetes on CHD mortality was greater, with relative death rates of 6.04 and 3.42 for women and men, respectively. CHD mortality and incidence displayed systematic socioeconomic trends with higher rates among worse-off diabetic and nondiabetic people, although gradients were generally steeper for nondiabetics. In the diabetic population, socioeconomic differences were rather similar for sudden CHD deaths and nonfatal CHD incident cases. For both genders, socioeconomic differences in mortality after CHD diagnosis were small in both diabetic and nondiabetic persons, except for the lowest compared to the highest income quintile. CONCLUSIONS: Socioeconomic CHD mortality differences among diabetic people in Finland were mainly explained by higher CHD incidence and particularly sudden deaths without prior CHD diagnosis. No systematic socioeconomic differences were found in long-term prognosis after CHD diagnosis.

Widening socioeconomic mortality disparity among diabetic people in Finland.

BACKGROUND: A clear social class gradient in mortality has been consistently reported among western populations. However, in the early 1980s in Finland, no major socioeconomic differences in mortality were found among people with diabetes. The present study examines whether this exceptional finding persisted in the 1990s. METHODS: All residents of Finland aged 30 to 74 in the 1980 and 1990 population censuses were classified as diabetic or non-diabetic according to entitlement to reimbursement for diabetes medication. The patient's age at onset of the disease was used as a proxy for diabetes type. All diabetic and non-diabetic persons were followed up for mortality in 1981-1985 and 1991-1996. Age-adjusted relative death rates were obtained from Poisson regression models. RESULTS: From the early 1980s to the early 1990s marked socioeconomic mortality disparities favouring the better-off emerged among diabetic people. The increase in socioeconomic mortality differences from 1981-1985 to 1991-1996 was mainly due to divergence in deaths from diabetes, which contributed 52% of the increase in mortality disparity among women and 35% among men, and from cardiovascular diseases, whose contribution was 21% for women and 25% for men. CONCLUSIONS: From the early 1980s to the 1990s in Finland a clear socioeconomic gradient in mortality emerged in every age group of diabetic people. This was largely due to a much worse development among blue-collar than white-collar workers in deaths from diabetes and cardiovascular diseases.