Trends in cardiovascular risk factor management in type 1 diabetes by sex
Introduction
The incidence of type 1 diabetes continues to increase annually1 and with that comes a growing concern for the burden posed by diabetes-associated microvascular and macrovascular complications.2 Increased risk of cardiovascular disease (CVD) has been repeatedly recognized as a complication of type 1 diabetes, and recent data still suggest a 10-fold greater risk.3 There are multiple modifiable risk factors, such as HbA1c, blood pressure, lipids, smoking, and obesity, which can be intervened upon to reduce CVD risk in type 1 diabetes.4 Indeed, results from the Diabetes Control and Complications Trial (DCCT) demonstrated that intensive management of hyperglycemia greatly reduces the development and progression of micro5- and macro-vascular6 disease in type 1 diabetes, transforming care for these individuals. Unfortunately, years after the advent of intensive insulin therapy, the rates of CVD are still higher in type 1 diabetes compared to the general population, suggesting that tighter control of non-glycemic factors might be beneficial. However, to what extent improvements in cardiovascular risk factor control have occurred in the general type 1 diabetes population and whether they may differ between men and women, is not clear. An earlier study suggested poor adherence.7 In the present study, we aimed to assess trends in CVD risk factors among men and women over the 25-year follow-up of a cohort study of individuals with childhood-onset type 1 diabetes.
For >20 years, the American Diabetes Association (ADA) has disseminated key recommendations for diabetes care standards and guidelines in an attempt to improve management.8 Understanding how well these guidelines are attained may give insight into what areas of care are needed to potentially reduce the continuing high CVD rates. We therefore aimed to determine the proportion of individuals within this type 1 diabetes cohort falling within the guidelines set by the ADA for the prevention and management of diabetes complications. We additionally assessed trends over time in the proportions adopting intensive insulin therapy as well as in the proportions of overweight/obesity, hypercholesterolemia and hypertension, given their close interrelation with ADA goal attainment.
Section snippets
The Pittsburgh epidemiology of diabetes complications (EDC) study
The EDC study is a historical prospective cohort study of risk factors for complications resulting from childhood-onset (<17 years old) type 1 diabetes. Participants were either diagnosed, or seen within 1 year of diagnosis, at Children's Hospital of Pittsburgh between 1950 and 1980. The cohort, which has been shown to be representative of the Allegheny County, Pennsylvania, type 1 diabetes population,9 has been described in detail elsewhere.10,11 Briefly, participants have been followed by
Results
The baseline characteristics for the total cohort of childhood-onset type 1 diabetes (n = 658, 49.4% female), as well as the characteristics stratified by gender, are presented in Table 1. Overall, the median (interquartile range) age and duration of diabetes were 27 (21.9, 33.3) years and 18.5 (13.2, 25.5) years, respectively. HbA1c was high for both men and women, with an overall median of 8.6% (7.7%, 9.7%) or 70 mmol/mol (61 mmol/mol, 83 mmol/mol). The cohort had a median body mass index
Discussion
In this cohort of individuals with childhood-onset type 1 diabetes, we observed that the proportion falling within the ADA recommendations for HbA1c increased, whereas the proportion meeting the ADA recommendations for LDL-C gradually decreased over the 25-year follow up period, reflecting the lowering of LDL-C goals. On the contrary, attainment of blood pressure and triglyceride goals remained high throughout follow-up. When analyses were restricted to individuals age 35–45 years at each time
Conflict of interest statement
The authors declare no conflicts of interest.
Acknowledgments
We thank all study participants for their invaluable contributions as well as the Epidemiology of Diabetes Complications (EDC) study staff.
Funding sources
This research was supported by NIH grant DK34818 and the Rossi Memorial Fund.
Author contributions
KS conducted the analysis and wrote the manuscript; TC researched, analyzed data, and wrote/edited the manuscript; TJO designed the EDC study and reviewed/edited the manuscript. This study was part of author KS’ Master's essay.
Prior presentation
Preliminary results were presented in abstract form at the 76th Scientific Sessions of the American Diabetes Association, New Orleans, LA, 10–14 June 2016.
References (40)
- et al.
Complications of type 1 diabetes
Endocrinol Metab Clin North Am
(2010) IDF Diabetes Atlas
(2015)- et al.
A contemporary estimate of total mortality and cardiovascular disease risk in young adults with type 1 diabetes: the Pittsburgh Epidemiology of Diabetes Complications Study
Diabetes Care
(2016) - et al.
Type 1 Diabetes and Associated Cardiovascular Risk and Disease
The effect of long-term intensified insulin treatment on the development of microvascular complications of diabetes mellitus
N Engl J Med
(1993)Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes
N Engl J Med
(2005)- et al.
Has control of hypercholesterolemia and hypertension in type 1 diabetes improved over time?
Diabetes Care
(2005) Standards of medical care for patients with diabetes mellitus: position statement
Diabetes Care
(1995)- et al.
The Pittsburgh study of insulin-dependent diabetes mellitus: risk for diabetes among relatives of IDDM
Diabetes
(1982) - et al.
The prevalence of complications in insulin-dependent diabetes mellitus by sex and duration: Pittsburgh epidemiology of diabetes complications study-II
Diabetes
(1990)
Factors associated with the avoidance of severe complications after 25 years of insulin-dependent diabetes mellitus: Pittsburgh epidemiology of diabetes complications study-I
Diabetes Care
The hypertension detection and follow-up program
Prev Med
Heparin-Mn2+ quantitation of high-density lipoprotein cholesterol: an ultrafiltration procedure for lipemic samples
Clin Chem
Manual of Laboratory Operations: Lipid Research Clinics Program
Enzymatic determination of total serum cholesterol
Clin Chem
Quantitative determination of serum triglycerides by the use of enzymes
Clin Chem
Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge
Clin Chem
Role of cardiovascular risk factors in prevention and treatment of macrovascular disease in diabetes: consensus statement
Diabetes Care
Standards of medical care in diabetes 2008: position statement
Diabetes Care
The 1984 report of the joint national committee on detection, evaluation, and treatment of high blood pressure
Arch Intern Med
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