Younger Type 2 Diabetes Patients Face Higher Mortality and CVD Risks

The younger a patient is when diagnosed with type 2 diabetes, the worse their cardiovascular disease prognosis and the shorter their lifespan, results from a new study show.

When compared with matched controls without diabetes mellitus, for example, individuals diagnosed with diabetes at 40 years or younger had a more than twofold greater risk for total mortality, a nearly threefold higher risk for cardiovascular mortality, and a more than fourfold greater risk for heart failure and coronary heart disease.

The incremental risks associated with type 2 diabetes are attenuated with an increasing age of diagnosis, such that there is no increased risk of all-cause or cardiovascular mortality in adults aged 80 years or older diagnosed with the metabolic disorder.

“Our paper adds more fuel to the idea that being diagnosed with type 2 diabetes in your 20s, 30s, or even 40s is associated with considerably more harm as it relates to the excess risk of complications,” senior investigator Naveed Sattar, MD, PhD (University of Glasgow, Scotland), told TCTMD. “There are considerably more life-years lost. When you’re around 20 years old, and diagnosed with type 2 diabetes, you will lose more than a decade of life expectancy, which is on par with type 1 diabetes. Whereas if you develop type 2 diabetes at the other end of the age spectrum, 80 years old, you don’t lose any life expectancy.”

The bottom line, said Sattar, is that type 2 diabetes is a completely different disease in terms of toxicity in the very young and old.

Younger Age, Higher Excess Risk vs Healthy Controls

The new study, which was published April 8, 2019, in Circulation, is an attempt to comprehensively assess the excess cardiovascular risk over the lifespan imposed on individuals with a diagnosis of type 2 diabetes. Previous studies have shown that younger individuals with type 2 diabetes are at an increased risk of cardiovascular disease, but those analyses did not compare mortality risks from the time of diagnosis, according to the investigators.

If you develop diabetes at age 80, should we really worry about sugar targets as long as the patients are not symptomatic? Naveed Sattar

Using data from the Swedish National Diabetes Registry, the researchers identified 214,278 patients with type 2 diabetes but without cardiovascular disease (mean age of diagnosis 62 years) and these patients were matched by age, sex, and country of residence with 1,363,612 healthy controls. The median follow-up was 5.63 years, a period in which there were 194,197 deaths, 66,184 cardiovascular deaths, 51,837 MIs, 60,346 strokes, and 61,501 heart failure hospitalizations.

Individuals without cardiovascular disease diagnosed with type 2 diabetes at 40 years or younger had the highest risk of cardiovascular morbidity and mortality when compared with controls. The hazard ratios for various clinical outcomes in this young population were as follows:

• HR 2.05 (95% CI 1.81-2.33) for total mortality
• HR 2.72 (95% CI 2.13-3.48) for cardiovascular mortality
• HR 1.95 (95% CI 1.68-2.25) for noncardiovascular mortality
• HR 4.33 (95% CI 3.82-4.91) for coronary heart disease
• HR 3.41 (95% CI 2.88-4.04) for acute MI
• HR 4.77 (95% CI 3.86-5.89) for heart failure

The risk of stroke was more than threefold higher in men and women 40 years and younger diagnosed with type 2 diabetes, while the risk of atrial fibrillation was twofold higher. An older age of diagnosis was associated with a lower risk of cardiovascular morbidity and mortality, such that by the time a patient was 80 years old and diagnosed with type 2 diabetes, there was no longer an increased risk of mortality compared with controls.

When investigators included patients with a history of cardiovascular disease, the results were largely similar—individuals diagnosed with diabetes at a younger age had a significantly increased risk of all-cause and cardiovascular death, as well as cardiovascular-related morbidity, and this risk declined with rising age of diagnosis.  

Estimating the impact of diabetes on longevity, the researchers determined that a diagnosis of type 2 diabetes at roughly 15 years of age led to a loss of approximately 12 years of life. A diagnosis at 45 years lessened the lifespan by roughly 6 years, while a diagnosis at 65 years shaved off 2 years of life. At 80 years, a diagnosis of type 2 diabetes had no effect on life-years lost.  

More Aggressive With Treatment Earlier  

The results, according to Sattar, should stimulate guideline committees to consider being more prescriptive with medical therapy in this younger population.

“If people developed type 2 diabetes under age 40, we typically are not that aggressive with cardiovascular protection as we are with patients older than 40 years,” said Sattar. “We’ve always hesitated in giving younger people drugs, such as statins and blood pressure-lowering medications. We also know it’s harder to control blood sugar levels when they develop diabetes younger because it progresses much faster.”

To TCTMD, Sattar noted that those who develop type 2 diabetes at an earlier age have a significantly higher body mass index (BMI) than those diagnosed later in life. For example, the BMI for those diagnosed at 40 years and younger was 33.6 kg/m2, compared with 30.7 kg/m2 for those aged 51-60 years and 28.9 kg/m2 for those aged 71-80 years. While lifestyle modification remains the cornerstone of cardiovascular risk prevention, physically activity is much harder for these heavier, younger patients, he noted.

Nonetheless, physicians treating such patients need to also be aggressive with lifestyle and advocate for a dietary overhaul that can achieve significant weight loss, such as low-calorie diets. “Things that really make people lose 10, 15, 20 kilograms,” said Sattar. “Getting 2 or 3 kilograms isn’t really going to shift things very much.”

In contrast with aggressive therapy in these younger patients, the new paper also suggests a need to reassess treatment goals and aggressive interventions in people diagnosed with type 2 diabetes after 80 years of age. “If you develop diabetes at age 80, should we really worry about sugar targets as long as the patients are not symptomatic?” said Sattar. “Should we really bother screening for type 2 diabetes in this population? My answer is probably not. There is not much to be gained. If you have limited resources, we should concentrate those on younger people.”