Predictors of 5-year mortality of 1,323 patients newly diagnosed with clinical type 2 diabetes in general practice With special emphasis on self-rated health Niels de Fine Olivarius Volkert Siersma Anni B. S. Nielsen Lars J. Hansen Lotte Rosenvinge Carl Erik Mogensen

Important predictors of mortality in type 2 diabetic patients Age Sex Blood glucose level Blood pressure Lipids Urinary albumin excretion Smoking Cardiovascular disease

Self-rated general health (SRH) Question to patients: "In general, how would you rate your health at present?"  Excellent  Good  Fair  Poor  Very poor

Implications of SRH In the general population SRH predicts both future morbidity such as ischaemic heart disease and mortality independently of established risk indicators, but evidence of this is scarce for people with diabetes

Aim of the study To investigate the contribution to 5-year all- cause and cardiovascular mortality of the characteristics found at the more or less acute state at diabetes diagnosis. In particular, we evaluated the possible independent effect of SRH on mortality.

Flow chart Inclusion criteria: 1)Diabetes mellitus diagnosed from 1 March 1989 to 28 February )Whole blood or plasma glucose concentration ≥ 7.0/8.0 mmol/l measured at a major laboratory 3)Age 40 years or older Eligible patients, n=1,543 Primary exclusions: Severe somatic disease, n=50 Severe mental illness, n=50 Declined to consent, n=62 Analysed, n=1,323 Secondary exclusions: Steroid treatment at diagnosis, n=46 Non-white ethnicity, n=12 Available patient sample, n=1,381

Outcome variables From the Danish National Death Register: All-cause mortality Cardiovascular mortality Median observation time: 5.2 years Number of deaths: 298

Baseline predictor variables Sex Age Living alone Education Diagnostic plasma glucose Fasting triglyceride Total cholesterol Urinary albumin Body mass index Resting heart rate Systolic blood pressure Physical activity Smoking Self-rated health Cardiovascular disease Diabetic retinopathy Peripheral neuropathy Cancer (former or present)

Statistical analysis Predictors of 5-year mortality The influence on all-cause and cardiovascular mortality of patient characteristics measured at diabetes diagnosis was investigated in Cox proportional hazard models. In these models the death intensity was represented as a function of patient age, multiplicatively affected by the characteristics.

Predictors of 5-year mortality Cox regression analyses * p<0.05 ** p<0.01 *** p<0.001

Estimated life expectancy according to predictors at diagnosis. Men only Values are median life expectancy according to baseline characteristics calculated from a Cox model which includes all baseline characteristics. The other faxtors in the model are kept fixed.

Implications 1 – the easy part In newly diagnosed diabetic patients: be attentive to patients who are/have - Relatively young - Inactive - Cardiovascular disease - (Micro)albuminuria

What does SRH measure? SRH ≈ A personal estimation of longevity? … taking into account - Current and previous health - Symptom perception - Personal resources - Physical functioning - Health behaviour - Comparison with age peers - Familial disposition

The SRH hypothesis SRH primarily carries risk information which cannot be uncovered by present-day technology, and this information has to a considerable degree a biological basis

A question from a colleague Non-excellent SRH Increased mortality “Does it mean that GPs can concentrate on making the patients feel content and happy about their lives and not worry so much about blood glucose, blood pressure and lipids” ?

Implications 2 - SRH This finding could motivate general practitioners and practice nurses to discuss perceptions of health with newly diagnosed diabetic patients and be attentive to patients with suboptimal health ratings Non-excellent SRH Increased mortality

The problem of frailty Frailty ≈ Heterogeneity among our patients in their susceptibility to dying Undiagnosed or even unascertainable conditions may have contributed to precipitate the diabetes diagnosis, and these conditions may be associated with both poor SRH or low physical activity and high risk of death.

Approaching heterogeneity Sub-group analysis of "healthy" patients (n=696) without CVD, diabetic retinopathy, peripheral neuropathy, cancer and proteinuria Analysis of deaths occurring within 3 years of diabetes diagnosis (n=153) and after this time (n=145) Analyses excluding deaths occurring within 6 months of diabetes diagnosis (n=25)

Predictors of 5-year all-cause mortality Cox regression analysis Bold: p<0.05

The excess mortality of type 2 diabetic patients