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Excess mortality and cardiovascular disease in young adults with type 1 diabetes in relation to age at onset: a nationwide, register-based cohort study
Open accessAbstract
Background People with type 1 diabetes are at elevated risk of mortality and cardiovascular disease, yet current guidelines do not consider age of onset as an important risk stratifier. We aimed to examine how age at diagnosis of type 1 diabetes relates to excess mortality and cardiovascular risk.Methods We did a nationwide, register-based cohort study of individuals with type 1 diabetes in the Swedish National Diabetes Register and matched controls from the general population. We included patients with at least one registration between Jan 1, 1998, and Dec 31, 2012. Using Cox regression, and with adjustment for diabetes duration, we estimated the excess risk of all-cause mortality, cardiovascular mortality, non-cardiovascular mortality, acute myocardial infarction, stroke, cardiovascular disease (a composite of acute myocardial infarction and stroke), coronary heart disease, heart failure, and atrial fibrillation. Individuals with type 1 diabetes were categorised into five groups, according to age at diagnosis: 0-10 years, 11-15 years, 16-20 years, 21-25 years, and 26-30 years.Findings 27 195 individuals with type 1 diabetes and 135 178 matched controls were selected for this study. 959 individuals with type 1 diabetes and 1501 controls died during follow-up (median follow-up was 10 years). Patients who developed type 1 diabetes at 0-10 years of age had hazard ratios of 4·11 (95% CI 3·24-5·22) for all-cause mortality, 7·38 (3·65-14·94) for cardiovascular mortality, 3·96 (3·06-5·11) for non-cardiovascular mortality, 11·44 (7·95-16·44) for cardiovascular disease, 30·50 (19·98-46·57) for coronary heart disease, 30·95 (17·59-54·45) for acute myocardial infarction, 6·45 (4·04-10·31) for stroke, 12·90 (7·39-22·51) for heart failure, and 1·17 (0·62-2·20) for atrial fibrillation. Corresponding hazard ratios for individuals who developed type 1 diabetes aged 26-30 years were 2·83 (95% CI 2·38-3·37) for all-cause mortality, 3·64 (2·34-5·66) for cardiovascular mortality, 2·78 (2·29-3·38) for non-cardiovascular mortality, 3·85 (3·05-4·87) for cardiovascular disease, 6·08 (4·71-7·84) for coronary heart disease, 5·77 (4·08-8·16) for acute myocardial infarction, 3·22 (2·35-4·42) for stroke, 5·07 (3·55-7·22) for heart failure, and 1·18 (0·79-1·77) for atrial fibrillation; hence the excess risk differed by up to five times across the diagnosis age groups. The highest overall incidence rate, noted for all-cause mortality, was 1·9 (95% CI 1·71-2·11) per 100 000 person-years for people with type 1 diabetes. Development of type 1 diabetes before 10 years of age resulted in a loss of 17·7 life-years (95% CI 14·5-20·4) for women and 14·2 life-years (12·1-18·2) for men.Interpretation Age at onset of type 1 diabetes is an important determinant of survival, as well as all cardiovascular outcomes, with highest excess risk in women. Greater focus on cardioprotection might be warranted in people with early-onset type 1 diabetes.Funding Swedish Heart and Lung Foundation.
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“The risk of diabetesrelated complications also remains notably high for all people with type 1 diabetes.1,2”
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“life expectancy remains reduced for individuals diagnosed with type 1 diabetes before age 10 years compared with both people diagnosed after 10 years and people without type 1 diabetes.1,2”
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“A recent risk tool, developed based on the Scottish/Swedish Diabetes Registry and validated in the Swedish National Diabetes Register can provide individualized risk predictions.793”
From 2023 ESC guidelines for the management of cardiovascular disease in patients with diabetes. (2023) · cites this paper as [793]
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Chen, X., Zhou, P., Zhang, M., Xu, Z., Zhao, Z., Lü, W., Chen, L., Luo, F., Chen, T., & Sun, C. (2021) · Frontiers in Endocrinology · doi:10.3389/fendo.2021.651589 · Cited by 27
Russo, G. T., Manicardi, V., Rossi, M. C., Orsi, E., & Solini, A. (2022) · Nutrition Metabolism and Cardiovascular Diseases · doi:10.1016/j.numecd.2022.08.011 · Cited by 28
Stătescu, C., Anghel, L., Benchea, L.-C., Tudurachi, B.-S., Leonte, A., Zăvoi, A., Zota, I. M., Prisacariu, C., Radu, R., Șerban, I.-L., et al. (2023) · International Journal of Molecular Sciences · doi:10.3390/ijms24065927 · Cited by 25
“45) for those diagnosed in the age range 0–10 years, with the risk levels being 90 times higher for women [27].”
BackgroundFornari, E., Piona, C. A., Rabbone, I., Cardella, F., Mozzillo, E., Predieri, B., Presti, D. L., Cherubini, V., Patera, I. P., Suprani, T., et al. (2020) · Pediatric Diabetes · doi:10.1111/pedi.13123 · Cited by 23
“The glucose control has a demonstrated long-term effect on CVD, also in children without other CVRFs.42 The need for prolonged time for glycemic control to influence cardiovascular risk may explain the nonsignificance of the association of HbA1c with the prevalence of major CVRFs in younger children.”
BackgroundPancreatic islet reserve in type 1 diabetes
Flatt, A. J., Greenbaum, C. J., Shaw, J., & Rickels, M. R. (2021) · Annals of the New York Academy of Sciences · doi:10.1111/nyas.14572 · Cited by 27
Sundberg, F., Nåtman, J., Franzén, S., Åkesson, K., & Särnblad, S. (2021) · Pediatric Diabetes · doi:10.1111/pedi.13211 · Cited by 24
“Early-onset type 1 diabetes (T1D) is associated with a high risk of early cardiovascular complications and premature death.(1) The strongest modifiable risk factor associated with diabetes-related mortality and morbidity due to microvascularand macrovascular complications is HbA1c.”
BackgroundSelf-citationZhang, Y., Guo, Q., Jiang, G., & Zhang, C. (2021) · Archives of Biochemistry and Biophysics · doi:10.1016/j.abb.2021.109000 · Cited by 24
Diabetic kidney disease in pediatric patients: A current review
Muntean, C. V., Stârcea, I. M., & Bănescu, C. V. (2022) · World Journal of Diabetes · doi:10.4239/wjd.v13.i8.587 · Cited by 24
Oh, R., Kim, S., Park, S., Jang, M., Cho, S. H., Kim, J. Y., Lee, Y., Jin, S., Hur, K. Y., Kim, J. H., et al. (2025) · Cardiovascular Diabetology · doi:10.1186/s12933-025-02712-w · Cited by 23
Cardiovascular disease in women: traditional and sex-specific risk factors
Appelman, Y., Gulati, M., van Lennep, J. E. R., Shaw, L. J., & Merz, C. N. B. (2025) · European Heart Journal · doi:10.1093/eurheartj/ehaf1001 · Cited by 31
Montagud‐Marrahí, E., Molina-Andújar, A., Pané, A., Ruiz, S., Amor, A. J., Esmatjes, E., Ferrer, J., Banon-Maneus, E., Hermida, E., Musquera, M., et al. (2021) · Transplantation · doi:10.1097/tp.0000000000003710 · Cited by 26
“INTRODUCTION Diabetes is a highly prevalent disease(1) with an important cardiovascular burden, being cardiovascular disease (CVD) the main cause of death of these patients.(2,3) Similarly, chronic kidney disease is a well-described independent cardiovascular risk factor leading, therefore, to a significant morbidity…”
BackgroundImmunotherapy for type 1 diabetes
Allen, L. A., & Dayan, C. M. (2021) · British Medical Bulletin · doi:10.1093/bmb/ldab027 · Cited by 24
Seget, S., Rusak, E., Polańska, J., & Jarosz-Chobot, P. A. (2022) · Diabetes Technology & Therapeutics · doi:10.1089/dia.2022.0148 · Cited by 22
“Type 1 diabetes is a chronic disease, requiring appropriate metabolic control in pediatric patients to prevent or delay the onset of related complications.(1,2) In line with the American Diabetes Association (ADA), the International Society for Pediatric and Adolescent Diabetes (ISPAD), and Diabetes Poland (PTD) recom…”
Backgroundde Beaufort, C. E., Schierloh, U. H. E., Thankamony, A., Ware, J., Wilinska, M. E., Fröhlich-Reiterer, E. E., Kapellen, T. M., Rami-Merhar, B. M., Hofer, S. E., Campbell, F., et al. (2022) · Diabetes Care · doi:10.2337/dc22-0693 · Cited by 23
Management of Lipid Abnormalities in Patients with Diabetes
Sillars, A., & Sattar, N. A. (2019) · Current Cardiology Reports · doi:10.1007/s11886-019-1246-1 · Cited by 24
Self-citationCardiovascular disease in young People with Type 1 Diabetes: Search for Cardiovascular Biomarkers
Schäfer, M., Nadeau, K. J., & Reusch, J. E. B. (2020) · Journal of Diabetes and its Complications · doi:10.1016/j.jdiacomp.2020.107651 · Cited by 26
Ifuku, M., Takahashi, K., Hosono, Y., Iso, T., Ishikawa, A., Haruna, H., Takubo, N., Komiya, K., Kurita, M., Ikeda, F., et al. (2020) · Pediatric Diabetes · doi:10.1111/pedi.13141 · Cited by 23
“In addition, T1DM patients with longer durations of the disease should be monitored more carefully for cardiac function, even those without heart failure, as patients with early onset T1DM have increased mortality and cardiovascular disease risks.(41)”
BackgroundAdult-onset type 1 diabetes: predictors of major cardiovascular events and mortality
Wei, Y., Andersson, T., Tuomi, T., Nyström, T., & Carlsson, S. (2025) · European Heart Journal · doi:10.1093/eurheartj/ehaf304 · Cited by 25
“10 In fact, the absolute risk difference in mortality and MACE between people with T1D and controls was greater for those diagnosed after age 40.”
A microRNA-based dynamic risk score for type 1 diabetes
Joglekar, M. V., Wong, W. K. M., Kunte, P. S., Hardikar, H. P., Kulkarni, R. A., Ahmed, I., Farr, R. J., Pham, N. H. T., Coles, M., Kaur, S., et al. (2025) · Nature Medicine · doi:10.1038/s41591-025-03730-7 · Cited by 22
“Apart from miRNAs, age at sample collection was identified as an important variable in the development of DRS. Early onset of T1D is more aggressive 54 and children with T1D are less likely to retain detectable residual C-peptide than adults with T1D 55 .”
van Mark, G., Lanzinger, S., Barion, R., Degenhardt, M., Badis, S., Noll, H., Danne, T., Bramlage, P., Seufert, J., & Holl, R. W. (2019) · Therapeutic Advances in Endocrinology and Metabolism · doi:10.1177/2042018819830867 · Cited by 22
Trajectories in HbA1c and other risk factors among adults with type 1 diabetes by age at onset
Edqvist, J., Rawshani, A., Rawshani, A., Adiels, M., Franzén, S., Bjorck, L. M., Svensson, J., Lind, M., Sattar, N. A., & Rosengren, A. (2021) · BMJ Open Diabetes Research & Care · doi:10.1136/bmjdrc-2021-002187 · Cited by 25
Self-citationThe Low-Expression Variant of FABP4 Is Associated With Cardiovascular Disease in Type 1 Diabetes
Dahlström, E. H., Saksi, J., Forsblom, C. M., Uglebjerg, N., Mars, N., Thorn, L. M., Harjutsalo, V., Rossing, P. R., Ahluwalia, T. S., Lindsberg, P. J., et al. (2021) · Diabetes · doi:10.2337/db21-0056 · Cited by 22
Association of Rosacea With Cardiovascular Disease: A Retrospective Cohort Study
Choi, D., Choi, S., Choi, S., Park, S. M., & Yoon, H. (2021) · Journal of the American Heart Association · doi:10.1161/jaha.120.020671 · Cited by 23
Toschi, E. (2023) · Endocrinology and Metabolism Clinics of North America · doi:10.1016/j.ecl.2022.10.006 · Cited by 23
Yeung, A. M., Huang, J. K., Pandey, A., Hashim, I. A., Kerr, D. E., Pop‐Busui, R., Rhee, C. M., Shah, V. N., Bally, L., Bayés‐Genís, A., et al. (2023) · Progress in Cardiovascular Diseases · doi:10.1016/j.pcad.2023.05.002 · Cited by 25
Sherr, J. L., Bergford, S., Gal, R. L., Clements, M. A., Patton, S. R., Calhoun, P. M., Beaulieu, L. C., & Riddell, M. C. (2024) · Diabetes Care · doi:10.2337/dc23-2212 · Cited by 22
Zaccardi, F., Davies, M. J., & Khunti, K. (2020) · Diabetes Obesity and Metabolism · doi:10.1111/dom.13929 · Cited by 22
Głowińska‐Olszewska, B., Borysewicz-Sańczyk, H., Sawicka, B., Klonowska, B., Charemska, D., Żelazowska‐Rutkowska, B., & Bossowski, A. T. (2020) · Frontiers in Endocrinology · doi:10.3389/fendo.2020.00431 · Cited by 25
Características clínicas y manejo de la diabetes tipo 1 en España. Estudio SED1
Peralta, F. G., Torre, E. L. M., Conde, S., Conget, I., & Novials, A. (2021) · Endocrinología Diabetes y Nutrición · doi:10.1016/j.endinu.2020.11.002 · Cited by 22
Armario, P., Brotons, C., Elosúa, R., de Leciñana, M. A., Castro, A., Clarà, A. B. I., Cortés, O., Rodríguez, Á. D., Herranz, M., Justo, S., et al. (2021) · Clínica e Investigación en Arteriosclerosis (English Edition) · doi:10.1016/j.artere.2021.02.001 · Cited by 20
Effectiveness and Safety of GLP-1 Receptor Agonists in Patients with Type 1 Diabetes
Almohareb, S. N., Alfayez, O. M., Aljuaid, S. S., Alshahrani, W. A., Bakhsh, G. H., Alshammari, M. K., Yami, M. S. A., Alshaya, O. A., Alomran, A. S., Korayem, G. B., et al. (2024) · Journal of Clinical Medicine · doi:10.3390/jcm13216532 · Cited by 24
“Moreover, increased body weight is a recognized risk factor of cardiovascular disease [24], which is a well-established cause of early mortality in individuals with T1DM [25,26].”
BackgroundChiesa, S. T., Marcovecchio, M. L., Benitez‐Aguirre, P., Cameron, F. J., Craig, M. E., Couper, J., Davis, E. A., Dalton, R. N., Daneman, D., Donaghue, K. C., et al. (2020) · Hypertension · doi:10.1161/hypertensionaha.120.15721 · Cited by 22
“diagnosed between the ages of 26 and 30 years and over a 30× higher risk than the general population.(2) These and other data(3)”
BackgroundVági, O. E., Svébis, M. M., Domján, B. A., Körei, A. E., Istenes, I., Putz, Z., Mészáros, S., Hajdú, N., Békeffy, M. Z., Tesfaye, S. H., et al. (2021) · Journal of Diabetes Research · doi:10.1155/2021/6662159 · Cited by 24
“Younger people in general have better health than older people, and a significant risk factor (such as DSPN) may substantially increase their risk of mortality [31, 32].”
BackgroundThe Multifactorial Progression from the Islet Autoimmunity to Type 1 Diabetes in Children
Bauer, W., Gyenesei, A., & Kretowski, A. J. (2021) · International Journal of Molecular Sciences · doi:10.3390/ijms22147493 · Cited by 25
“Diabetes patients have an increased risk of cardiovascular diseases and increased death rates [30,31].”
BackgroundResidual C-peptide secretion and hypoglycemia awareness in people with type 1 diabetes
Wellens, M. J., Vollenbrock, C. E., Dekker, P., Boesten, L. S. M., Geelhoed-Duijvestijn, P. H. L. M., de Vries, M., Nefs, G., Wolffenbuttel, B. H. R., Aanstoot, H., & van Dijk, P. R. (2021) · BMJ Open Diabetes Research & Care · doi:10.1136/bmjdrc-2021-002288 · Cited by 19
Cefalu, W. T., Andersen, D. K., Arreaza-Rubín, G., Pin, C. L., Sato, S. M., Verchere, C. B., Woo, M., & Rosenblum, N. D. (2021) · Diabetes · doi:10.2337/db21-0777 · Cited by 20
Talbo, M. K., Lebbar, M., Wu, Z., Vanasse, A., Lalanne‐Mistrih, M., Brazeau, A., & RABASA-LHORET, R. P. R. (2023) · Diabetes Research and Clinical Practice · doi:10.1016/j.diabres.2023.110822 · Cited by 22
Wretlind, A., Curovic, V. R., Suvitaival, T., Theilade, S., Tofte, N., Winther, S. A., Vilsbøll, T., Vestergaard, H., Rossing, P. R., & Legido‐Quigley, C. (2023) · Diabetes · doi:10.2337/db23-0052 · Cited by 21
“Twomajor complications to T1D are cardiovascular (CV) disease (CVD) and chronic kidney disease, the former being the leading cause of death in individuals with T1D (2,3).”
Background
Metadata
- Authors
- Rawshani, A., Sattar, N., Franzén, S., Rawshani, A., Hattersley, A. T., Svensson, A.-M., Eliasson, B., & Gudbjörnsdottir, S.
- Affiliations
- Sahlgrenska University Hospital (SE)
- University of Glasgow (GB)
- Region Västra Götaland (SE)
- University of Exeter (GB)
- University of Gothenburg (SE)
- Corresponding author
- Rawshani, Araz
- Sattar, Naveed
- ORCID
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2018-08
- Volume
- 392
- Issue
- 10146
- Pages
- 477-486
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- PMC
- PMC6828554
- OpenAlex
- W2887373570
- Cited by
- 802
- References
- 40
- Citations by year
- 2026: 81 · 2025: 103 · 2024: 113 · 2023: 108 · 2022: 101 · 2021: 114 · 2020: 105 · 2019: 67 · 2018: 9
- FWCI
- 58.64
- Type
- journal article
- Language
- en
- Open access
- green
- hdl.handle.net
- Licence
- Locations
- The Lancet (publishedVersion)
- PubMed (publishedVersion)
- Open Research Exeter (University of Exeter) (acceptedVersion, cc-by-nc-nd)
- PubMed Central (acceptedVersion)
- ENLIGHTEN (Jurnal Bimbingan dan Konseling Islam) (acceptedVersion, cc-by-sa)
- Figshare (submittedVersion)
- Royal Devon and Exeter Research Repository (Royal Devon and Exeter) (submittedVersion)
- Funders
- Hjärt-Lungfonden
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Diabetes and associated disorders
- Keywords
- type 1 diabetes, age at diagnosis, excess mortality, cardiovascular disease, cardiovascular mortality, coronary artery disease, heart failure, atrial fibrillation, acute myocardial infarction, stroke, young adults, risk stratification, diabetes duration, non-cardiovascular mortality, Swedish National Diabetes Register, sex differences in mortality
- MeSH terms
- Adolescent, Adult, Age Factors, Cardiovascular Diseases, Child, Child, Preschool, Diabetes Mellitus, Type 1, Female, Humans, Infant, Infant, Newborn, Male, Registries, Sweden, Cohort Studies, Proportional Hazards Models, Age of Onset, Diabetes Complications, Young Adult
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