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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”
From The future of type 1 diabetes therapy (2025) · cites this paper as [1]
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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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“Patients diagnosed with T1D before the age of 10 years may have 30 times increased risk of coronary heart disease and acute myocardial infarction in the early adult years [31].”
BackgroundPorto, A. D., Candido, R., Rocca, A., Manicardi, V., Nicolucci, A., Miranda, C., Cimino, E., Bartolo, P. D., Cianni, G. D., & Russo, G. T. (2024) · Journal of Endocrinological Investigation · doi:10.1007/s40618-024-02327-0 · Cited by 9
“…dyslipidemia, and obesity in these patients [5] People with type 1 diabetes (T1D) are characterized by a distinctive aspect of cardiovascular risk, that is different from those with T2D and generally far higher for women than for men in contrast to what is observed in the general population [6].”
Sekercioglu, N., Lovblom, L. E., Bjornstad, P., Lovshin, J. A., Lytvyn, Y., Boulet, G., Farooqi, M. A., Orszag, A., LAI, V. S., TSE, J. M., et al. (2019) · Renal Failure · doi:10.1080/0886022x.2019.1614057 · Cited by 9
“The rate and extent of beta cell destruction may also differ [31].”
BackgroundTreatment of cardiometabolic risk factors in patients with type 1 diabetes
Niechciał, E., & Marcovecchio, M. L. (2020) · Current Opinion in Pediatrics · doi:10.1097/mop.0000000000000915 · Cited by 7
Campas-Lebecque, M. N., Pochelu, S., Vautier, V., Bachere, N., Beau, C., Benoit, M., Cammas, B., Carré, M., Chevrel, J., Compain, F., et al. (2021) · Archives de Pédiatrie · doi:10.1016/j.arcped.2021.02.007 · Cited by 8
D’Amato, G., Ciccone, M. M., Faienza, M. F., Scicchitano, P., Lamparelli, R., Zaza, P., Cecere, A., Brunetti, G., Cortese, F., Valente, F., et al. (2021) · Experimental and Clinical Endocrinology & Diabetes · doi:10.1055/a-1523-7574 · Cited by 8
Matetić, A., Doolub, G., Bharadwaj, A. S., Osman, M., Biondi‐Zoccai, G., Ullah, W., Bagur, R., Velagapudi, P., Alraies, M. C., Mohamed, M., et al. (2021) · Cardiovascular revascularization medicine · doi:10.1016/j.carrev.2021.08.018 · Cited by 8
Pintaudi, B., Scatena, A., Piscitelli, G., Frison, V., Corrao, S., Manicardi, V., Graziano, G., Rossi, M. C., Gallo, M., Mannino, D., et al. (2021) · Diabetes Research and Clinical Practice · doi:10.1016/j.diabres.2021.109131 · Cited by 9
Excess all‐cause and cause‐specific mortality for people with diabetes and end‐stage kidney disease
Morton, J. I., Sacre, J. W., McDonald, S. P., Magliano, D. J., & Shaw, J. E. (2021) · Diabetic Medicine · doi:10.1111/dme.14775 · Cited by 8
Setny, M., Jankowski, P., Kamiński, K. A., Gąsior, Z., Haberka, M., Czarnecka, D., Pająk, A., Kozieł, P., Szóstak-Janiak, K., Sawicka, E., et al. (2021) · Polskie Archiwum Medycyny Wewnętrznej · doi:10.20452/pamw.16179 · Cited by 8
Al‐Salameh, A., Bouzegaoui, N. E., & Saraval, M. (2022) · Annales d Endocrinologie · doi:10.1016/j.ando.2022.09.023 · Cited by 11
What does the licensing of teplizumab mean for diabetes care?
Quinn, L. M., Swaby, R., Tatović, D., Narendran, P., Besser, R. E. J., & Dayan, C. M. (2023) · Diabetes Obesity and Metabolism · doi:10.1111/dom.15071 · Cited by 7
Chantzichristos, D., Persson, A., Miftaraj, M., Eliasson, B., Svensson, A.-M., & Johannsson, G. (2019) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2018-02064 · Cited by 9
Self-citationWatso, J. C., Robinson, A. T., Singar, S., Cuba, J. N., & Koutnik, A. P. (2024) · American Journal of Physiology-Cell Physiology · doi:10.1152/ajpcell.00694.2023 · Cited by 8
Lakshmi, K., Deeba, K., Harave, V., & Bharti, S. (2024) · International Conference on Knowledge Engineering and Communication Systems (ICKECS) · doi:10.1109/ickecs61492.2024.10616598 · Cited by 7
“Those diagnosed at age 5-14 had a reduction of approximately 19 years, and those diagnosed before age 5 had a reduction of approximately 20 years [19].”
BackgroundChuang, S.-T., Alcazar, O., Watts, B. M., Abdulreda, M. H., & Buchwald, P. (2024) · Frontiers in Immunology · doi:10.3389/fimmu.2024.1484425 · Cited by 7
Khalafi, M., Dinizadeh, F., Rosenkranz, S. K., Symonds, M. E., & Fatolahi, S. (2025) · Healthcare · doi:10.3390/healthcare13030246 · Cited by 7
“Type 1 diabetes mellitus (T1D) is a chronic autoimmune disease caused by the immune-mediated destruction of beta cells that is characterized by hyperglycemia and insulin deficiency [1,2].”
McAleese, C. A., Joudah, G., Salt, I. P., Petrie, J. R., LEIPER, J. M., & Dowsett, L. (2025) · The Journal of Physiology · doi:10.1113/jp288006 · Cited by 7
Safety and Effectiveness of Statins for Primary Prevention in Adults With Type 1 Diabetes
Blais, J. E., Yan, V. K. C., Chan, E. W., Wong, I. C. K., & Wan, E. Y. F. (2025) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2025.07.013 · Cited by 7
Marlow, A. L., King, B. R., Trost, S. G., Weaver, N., & Smart, C. E. (2023) · Diabetes Research and Clinical Practice · doi:10.1016/j.diabres.2023.110879 · Cited by 7
Seget, S., Chobot, A. P., Rusak, E., Ochab, A., Bielawska, A., Polańska, J., & Jarosz-Chobot, P. A. (2023) · Technology and Health Care · doi:10.3233/thc-230490 · Cited by 7
“Unfortunately, the time spent living with diabetes for these patients significantly influences the risk of late complications and well-life expectancy [25].”
Marigliano, M., Lanzinger, S., Imane, Z., Barcala, C., SHAH, A. S., Svensson, J., Tsochev, Κ., Mazur, A., Galli‐Τsinopoulou, A., Ioacără, S., et al. (2024) · Diabetes Research and Clinical Practice · doi:10.1016/j.diabres.2024.111616 · Cited by 7
Renard, É., Tubiana‐Rufi, N., Chaillous, L., Bonnemaison, É., Hanaire, H. P., Bismuth, É., Joubert, M., Coutant, R., Schaepelynck, P., Beltrand, J., et al. (2024) · Médecine des Maladies Métaboliques · doi:10.1016/j.mmm.2024.04.002 · Cited by 7
Leutner, M., Tscharre, M., Farhan, S., Waghefi, H. T., Harreiter, J., Vogel, B., Tentzeris, I., Szekeres, T., Fritzer‐Szekeres, M., Huber, K., et al. (2019) · Frontiers in Endocrinology · doi:10.3389/fendo.2019.00105 · Cited by 7
Østergaard, J. A., Sigfrids, F. J., Forsblom, C. M., Dahlström, E. H., Thorn, L. M., Harjutsalo, V., Flyvbjerg, A., Thiel, S., Hansen, T. K., & Groop, P. (2021) · Scientific Reports · doi:10.1038/s41598-021-88352-y · Cited by 7
Microvascular Sex- and Age- Dependent Phosphodiesterase Expression
Wang, J., Kazmi, M., & Huxley, V. H. (2021) · Frontiers in Aging · doi:10.3389/fragi.2021.719698 · Cited by 7
“Among the observations in pre-adolescent humans, are the worse cardiovascular outcomes and earlier death for girls who developed type 1 diabetes at <10 years of age relative to comparable boys (Rawshani et al., 2018).”
BackgroundStahl‐Pehe, A., Selinski, S., Bächle, C., Castillo, K., Lange, K., Holl, R. W., & Rosenbauer, J. (2022) · Diabetology & Metabolic Syndrome · doi:10.1186/s13098-022-00809-w · Cited by 7
“In our opinion, the studied group of patients with earlyonset, long-duration type 1 diabetes is particularly interesting and relevant because early-onset type 1 diabetes is an important determinant of long-term complications and survival [58].”
BackgroundPapoutsi, C., Hargreaves, D. S., Hagell, A., Hounsome, N., Skirrow, H., Muralidhara, K., Colligan, G., Vijayaraghavan, S., Greenhalgh, T., & Finer, S. (2022) · Health and Social Care Delivery Research · doi:10.3310/nkcr8246 · Cited by 7
Alcazar, O., Ogihara, M., Ren, G., Buchwald, P., & Abdulreda, M. H. (2022) · Biomolecules · doi:10.3390/biom12101444 · Cited by 7
“Despite improved management and control of diabetes, there is still excess mortality and loss of 10–20 life-years among those diagnosed with T1D [4,5], and all-cause mortality risk is about three-fold higher in them compared to the general population [6]; it is also more than four times in those who develop T1D before…”
BackgroundWeaver, O. R., Ye, M., Vena, J. E., Eurich, D. T., & Proctor, S. D. (2023) · Diabetic Medicine · doi:10.1111/dme.15133 · Cited by 7
Goh, Y. A., Lan, N. S. R., Linn, K., Wood, C., Gupta, A., Yeap, B. B., & Fegan, P. G. (2023) · Journal of Diabetes and its Complications · doi:10.1016/j.jdiacomp.2023.108557 · Cited by 8
Type 1 diabetes in the pancreas: A histological perspective
Leete, P. (2023) · Diabetic Medicine · doi:10.1111/dme.15228 · Cited by 7
Mallone, R., Bismuth, É., Thivolet, C., Benhamou, P., Hoffmeister, N., Collet, F., Nicolino, M. P., Reynaud, R., Beltrand, J., Beltrand, J., et al. (2024) · Médecine des Maladies Métaboliques · doi:10.1016/j.mmm.2024.06.003 · Cited by 8
“L'impact sur l'espérance de vie et les comorbidités de l'âge à la découverte du DT1 [18] et de la préservation d'une insulinosé-crétion endogène (voir section « L'enjeu de préservation de l'insulinosécrétion endogène ») plaide aussi pour un dépistage et une prise en charge précoce de la maladie.”
Hoffman, W. H., Ishikawa, T., Blum, J., Tani, N., Ikeda, T., & Artlett, C. M. (2019) · Journal of Clinical Research in Pediatric Endocrinology · doi:10.4274/jcrpe.galenos.2019.2019.0076 · Cited by 7
“The recent article by Rawshani et al (17) gives reason to reconsider the seriousness of poorly controlled T1D in terms of longevity in children, even though DKA is not referred to.”
New era of therapy for endocrine autoimmune disorders
Oftedal, B. E., & Wolff, A. S. B. (2020) · Scandinavian Journal of Immunology · doi:10.1111/sji.12961 · Cited by 7
“glucagon-like peptide 1-(7-36)amide, GLP-184) and suppressors.”
Chen, X., Yan, X.-R., Liu, J., & Zhang, L. (2020) · PubMed Central · Cited by 7
Makvandi, K., Eliasson, B., Carlsen, H. K., & Baid‐Agrawal, S. (2024) · Diabetes Care · doi:10.2337/dc24-0908 · Cited by 8
Self-citationXu, Z., Zhu, T., & Guo, Y. (2025) · Frontiers in Nutrition · doi:10.3389/fnut.2025.1530012 · Cited by 8
Jones, T. L. Z., Kusmartseva, I., Litovsky, S. H., Thakar, R. G., Posgai, A. L., Eckel, R. H., & Atkinson, M. A. (2025) · Diabetes · doi:10.2337/db25-0017 · Cited by 8
Remnant Cholesterol: From Pathophysiology to Clinical Implications in Type 1 Diabetes
Sebastián‐Valles, F., Muñiz, Á. M., & Marazuela, M. (2025) · Endocrines · doi:10.3390/endocrines6030046 · Cited by 6
“Cardiovascular disease remains the leading cause of mortality in individuals with type 1 diabetes [41,42].”
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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