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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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Platelet Indices and Adipokines in Adults with Long-Standing Type 1 Diabetes
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Pinés-Corrales, P. J., López-García, M. C., Jiménez, L. M. L., Moya, A. J. M., Valverde, A. R. D. A., Vidal, M. J., Martínez, M. G., Delicado-Hernández, C., & Mangas-Mellado, P. (2026) · Journal of Clinical Medicine · doi:10.3390/jcm15124638
Luterbacher, F., Jiménez‐Sánchez, C., Anastasiadou, M. L., Prados, J., Renström, F., Brändle, M., Bilz, S., & Schwitzgebel, V. (2026) · Cardiovascular Diabetology · doi:10.1186/s12933-026-03252-7
Rydberg, M., Lakhlani, D., Sutjiadi, B. J., Fox, P. M., & Curtin, C. M. (2026) · Journal of Diabetes and its Complications · doi:10.1016/j.jdiacomp.2026.109364
Guzman, H., Markiewitz, N., Gettings, J. M., Olivos‐Stewart, D., Moyer, J., & Willi, S. M. (2026) · Journal of Pediatric Psychology · doi:10.1093/jpepsy/jsag047
VIDOU, A., Cate, I. P.-T., Campbell, F., Ware, J., Hovorka, R., Wilinska, M. E., Schierloh, U. H. E., Hofer, S. E., Fröhlich-Reiterer, E. E., Rami-Merhar, B. M., et al. (2026) · Diabetic Medicine · doi:10.1111/dme.70408
Hyperlipidaemia in youth with type 1 diabetes: Are current guidelines clinically useful?
Rodrigues, F., White, M., & O’Connell, M. A. (2026) · Diabetic Medicine · doi:10.1111/dme.70382
Dovč, K., Mianowska, B., Boettcher, C., Cardona‐Hernandez, R., Berge, T. V. D., Davis, E. A., Kosteria, I., Marigliano, M., Rami-Merhar, B. M., Scharf, M., et al. (2026) · Diabetes Technology & Therapeutics · doi:10.1177/15209156261463841
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Tas, E., Gumus, M., Movva, S., Mendizábal, B., Barinas-Mitchell, E. J. W., Gong, Z., Dranoff, J. A., Muzumdar, R. H., & Libman, I. M. (2026) · Diabetes and Vascular Disease Research · doi:10.1177/14791641261470422
Twardawa, P., Kubisiak, A., Matejko, B., CYRANKA, K., Lushchyk, M. L., Hajduk, J., Krzyżowska, S., Malecki, M. T., Targosz‐Korecka, M., & Klupa, T. (2026) · British Journal of Pharmacology · doi:10.1111/bph.70613
Hornbrinck, E., Lundqvist, M., Lampa, E., Eriksson, J. W., & Svensson, M. K. E. (2026) · Journal of Diabetes and its Complications · doi:10.1016/j.jdiacomp.2026.109390
“10 In addition, genetic and perinatal factors, e.g., low birth weight and pre-term birth, may increase susceptibility to diabetes-related complications, especially DN. 11 Modifiable risk factors including overweight and tobacco use, have also been shown to influence the risk of DR. 12 Furthermore,…”
Nielsen, T. C., Lain, S. J., Craig, M. E., Bell, K. J., Baldwin, H., Jenkins, A. J., Liew, G., Donaghue, K. C., & Nassar, N. (2026) · Diabetes Care · doi:10.2337/dc26-0964
Yoon, J., Kim, J., Park, S., & Kim, W. (2026) · Frontiers in Endocrinology · doi:10.3389/fendo.2026.1938241
New Therapeutic Approaches in Diabetes Treatment: Immune Interventions
Allen, L. A., Mahmood, Z. S., & Dayan, C. M. (2026) · Springer eBooks · doi:10.1007/978-3-032-24854-1_28
Legault, L., Sherr, J. L., Davis, E. A., Cerezales, M., Mirón, A. K., Syleouni, M., & Ng, S. M. (2026) · Diabetes Technology & Therapeutics · doi:10.1177/15209156261486122
Translating gut microbiome research into therapies for type 1 diabetes
Kok, S. P., Nieuwdorp, M., & Rampanelli, E. (2026) · Experimental Physiology · doi:10.1113/ep093273 · Cited by 1
Weiskorn, J., Hotze, S., von Gise, A. F., Busse, M., & Kordonouri, O. (2026) · Cardiovascular Diabetology · doi:10.1186/s12933-026-03377-9
Type 1 diabetes and cardiovascular medicine
Jenkins, A. J., Huang, M., Hemphill, M., Chen, D., Ha, J. T., Sata, Y., Sindone, A. P., Gnanenthiran, S. R., & Lan, N. S. R. (2026) · Cardiovascular Diabetology – Endocrinology Reports · doi:10.1186/s40842-026-00338-9
“Relative to peers without diabetes, people with T1D are at ≥ 3-fold higher risk of CVD, with those with T1D-ons-est before 10 years old having a > 30-fold higher lifetime risk of CAD [4].”
Benedetto, C., Gulati, M., Khadilkar, S. S., Maas, A. H. E. M., Frezet, F., de Oliveira, G. M. M., Genazzani, A. R., Divakar, H., & Poppas, A. (2026) · Global Heart · doi:10.5334/gh.1576
Mackett, K., Santesso, N. A., Sherifali, D., de Souza, R. J., Bowen, J. M., Dostie, S., Ndjaboué, R., Greenberg, D. T., Greiver, M., & Witteman, H. O. (2026) · Primary care diabetes · doi:10.1016/j.pcd.2026.09.003
Benedetto, C., Gulati, M., Khadilkar, S. S., Maas, A. H. E. M., Frezet, F., de Oliveira, G. M. M., Genazzani, A. R., Divakar, H., Poppas, A., & the World Heart Federation (WHF) and the International Federation of Gynecology and Obstetrics (FIGO) (2026) · International Journal of Gynecology & Obstetrics · doi:10.1002/ijgo.71356
Points to Consider Regarding Biomarker Measurement and Evaluation in Diabetes Screening
Kimura, T. (2026) · Diabetology · doi:10.3390/diabetology7100192
Cosson, E., Aguayo, G., Créquer-Grandhomme, A., Bahloul, A., Renard, É., Potier, L., Schaepelynck, P., Sola‐Gazagnes, A., Spiteri, A., Riveline, J., et al. (2026) · Diabetes Obesity and Metabolism · doi:10.1111/dom.71393
“It should be noted that earlier literature has studied DKA at the time of initial presentation of type diagnosis [20].”
Braithwaite, J., Fisher, G., Harrison, R., Mumford, V., Davis, E. A., de Wet, C., Homaira, N., Mitchell, R. J., Jaffé, A., Willcock, S., et al. (2026) · IJQHC Communications · doi:10.1093/ijcoms/lyag047
Liu, W., Ji, L., Chen, Y., Li, X., Li, W., Li, M., Zhang, M., Tan, J., & Song, M. (2026) · Journal of Medical Economics · doi:10.1080/13696998.2026.2738350
Sato, J., Mita, T., Negami, T., FUJIKAWA, S., Nagashima, H., Takagi, E., Aoyama, S., Otani, E., Nishida, Y., Ikeda, F., et al. (2026) · Journal of Diabetes Investigation · doi:10.1111/jdi.70468
“Macrovascular events are a leading cause of mortality in type 1 diabetes, and their prevention remains a major challenge 1 .”
Murashko, M. A., Mokrysheva, N. G., & Petryaykina, E. E. (2026) · National Health Care (Russia) · doi:10.47093/2713-069x.2026.7.2.5-17
Type 1 Diabetes in the Youngest: From Distinct Needs to New Frontiers in Care
Ingrosso, D. M. F., Polle, O. G., Perge, K., Pélicand, J., Vermillac, G., Godot, C., Besançon, A., CHIARELLI, F., & Beltrand, J. (2026) · Hormone Research in Paediatrics · doi:10.1159/hrp/adaag026
Bass, L. E., Taylor, T. C., Forchetti, M. V., Scaglione, S., Padgett, M. L., Skellett, A. M., Byers, C. W., Mahajan, A., Brannon, C. T., Wasdin, P. T., et al. (2026) · bioRxiv (Cold Spring Harbor Laboratory) · doi:10.64898/2026.10.20.760517
Maladie cardiovasculaire et diabète de type 1 : données épidémiologiques et physiopathologiques
Vergès, B. (2026) · Médecine des Maladies Métaboliques · doi:10.1016/j.mmm.2026.10.006
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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