Cited by 889Diabetes, Cardiovascular Risks, and LipoproteinsDiabetes Management and ResearchDiabetes Management and Education

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Mortality in Adults With and Without Diabetes in a National Cohort of the U.S. Population, 1971–1993

Gu, Ken, Cowie, Catherine C, Harris, Maureen I·1998·Diabetes Care

DOI 10.2337/diacare.21.7.1138

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Abstract

OBJECTIVE: To examine 22-year mortality (1971-1993), causes of death, life expectancy, and survival in a national sample of diabetic and nondiabetic adults according to age, sex, and race. RESEARCH DESIGN AND METHODS: A representative national cohort of 14,374 adults aged 25-74 years was identified in 1971-1975 in the First National Health and Nutrition Examination Survey (NHANES I). Diabetes was ascertained by medical history interview. The cohort was followed for mortality through 1992-1993, with verification of vital status for 96.2% (n = 13,830). Causes of death were determined from death certificates. RESULTS: Diabetic subjects comprised 5.1% of the cohort and accounted for 10.6% of the deaths. Mortality for diabetic subjects increased from 12.4 per 1,000 person-years for those aged 25-44 years at baseline to 89.7 per 1,000 person-years for those aged 65-74 years. The age-adjusted mortality rate was 57% higher for diabetic men than for diabetic women; the rate was 27% higher for diabetic non-Hispanic blacks than for diabetic non-Hispanic whites. Mortality rates were highest for insulin-treated subjects and for those with > or = 15 years' duration of diabetes. Diabetes was listed on the death certificate as the underlying cause of death for only 7.7% of diabetic men and 13.4% of diabetic women. Considering multiple causes of death, heart disease was listed the most frequently and was present on 69.5% of death certificates of people with diabetes. Death rates were higher for diabetic than for nondiabetic subjects in all age, sex, and race groups. The relative risk of death (diabetic versus nondiabetic subjects) declined with age from a value of 3.6 for those aged 25-44 years at baseline to 1.5 for those aged 65-74 years. The relative risk was elevated in diabetic subjects for all major causes of death except malignant neoplasms. Survival of diabetic subjects was lower than that of nondiabetic subjects in all age, sex, and race groups. Median life expectancy was 8 years lower for diabetic adults aged 55-64 years and 4 years lower for those aged 65-74 years. CONCLUSIONS: In this representative national sample of adults, mortality rates were higher for diabetic men than for diabetic women and for diabetic blacks than for diabetic whites. The study confirms the substantially higher risk of death, lower survival, and lower life expectancy of diabetic adults compared with nondiabetic adults.

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“Introduction The prevalence of diabetes mellitus (DM) is increasing worldwide and macrovascular disease remains the leading cause of morbidity and mortality among diabetic patients.(1) Randomised trials have demonstrated the benefit of intensive glycaemic control on microvascular disease risk associated with DM,(2-4)…”
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Background
Renal Biopsy in Type 2 Diabetic Patients
Espinel, E., Agraz, I., Ibernón, M., Ramos-Terrades, N., Fort, J., & Serón, D. (2015) · Journal of Clinical Medicine · doi:10.3390/jcm4050998 · Cited by 81
The associations of hepatic steatosis and fibrosis using fatty liver index and BARD score with cardiovascular outcomes and mortality in patients with new-onset type 2 diabetes: a nationwide cohort study
Park, J., Kim, G., Kim, B., Han, K., Kwon, S. Y., Park, S., Lee, Y., Jin, S., & Kim, J. H. (2022) · Cardiovascular Diabetology · doi:10.1186/s12933-022-01483-y · Cited by 79
“NAFLD is considered a CV risk factor independent of established atherosclerotic risk factors and features of metabolic syndrome, and CVD in NAFLD is a leading cause of death [3, 7, 8, 21].”
Background
Elevated Serum Osteoprotegerin Levels Are Associated With Vascular Endothelial Dysfunction in Type 2 Diabetes
Shin, J. Y., Shin, Y. G., & Chung, C. H. (2006) · Diabetes Care · doi:10.2337/dc06-0631 · Cited by 77
Selecting Indicators for the Quality of Diabetes Care at the Health Systems Level in OECD Countries
Greenfield, S., Nicolucci, A., & Mattke, S. (2004) · OECD health technical papers · doi:10.1787/165531523300 · Cited by 77
Diabetes and Coronary Heart Disease as Risk Factors for Mortality in Older Adults
Carnethon, M. R., Biggs, M. L., Barzilay, J., Kuller, L. H., Mozaffarian, D., Mukamal, K., Smith, N. L., & Siscovick, D. (2010) · The American Journal of Medicine · doi:10.1016/j.amjmed.2009.11.023 · Cited by 77
Long-Term Prognosis in Patients With Type 1 and 2 Diabetes Mellitus After Coronary Artery Bypass Grafting
Holzmann, M. J., Rathsman, B., Eliasson, B., Kuhl, J., Svensson, A., Nyström, T., & Sartipy, U. (2015) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2015.02.052 · Cited by 76
Diabetes Mellitus and Ischemic Heart Disease: The Role of Ion Channels
Severino, P., D’Amato, A., Netti, L., Pucci, M., Marchis, M. D., Palmirotta, R., Volterrani, M., Mancone, M., & Fedele, F. (2018) · International Journal of Molecular Sciences · doi:10.3390/ijms19030802 · Cited by 82
“The most common cause of death among diabetic patients is cardiovascular disease, and IHD [37] is responsible for the majority of deaths.”
Background
Improved trends in cardiovascular complications among subjects with type 2 diabetes in Korea: a nationwide study (2006–2013)
on Behalf of the Taskforce Team of Diabetes Fact Sheet of the Korean Diabetes Association, Jung, C. H., Chung, J. O., Han, K., Ko, S.-H., Ko, K. S., & Park, J.-Y. (2017) · Cardiovascular Diabetology · doi:10.1186/s12933-016-0482-6 · Cited by 74
Cardiovascular Disease in Diabetes Mellitus
Szuszkiewicz-Garcia, M., & Davidson, J. A. (2013) · Endocrinology and Metabolism Clinics of North America · doi:10.1016/j.ecl.2013.09.001 · Cited by 76
“The most common cause of death amongpatientswith diabetes is cardiovascular disease, with heart disease responsible for 70% of deaths.(3) The risk of increased cardiovascular morbidity and mortality has”
Efficacy and safety of ezetimibe co‐administered with simvastatin in thiazolidinedione‐treated type 2 diabetic patients
Gaudiani, L., Lewin, A., Meneghini, L., Perevozskaya, I. T., Plotkin, D. J., Mitchel, Y., & Shah, S. (2004) · Diabetes Obesity and Metabolism · doi:10.1111/j.1463-1326.2004.00420.x · Cited by 73
Risks of cardiovascular diseases associated with dipeptidyl peptidase-4 inhibitors and other antidiabetic drugs in patients with type 2 diabetes: a nation-wide longitudinal study
Ou, H., Chang, K., Li, C., & Wu, J. (2016) · Cardiovascular Diabetology · doi:10.1186/s12933-016-0350-4 · Cited by 72
Diabetes Mellitus in the Hispanic/Latino Population: An Increasing Health Care Challenge in the United States
Umpierrez, G. E., Gonzalez, A., Umpierrez, D., & Pimentel, D. (2007) · The American Journal of the Medical Sciences · doi:10.1097/maj.0b013e3180a6efe3 · Cited by 70
Diabetes with heart failure increases methylglyoxal modifications in the sarcomere, which inhibit function
Papadaki, M., Holewinski, R. J., Previs, S. B., Martin, T. G., Stachowski, M. J., Li, A. S., Blair, C. A., Moravec, C. S., Eyk, J. E. V., Campbell, K. S., et al. (2018) · JCI Insight · doi:10.1172/jci.insight.121264 · Cited by 71
“Introduction In patients with diabetes mellitus, which affects almost 10% of Americans, the primary causes of death are cardiovascular disorders (1, 2).”
Background
Reductions in the risks of recurrent stroke in patients with and without diabetes: The PROGRESS Trial
Berthet, K., Neal, B. C., Chalmers, J. P., MacMahon, S. W., Bousser, M., Colman, S., Woodward, M., & on behalf of the PROGRESS collaborative group (2004) · Blood Pressure · doi:10.1080/08037050410029605 · Cited by 71
“There also appeared to be a qualitatively different effect of diabetes on the risk of major stroke subtypes, with the anticipated positive association for diabetes and ischaemic strokes [14, 15] but a trend towards an inverse association for diabetes and haemorrhagic strokes.”
Background
Diabetes mellitus, coronary heart disease incidence, and death from all causes in African American and European American women: The NHANES I epidemiologic follow-up study.
Gillum, R., Mussolino, M., & Madans, J. (2000) · Journal of Clinical Epidemiology · doi:10.1016/s0895-4356(99)00208-5 · Cited by 75
NASH and the risk of cirrhosis and hepatocellular carcinoma in type 2 diabetes
Bugianesi, E., Vanni, E., & Marchesini, G. (2007) · Current Diabetes Reports · doi:10.1007/s11892-007-0029-z · Cited by 70
“In a national sample of US adults followed up for 22 years, the risk of liver-related deaths was almost twice as high in diabetic men, but not in women, compared with the nondiabetic population [ 10 ]; however, this result was not always confirmed [11].”
Result
A Review of Metabolic and Cardiovascular Effects of Oral Antidiabetic Agents: Beyond Glucose-Level Lowering
Ginsberg, H. N., Plutzky, J., & Sobel, B. E. (1999) · European Journal of Cardiovascular Prevention & Rehabilitation · doi:10.1177/204748739900600512 · Cited by 69
Associations of Diabetes Mellitus and Ethnicity with Mortality in a Multiethnic Asian Population: Data from the 1992 Singapore National Health Survey
Ma, S. (2003) · American Journal of Epidemiology · doi:10.1093/aje/kwg199 · Cited by 68
“The findings of both of the US studies suggested that mortality associated with diabetes was higher in non-Hispanic Blacks than in non-Hispanic Whites (3, 8).”
Result
Diabetes mellitus and risk of fatal ischaemic heart disease by gender: 18 years follow-up of 74 914 individuals in the HUNT 1 Study
Dale, A. C., Nilsen, T. I. L., Vatten, L. J., Midthjell, K., & Wiseth, R. (2007) · European Heart Journal · doi:10.1093/eurheartj/ehm447 · Cited by 67
Integration of Metabolomics in Heart Disease and Diabetes Research: Current Achievements and Future Outlook
Dunn, W. B., Goodacre, R., Neyses, L., & Mamas, M. A. (2011) · Bioanalysis · doi:10.4155/bio.11.223 · Cited by 73
The role of non-invasive imaging in the risk stratification of asymptomatic diabetic subjects
Anand, D. V., Lim, E., Lahiri, A., & Bax, J. J. (2005) · European Heart Journal · doi:10.1093/eurheartj/ehi441 · Cited by 69
Methods of competing risks analysis of end-stage renal disease and mortality among people with diabetes
Lim, H. J., Zhang, X., Dyck, R. F., & Osgood, N. D. (2010) · BMC Medical Research Methodology · doi:10.1186/1471-2288-10-97 · Cited by 66
“It has been reported that T2DM contributes to and is associated with increased mortality in endstage renal disease (ESRD) populations [18, 28 ,30].”
BackgroundInfluential
Mortality and educational level among diabetic and non-diabetic population in the Turin Longitudinal Study: a 9-year follow-up
Gnavi, R. (2004) · International Journal of Epidemiology · doi:10.1093/ije/dyh089 · Cited by 67
Sensitivity and Specificity of Death Certificates for Diabetes
Cheng, W. S., Wingard, D. L., Kritz-Silverstein, D., & Barrett-Connor, E. (2008) · Diabetes Care · doi:10.2337/dc07-1327 · Cited by 66
Canagliflozin Inhibits Human Endothelial Cell Proliferation and Tube Formation
Behnammanesh, G., Durante, Z. E., Peyton, K. J., Martinez-Lemus, L. A., Brown, S. M., Bender, S. B., & Durante, W. (2019) · Frontiers in Pharmacology · doi:10.3389/fphar.2019.00362 · Cited by 61
Carotid intima media thickness in type 2 diabetes mellitus with ischemic stroke
Kota, S., Mahapatra, G., Kota, S., Syed, N. A., Tripathy, P., Jammula, S., & Modi, K. D. (2013) · Indian Journal of Endocrinology and Metabolism · doi:10.4103/2230-8210.113767 · Cited by 65
“Cardiovascular diseases are the most common cause of mortality in patients with type 2 diabetes mellitus (T2DM).[1] The Framingham study and the Multiple Risk Factor Intervention Trial (MRFIT) showed a 2–3 fold elevation in the risk of clinically evident atherosclerotic disease in patients with T2DM.”
Background
Life Expectancy in a Large Cohort of Type 2 Diabetes Patients Treated in Primary Care (ZODIAC-10)
Lutgers, H. L., Gerrits, E. G., Sluiter, W. J., Ubink-Veltmaat, L. J., Landman, G. W. D., Links, T. P., Gans, R. O. B., Smit, A. J., & Bilo, H. J. G. (2009) · PLoS ONE · doi:10.1371/journal.pone.0006817 · Cited by 65
“Most published data were extracted from representative national cohorts in North-America or the United Kingdom. Some reports showed a decline in mortality rates amongst diabetic men only, whereas women showed an increase or no change in mortality rates at all”
Background
Risk of Acute Complications of Diabetes Among People With Schizophrenia in Ontario, Canada
Becker, T., & Hux, J. E. (2010) · Diabetes Care · doi:10.2337/dc10-1139 · Cited by 64
“There is also a well-established relationship between DM and cardiovascular disease, with cardiovascular disease accounting for the majority of deaths among people with DM (32)(33).”
Background
Population-based estimates of mortality associated with diabetes: use of a death certificate check box in North Dakota
Tierney, E. F., Geiss, L. S., Engelgau, M. M., Thompson, T. J., Schaubert, D. R., Shireley, L. A., Vukelic, P. J., & McDonough, S. L. (2001) · American Journal of Public Health · doi:10.2105/ajph.91.1.84 · Cited by 65
Pharmacological Management of Diabetic Macular Edema in Real-Life Observational Studies
Kodjikian, L., Bellocq, D., & Mathis, T. (2018) · BioMed Research International · doi:10.1155/2018/8289253 · Cited by 64

Authors: Gu, K., Cowie, C. C., & Harris, M. I.
Affiliations: National Institutes of Health (US)
ORCID: Gu, Ken
Cowie, Catherine C
Venue: Diabetes Care
Publisher: American Diabetes Association
Published: 1998-07-01
Volume: 21
Issue: 7
Pages: 1138-1145
ISSN: 0149-5992 (ISSN-L)
1935-5548
DOI: 10.2337/diacare.21.7.1138
OpenAlex: W2050695519
Cited by: 881
References: 0
Citations by year: 2026: 1 · 2025: 12 · 2024: 15 · 2023: 11 · 2022: 21 · 2021: 25 · 2020: 25 · 2019: 27 · 2018: 33 · 2017: 39 · 2016: 36 · 2015: 26 · 2014: 32 · 2013: 44 · 2012: 48
FWCI: 10.98
Type: journal article
Language: en
Open access: closed
Locations: Diabetes Care (publishedVersion)
PubMed (publishedVersion)
Topics: Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
Keywords: diabetes mortality, causes of death, life expectancy, survival, sex differences, racial differences, non-Hispanic blacks, insulin-treated diabetes, diabetes duration, heart disease, death certificates, adults with diabetes, age differences in mortality risk, cancer
MeSH terms: Adult, Aged, Cause of Death, Diabetes Mellitus, Female, Humans, Life Expectancy, Male, Middle Aged, Mortality, Population, United States, Cohort Studies, Survival Rate, Survival Analysis

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Mortality in Adults With and Without Diabetes in a National Cohort of the U.S. Population, 1971–1993

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