Danish National Diabetes Register Research Articles

Diabetes, sleep disorders and risk of depression - A Danish register-based cohort study

AimsWe examined the influence of comorbid sleep disorder on the association between type 2 diabetes (T2D) and risk of incident depression. MethodsThe study population (N = 232,489) was based on all individuals registered aged ≥40 years with a T2D diagnosis between January 1, 2000 to December 31, 2012 in the Danish National Diabetes Register and a matched reference population. The risk of incident depression (diagnosis or anti-depressant medication) following T2D and possible effect modification of comorbid sleep disorder was estimated using adjusted Cox proportional hazards regression. Sleep disorder was defined as a diagnosis of insomnia, hypersomnia or sleep-wake schedule disorders or use of sleep medication (z-drugs or melatonin) in the Danish National Patient Registry or the Danish National Prescription Registry. ResultsAt study entry, 15.3 % of the participants had a sleep disorder. During follow-up, 2.6 % were diagnosed with depression and 32.1 % received antidepressant medication. The unadjusted hazard ratio (HR) for depression was 1.54 (95%CI 1.52–1.56) for patients with diabetes, which attenuated to 1.50 (1.48–1.52) after adjustment for sleep disorders, which further attenuated to 1.27 (1.26–1.29) in the model further adjusted for psychiatric and somatic comorbidities. The analyses of T2D and sleep disorder as independent and combined variables compared with none of the conditions on risk of depression, showed a HR of 1.27 (95 % CI 1.19–1.35) for T2D without sleep disorder, 1.46 (95 % CI 1.33–1.59) for sleep disorders without T2D, and 1.49 (95%CI 1.37–1.63) for both conditions. ConclusionsT2D and sleep disorders were independently associated with subsequent risk of depression and individuals with both conditions experienced the greatest relative risk. Sleep disorders neither explained nor amplified the relation between diabetes and depression.

Changes in intake of dairy product subgroups and risk of type 2 diabetes: modelling specified food substitutions in the Danish Diet, Cancer and Health cohort

We investigated the association between an increased intake of one dairy product subgroup at the expense of another within a 5-year period and the subsequent 10-year risk of type 2 diabetes. The cohort included 39,393 adults with two measurements of diet assessed using food frequency questionnaires (FFQ) administered in 1993-1997 and 1999-2003. Dairy products were milk (skimmed, semi-skimmed, whole fat), buttermilk, low-fat yogurt, whole-fat yogurt, cheese and butter. Type 2 diabetes cases were ascertained from the Danish National Diabetes Register. The pseudo-observation method was used to calculate risk differences (RD) with 95% confidence intervals (CI). The data were analysed in age strata to fulfil the assumption of independent entry. Among participants aged 56-59years at completion of the follow-up FFQ, increased intake of whole-fat yogurt in place of skimmed, semi-skimmed or whole-fat milk was associated with a reduced risk (RD% [95% CI]: -0.8% [-1.3, -0.2]; -0.6% [-1,1, -0.1]; -0.7 [-1.2, -0.1]; per 50g/d, respectively). Among participants aged 60-64 and 65-72, substitution of skimmed milk for semi-skimmed milk was associated with an increased risk of type 2 diabetes (0.5% [0.2, 0.7]; 0.4% [0.1, 0.7]; per 50g/d, respectively). Similar patterns of associations were found after adjustment for potential mediators. Our results suggest that substitution of whole-fat yogurt for milk among those aged 56-59 decreases risk of type 2 diabetes and substitution of skimmed milk for semi-skimmed milk may increase the risk among those aged 60-64 and 65-72.

Adherence to the Danish food-based dietary guidelines and risk of type 2 diabetes: the Danish diet, cancer, and health cohort.

We evaluated the association between adherence to the 2013 Danish dietary guidelines and the risk of type 2 diabetes (T2D) in a Danish cohort. We used data from the Danish Diet, Cancer, and Health cohort. Participants aged 50-64 years were included from 1993-1997. Information on diet and covariates was collected at baseline using questionnaires and physical assessments. A diet index was developed to assess adherence to the Danish dietary guidelines. T2D cases were identified using the Danish National Diabetes Register. Cox proportional hazards regression was used to estimate hazard ratios (HR), and the pseudo-observation method was used to estimate risk differences, and 95% confidence intervals (CI). A total of 54,305 subject were included. During a median follow-up of 15 years, 7136 participants were diagnosed with T2D. After multivariable adjustment, the HR for high versus low adherence to the index was 0.57 (95 % CI: 0.48, 0.69) in men, and 0.71 (95% CI: 0.60, 0.83) in women. Compared with the lowest adherence to the index, high adherence was associated with a 6.58% (95% CI: -8.69; -4.47%) or 3.17% (95% CI: -4.90, -1.44%) lower risk of T2D in men and women, respectively. High adherence to the Danish food-based dietary guidelines was associated with lower risk of T2D in a Danish cohort, both on a relative and an absolute scale. Shifting from low to high adherence to the dietary guidelines may provide public health benefit.

Replacing Red Meat with Alternative Food Sources of Protein on Risk of Type 2 Diabetes - Modeling Dietary Changes in a Causal Framework

Abstract Objectives We investigated whether decreasing the intake of red meat and simultaneously increasing the intake of alternative food sources of protein affects the risk of type 2 diabetes compared with no changes in the substituted foods. We also examined interaction with the age at which participants changed their diet. Methods We used the Danish Diet, Cancer and Health cohort including men and women, two measures of diet taken roughly 5 years apart using food frequency questionnaires and information on incident type 2 diabetes derived from the Danish National Diabetes Register (n = 39,349; aged 55 to 72 years at the second diet measure; n cases = 3759). The pseudo-observation method was used to estimate the average exposure effect of decreasing the intake of red meat (processed and unprocessed) while increasing the intake of either poultry, fish, cheese, eggs or whole grains compared with no changes in the substituted foods on the subsequent 10-year risk of development type 2 diabetes. Results In multivariable adjusted models, we found that replacing 1 serving/day (100 g) of red meat with 1 serving/day of eggs (50 g) (risk difference −2.4%, 95% confidence interval −3.7 to −1.1%) or whole grains (30 g) (−1.4%, −2.2 to −0.6%) was associated with a reduced risk of type 2 diabetes. No effects were observed for other replacements. In general, the lowest risk was observed for replacements at age 55 years compared with older ages (up to 70 years) for all replacements. Conclusions Replacing red meat with eggs or whole grains may reduce the risk of type 2 diabetes compared with no changes in the substituted foods. Changing red meat intake in midlife may be more beneficial than at older ages. Funding Sources Aarhus University.

Antidiabetic medication and risk of dementia in patients with type 2 diabetes: a nested case-control study.

Diabetes is a risk factor for dementia, but whether antidiabetic medication decreases the risk is unclear. We examined the association between antidiabetic medication and dementia. We performed a nested case-control study within a cohort of all 176 250 patients registered with type 2 diabetes in the Danish National Diabetes Register between 1995 and 2012. This population was followed for dementia diagnosis or anti-dementia medication use until May 2018. Using risk-set sampling, each dementia case (n = 11 619) was matched on follow-up time and calender year of dementia with four controls randomly selected among cohort members without dementia (n = 46 476). Ever use and mean daily defined dose of antidiabetic medication was categorized in types (insulin, metformin, sulfonylurea and glinides combined, glitazone, dipeptidyl peptidase 4 (DPP4) inhibitors, glucagon-like peptide 1 (GLP1) analogs, sodium-glucose transport protein 2 (SGLT2) inhibitors and acarbose). Conditional logistic regression models were fitted to calculate odds ratios (ORs) for dementia associated with antidiabetic medication use, adjusting for potential confounders. Use of metformin, DPP4 inhibitors, GLP1 analogs, and SGLT2 inhibitors were associated with lower odds of dementia after multible adjustments (ORs of 0.94 (95% confidence interval (CI): 0.89-0.99), 0.80 (95% CI 0.74-0.88), 0.58 (95% CI: 0.50-0.67), and 0.58 (95% CI: 0.42-0.81), respectively), with a gradual decrease in odds of dementia for each increase in daily defined dose. Analyses of the most frequent treatment regimes did not show any synergistic effects of combined treatment. Use of metformin, DPP4 inhibitors, GLP1 analogs and SGLT2 inhibitors was associated with lower risk of dementia in patients with diabetes.

Lean body mass and risk of type 2 diabetes - a Danish cohort study.

Excess body fat is a commonly known risk factor for type 2 diabetes. However, whether lean body mass, or fat free mass, could have a protective effect against type 2 diabetes, remains unclear. The aim of this study was to explore the association between lean body mass, fat mass and type 2 diabetes. This study used data from the Danish Diet, Cancer and Health cohort of 37,053 men and women, aged 50-64years at baseline (1993-1997). The exposure was measurements of body composition using bioelectrical impedance analysis. Incident diabetes during follow-up was determined through linkage to the Danish National Diabetes Register. Cox proportional hazards regression analysis was used to estimate HR and 95%CI for the association between lean body mass and incident type 2 diabetes, with and without adjustment for fat mass. A sensitivity analysis was performed, excluding cases of incident type 2 diabetes within the first 2 years of follow-up. When adjusted for fat mass, the main analysis showed non-linear inverse association between lean body mass and risk of diabetes for men, but not for women. However, the sensitivity analysis found no association for either men or women. Lean body mass was not associated with incident type 2 diabetes when excluding cases that may have been subclinical at baseline. The results imply that public health should focus on reduction of fat mass for diabetes prevention.

1438-P: Antidiabetic Medication and Risk of Dementia in Patients with Type 2 Diabetes

Background: Diabetes is a risk factor for dementia, but whether antidiabetic medication decreases the risk is unclear. We examined the association between antidiabetic medication and dementia. Methods: We performed a nested case-control study within a cohort of all 176,250 patients registered with type 2 diabetes in the Danish National Diabetes Register between 1995-2012. This population was followed for dementia diagnosis or anti-dementia medication use until May 2018. Using risk-set sampling, each dementia case (n=11,619) was matched on follow-up time and calendar year of dementia with four controls randomly selected among cohort members without dementia (n=46,476). Ever use and mean daily defined dose of antidiabetic medication was categorized in types (insulin, metformin, sulfonylurea and glinides combined, glitazone, dipeptidyl peptidase 4 (DPP-4) inhibitors, glucagon-like peptide 1 (GLP-1) analogs, sodium-glucose transport protein 2 (SGLT2) inhibitors and acarbose). Conditional logistic regression models were fitted to calculate odds ratios (ORs) for dementia associated with antidiabetic medication use, adjusting for potential confounders. Results: Use of metformin, DPP-4 inhibitors, GLP-1 analogs, and SGLT2 inhibitors were associated with lower odds of dementia after multiple adjustments (ORs of 0.90 (95% confidence interval (CI) 0.86-0.96), 0.80 (95% CI 0.73-0.88), 0.53 (95% CI 0.38-0.74), and 0.53 (95% CI 0.38-0.74), respectively), with a gradual decrease in odds of dementia for each increase in daily defined dose. Analyses of the most frequent treatment regimens did not show any synergistic effects of combined treatment. Conclusion: Use of metformin, DPP-4 inhibitors, GLP-1 analogs and SGLT2 inhibitors were associated with lower risk of dementia in patients with type 2 diabetes. If confirmed in future studies these antidiabetics should be considered in interventions to prevent dementia. Disclosure I. Wium-Andersen: None. M. Osler: None. M. Jørgensen: None. J. Rungby: None. M. Wium-Andersen: None. Funding Jaschafonden; Lundbeck Foundation; Danish Medical Association; Danish Diabetes Association; M.D. Gerhard Linds Grant; Lundbeck Foundation/Novo Nordisk Foundation; Family Hede Nielsen Foundation; Holger Rabitz and Wife Doris Mary, born Phillip’s Memorial Foundation

Long-Term Exposure to Road Traffic Noise and Incidence of Diabetes in the Danish Nurse Cohort.

Background:Evidence on the association between road traffic noise and diabetes risk is sparse and inconsistent with respect to how confounding by air pollution was treated.Objectives:In this study, we aimed to examine whether long-term exposure to road traffic noise over 25 years is associated with incidence of diabetes, independent of air pollution.Methods:A total of 28,731 female nurses from the Danish Nurse cohort ( at recruitment in 1993 or 1999) were linked to the Danish National Diabetes Register with information on incidence of diabetes from 1995 until 2013. The annual mean weighted levels of 24-h average road traffic noise () at nurses’ residences from 1970 until 2013 were estimated with the Nord2000 method and annual mean levels of particulate matter (PM) with diameter and ( and ), nitrogen dioxide (), and nitrogen oxide () with the Danish AirGIS modeling system. Cox proportional hazards regression models were used to examine the association between residential in four different exposure windows (1-, 5-, 10-, and 25-years) and the incidence of diabetes, adjusted for lifestyle factors and air pollutants.Results:Of 23,762 nurses free of diabetes at the cohort baseline, 1,158 developed diabetes during a mean follow-up of 15.2 years. We found weak positive associations between 5-y mean exposure to (per increase) and diabetes incidence in a crude model [hazard ratio (HR): 1.07; 95% confidence interval (CI): 0.99, 1.12], which attenuated in a model adjusted for lifestyle factors (HR:1.04; 95% CI: 0.97, 1.12), and reached unity after additional adjustment for (HR: 0.99; 0.91, 1.08). In analyses by level of urbanization, we found a positive association between noise and diabetes in urban areas (HR:1.27; 95% CI: 0.98, 1.63) that was unchanged after adjusting for (HR: 1.25; 95% CI: 0.97, 1.62), but we found no apparent association in provincial (HR: 1.02; 95% CI: 0.88, 1.18) or rural areas (HR: 0.97; 95% CI: 0.87, 1.08). Conclusion:In the nationwide cohort of Danish nurses 44 years of age and older, we found no association between long-term exposure to road traffic noise and diabetes incidence after adjustment for but found suggestive evidence of an association limited to urban areas. https://doi.org/10.1289/EHP4389

A randomized general population study of the effects of repeated health checks on incident diabetes.

It is not clear whether offering health checks to the general population can be used to prevent diabetes. Few randomized studies have had a long-term follow-up. We used a randomly selected population cohort as a randomized trial to examine the effect of repeated health checks on the 30-year incidence of diabetes. The study included all persons from 11 municipalities in Copenhagen aged 30, 40, 50, and 60 years (n = 17845). An age-stratified and gender-stratified random sample (N = 4789) was invited to participate in a maximum of three health checks between 1982 and 1994 ('intervention group'). The remaining 12994 persons were defined as the 'control group'. The health checks included a questionnaire, a physical examination including assessment of overweight and blood pressure, and blood sampling with determination of serum lipid levels. Based on the person's answers and test results, the participants were given individual information about the results, disease risk and lifestyle. Their general practitioner, too, was provided with written information on the test results. Both groups were followed in the Danish Civil Registration System, the Danish National Diabetes Register, the Cause of Death Registry, and the National Patient Registry until 31 December 2012. There were 2636 incident cases of diabetes and a mean follow-up time of 24.1 years. The age-adjusted and gender-adjusted hazard ratio (HR) (95% confidence interval, CI) for the intervention group versus the control group was HR = 1.07 (95% CI: 0.98, 1.16, p = 0.153). Offering repeated general health checks to the general population had no preventive effect on the development of diabetes during 30 years of follow-up.

Substitutions between dairy product subgroups and risk of type 2 diabetes: the Danish Diet, Cancer and Health cohort.

The aim of this study was to investigate the associations for specified substitutions between different subgroups of dairy products and the risk of type 2 diabetes. We used data from the Danish Diet, Cancer and Health cohort including 54 277 men and women aged 50-64 years at baseline. Information regarding intake of dairy products was obtained from a validated FFQ, and cases of type 2 diabetes were identified through the Danish National Diabetes Register. Cox proportional hazards regressions were used to estimate associations. During a median follow-up of 15·3 years, 7137 cases were identified. Low-fat yogurt products in place of whole-fat yogurt products were associated with a higher rate of type 2 diabetes (hazard ratio (HR) 1·17; 95 % CI 1·06, 1·29) per serving/d substituted. Whole-fat yogurt products in place of low-fat milk, whole-fat milk or buttermilk were associated with a lower rate of type 2 diabetes (HR 0·89; 95 % CI 0·83, 0·96; HR 0·89; 95 % CI 0·82, 0·96; HR 0·89; 95 % CI 0·81, 0·97; per serving/d substituted, respectively). The pattern of associations was similar when intake was expressed as kJ/d (kcal/d). These findings suggest that intake of whole-fat yogurt products in place of low-fat yogurt products, low-fat milk, whole-fat milk and buttermilk are associated with a lower rate of type 2 diabetes.

Burden of Mortality Attributable to Diagnosed Diabetes: A Nationwide Analysis Based on Claims Data From 65 Million People in Germany

In Germany, as in many other countries, nationwide data on mortality attributable to diagnosed diabetes are not available. This study estimated the absolute number of excess deaths associated with diabetes (all types) and type 2 diabetes in Germany. A prevalence approach that included nationwide routine data from 64.9 million people insured in the German statutory health insurance system in 2010 was used for the calculation. Because nationwide data on diabetes mortality are lacking in Germany, the mortality rate ratio from the Danish National Diabetes Register was used. The absolute number of excess deaths associated with diabetes was calculated as the number of deaths due to diabetes minus the number of deaths due to diabetes with a mortality that was as high as in the population without diabetes. Furthermore, the mortality population-attributable fraction was calculated. A total of 174,627 excess deaths were due to diabetes in 2010, including 137,950 due to type 2 diabetes. Overall, 21% of all deaths in Germany were attributable to diabetes and 16% were attributable to type 2 diabetes. Most of the excess deaths (34% each) occurred in the 70- to 89-year-old age-group. In this first nationwide calculation of excess deaths related to diabetes in Germany, the results suggest that the official German estimates that rely on information from death certificates are grossly underestimated. Countries without national cohorts or diabetes registries could easily use this method to estimate the number of excess deaths due to diabetes.

Alcohol drinking patterns and risk of diabetes: a cohort study of 70,551 men and women from the general Danish population.

Alcohol consumption is inversely associated with diabetes, but little is known about the role of drinking patterns. We examined the association between alcohol drinking patterns and diabetes risk in men and women from the general Danish population. This cohort study was based on data from the Danish Health Examination Survey 2007-2008. Of the 76,484 survey participants, 28,704 men and 41,847 women were eligible for this study. Participants were followed for a median of 4.9years. Self-reported questionnaires were used to obtain information on alcohol drinking patterns, i.e. frequency of alcohol drinking, frequency of binge drinking, and consumption of wine, beer and spirits, from which we calculated beverage-specific and overall average weekly alcohol intake. Information on incident cases of diabetes was obtained from the Danish National Diabetes Register. Cox proportional hazards model was applied to estimate HRs and 95% CIs. During follow-up, 859 men and 887 women developed diabetes. The lowest risk of diabetes was observed at 14 drinks/week in men (HR 0.57 [95% CI 0.47, 0.70]) and at 9 drinks/week in women (HR 0.42 [95% CI 0.35, 0.51]), relative to no alcohol intake. Compared with current alcohol consumers consuming <1day/week, consumption of alcohol on 3-4days weekly was associated with significantly lower risk for diabetes in men (HR 0.73 [95% CI 0.59, 0.94]) and women (HR 0.68 [95% CI 0.53, 0.88]) after adjusting for confounders and average weekly alcohol amount. Our findings suggest that alcohol drinking frequency is associated with risk of diabetes and that consumption of alcohol over 3-4days per week is associated with the lowest risk of diabetes, even after taking average weekly alcohol consumption into account.

Diabetes and depression in Denmark 1996-2010: national data stratified by occupational status and annual income.

To assess the socio-economic distribution of comorbid depression and diabetes among the Danish workforce using national registry data. Using national registers, all eligible Danish adults aged 18-59 years on 1 January 1996 were followed until 31 December 2010. Diabetes status was obtained from the Danish National Diabetes Register and information on purchase of prescription antidepressants from the Register of Medicinal Product Statistics. Data were also obtained on people's occupational status and gross annual income. The people included in the study were stratified according to their highest occupational group during the study period. Annual incomes were adjusted to 2013 levels and, using the distribution of the study population's incomes, we stratified participants into income quintiles. A total of 3 434 420 individuals met the inclusion criteria at baseline, with 98 006 developing diabetes during follow-up. There were 603 498 new prescriptions of antidepressants during follow-up; 19 849 (20.3%) among people with diabetes and 583 649 (17.5%) among those without. People with diabetes in all income quintiles (risk ratio 1.65; 95% CI 1.62-1.67) and all occupational groups (risk ratio 1.70; 95% CI 1.68- 1.73) had a significantly elevated risk compared with the general population. Risk ratios were significantly higher among the lowest occupational groups and income quintiles. Our results provide robust data underlining the associations between diabetes, depression and socio-economic status. They highlight and encourage further focus on the issue of comorbid diabetes and depression, particularly among the most disadvantaged.

Incidence of register-based diabetes 10 years after a stepwise diabetes screening programme: the ADDITION-Denmark study.

Screening programmes for type 2 diabetes inevitably find more people at high risk of developing diabetes than people with undiagnosed prevalent diabetes. We describe the incidence of diabetes for risk groups according to advancement in a screening process. In 2001-2006, a diabetes screening programme based on the Danish diabetes risk score and measures of HbA1c and glucose was carried out in Danish general practices. The present study includes 13,249 individuals with low diabetes risk scores and 22,726 with high diabetes risk scores but no diabetes according to WHO 1999 criteria. Seven incremental levels of diabetes risk were defined and followed for incident diabetes recorded in the Danish National Diabetes Register until December 2012. For each group, cumulative diabetes incidence was calculated. Incidence rates and rate ratios were estimated by Poisson regression analyses. After 10 years of follow-up 1,164 new diabetes cases were registered. Incidence rates were 1.0, 4.2, 14.5, 28.8 and 52.6 per 1,000 person-years in individuals at low risk and in those with normal glucose tolerance, impaired fasting glucose, impaired glucose tolerance and one diabetic glucose value, respectively. For each step in the screening algorithm, the risk of developing diabetes was higher than in the previous step. The risk of developing clinical diabetes in people who screen negative for diabetes depends on the level of risk stratification at screening, even at lower risk levels. This risk increases markedly in the presence of impaired glucose regulation. These results can inform policy recommendations concerning prevention strategies following screening.

Substantial reduction in the number of amputations among patients with diabetes: a cohort study over 16 years.

The aim of this study was to describe the trends in rates of amputation among individuals with and without diabetes. We studied amputation rates in the County of Funen (approximately 0.5 million residents) during the period 1996-2011. Amputations were identified from the hospital administrative system, diabetes status by linkage with the Danish National Diabetes Register, and mortality and population data by extraction from Statistics Denmark. Amputation rates were analysed using proportional hazard models. We analysed the incidence of the first amputation at each level as well as the incidence of further amputations, subdivided by level of amputation. During the period 1996-2011, a total of 2,832 amputations were performed, of which 1,285 were among patients with diabetes and 1,547 among individuals without diabetes. Relative to persons without diabetes, patients with diabetes had an HR for below-ankle amputations (BAAs) of 14.7 for men and 7.5 for women, and for from-ankle-to-knee amputations (BKAs) of 7.6 and 8.4 for men and women, respectively. For above-knee amputations (AKAs) the numbers were 4.0 for men and 3.7 for women. We found an annual reduction in BAA rates among patients with diabetes of 9.8%, and the annual reduction in BKA for patients with diabetes was 15.1%. The amputation rate in patients with diabetes is still several-fold higher than in persons without diabetes, but the improvements in diabetes care in recent years have resulted in a steady decline in amputation rates among patients with diabetes from this Danish cohort.

Societal costs of diabetes mellitus in Denmark

AimTo provide comprehensive real‐world evidence on societal diabetes‐attributable costs in Denmark.MethodsNational register data are linked on an individual level through unique central personal registration numbers in Denmark. All patients in the Danish National Diabetes Register in 2011 (N = 318 729) were included in this study. Complication status was defined according to data from the Danish National Hospital Register. Diabetes‐attributable costs were calculated as the difference between costs of patients with diabetes and the expected costs given the annual resource consumption of the diabetes‐free population.ResultsSocietal costs attributable to diabetes were estimated to be at least 4.27 billion EUR in 2011, corresponding to 14,349 EUR per patient‐year. A twofold higher healthcare resource usage was found for patients with diabetes as compared with the diabetes‐free population. Attributable costs, grouped according to different components, were 732 million EUR for primary and secondary care services, 153 million EUR for pharmaceutical drugs, 851 million EUR for nursing services, 1.77 billion EUR in lost productivity and 761 million EUR for additional costs. A steep increase in diabetes‐attributable costs was found for patients with major complications compared with patients without complications across all cost components. For attributable healthcare costs this increase was estimated to be 6,992 EUR per person‐year after controlling for potential confounders.ConclusionsNearly half of the total costs of patients with diabetes can be attributed directly to their diabetes. The majority of costs are incurred among patients with major complications pointing to the importance of secondary preventive efforts among patients with diabetes.

Incidence, morbidity, mortality, and prevalence of diabetes in Denmark, 2000-2011: results from the Diabetes Impact Study 2013.

PurposeAs part of the Danish Diabetes Impact Study 2013, we present trends in the incidence, morbidity, mortality, and prevalence of diabetes in Denmark for the period 2000 through 2011.Patients and methodsThe Danish National Diabetes Register was established in 2006 and is assumed to cover all patients with diabetes, alive as of the end of 1996, and all subsequent new cases. The present study is based on the content of the register as of July 3, 2013 (n=497,232 patients). Using the personal identification code assigned to all Danish inhabitants, all available supplementary information from the Danish National Patient Register and the Danish Civil Registration Service was used to define the date of diagnosis of diabetes and the first date of experiencing complications (grouped according to impact and severity).ResultsDuring the period of 2000 to 2011, the incidence rate of diabetes increased approximately 5% annually. During the same period, decreasing trends were observed for both the rates of progression in complications and of the complication-specific mortality. During the same period, the prevalence of diabetes doubled.ConclusionThe increasing prevalence of diabetes in Denmark is driven by increasing incidence combined with decreasing morbidity and mortality in the population of patients with diabetes. These mechanisms will be explored further as part of the Diabetes Impact Study 2013, together with investigations into the socioeconomic and health economic aspects of diabetes.

The Relationship between Diabetes and Retirement from Work: A Ten-Year Follow-Up in National Registers

Objectives: To investigate the relationship between diabetes, mortality and exit from work using various Danish Pension schemes. Methods: We linked the Danish National Diabetes register with socioeconomic and population-based registers and followed prevalent and incident cases of diabetes for ten years, adjusting for gender, age and socio-occupational group. We analysed the proportion of individuals with diagnosed diabetes before and after entering a normal retirement pen-sion, voluntary early retirement pension or disability pension. Risk ratios for entering pensions, emigration and mortali-ty were calculated using Poisson regression. Results: Among 1,628,087 adults between the ages of 30 and 59, the relative risk for mortality was increased for those with incident and prevalent diabetes by 11-145%, compared to individuals without diabetes. Voluntary early retirement pension was the most common path out of the workforce, especially for individuals with diabetes. Compared to those without diabetes, the relative risk of disability retirement for individuals with prevalent and incident diabetes was 2.98 (95% CI, 2.89 – 3.07) and 2.40 (95% CI, 2.34 – 2.45), respectively. More than one fifth of participants were diagnosed with diabetes after retirement. There was a marked negative socio-occupational gradient for mortality, voluntary early retirement and disability pension. Conclusions: Increasing the retirement age will increase the proportion of workers who develop diabetes while still in the workforce. Since the number and severity of complications are related to longer disease duration, it is likely that, under proposed retirement reforms, more employees will experience health problems managing their jobs, especially among the most vulnerable socioeconomic groups. therefore expected to become more important as the retirement age increases. However, there is only scarce knowledge of how the incidence and prevalence of diabetes are distributed among different pension schemes.

Societal Costs of Diabetes Mellitus 2025 and 2040—Forecasts Based on Real World Cost Evidence and Observed Epidemiological Trends in Denmark

Aim: The objective is to contribute with real world evidenced economic forecasts of diabetes attributable costs in 2025 and 2040 differentiated according to patients’ morbidity status which is a novel approach within forecasting. Methods: Method of forecasting is based on an annual calendar year prediction of diabetes attributable costs by using the BOX-model, an established and tested epidemiological transition-state model. The study population includes all Danish diabetes patients presented in 2011 (N = 318,729) according to the Danish National Diabetes Register. Forecasting is based on individual patient data from 2000 to 2011 for incidence, mortality, patterns of morbidity and complication rates combined with demographic population projections from Statistics Denmark. The 2011 estimation of diabetes attributable costs were applied to the epidemiological framework. Forecasting was performed for three different epidemiological scenarios. Results: Our three epidemiological scenarios indicate that within the shorter time span increases in the prevalent population are difficult to change primarily due to the already achieved historic improvements in diabetes mortality and morbidity. These will approximately double societal costs of diabetes in the next 10 years assuming current trends in morbidity and mortality are maintained. The resulting diabetes population will incur three times current costs in 2040. A 20% reduction in cost per PYRS shows how the relative distribution of patients with complications is expected to change over time with patients living better with their disease and hence incur a lower demand for health and nursing care services.

Validation of the danish national diabetes register.

The Danish National Diabetes Register (NDR) was established in 2006 and builds on data from Danish health registers. We validated the content of NDR, using full information from the Danish National Patient Register and data from the literature. Our study indicates that the completeness in NDR is ≥95% concerning ascertainment from data sources specific for diabetes, ie, prescriptions with antidiabetic drugs and diagnoses of diabetes in the National Patient Register. Since the NDR algorithm ignores diabetes-related hospital contacts terminated before 1990, the establishment of the date of inclusion is systematically delayed for ≥10% of the registrants in general and for ≥30% of the inclusions before 1997 in particular. This bias is enhanced for ascertainment by chiropody services and by frequent measurements of blood glucose because the date of reimbursement of services, rather than the date of encounter, has been taken as the date of inclusion in NDR. We also find that some 20% of the registrations in NDR may represent false positive inclusions of persons with frequent measurements of blood glucose without having diabetes. We conclude that NDR is a novel initiative to support research in the epidemiological and public health aspects of diabetes in Denmark, but we also present a list of recommended changes for improving validity, by reducing the impact of current sources of bias and misclassifications.