Characteristics, vascular risk, and complications in people with diabetes

Characteristics of Adults with Diabetes and Vascular Risk

These data are from the Entred studies, conducted in 2001 and 2007. The adult diabetic population is generally older (median age of 66), economically more disadvantaged than the general population of the same age, and 23% of whom were born abroad. Type 2 diabetes is the most common form (92%). Type 2 diabetes has been diagnosed for an average of 11 years, which exposes patients to a high risk of complications. Among people with type 2 diabetes, a notable decrease in vascular risk was observed between 2001 and 2007. While obesity has become even more common (41%, +7 percentage points since 2001), glycemic control has improved (median HbA1c: 6.9%, -0.3%), and blood pressure (median 130/80 mmHg, -3/-2 mmHg) and cholesterol (median LDL: 1.06 g/L, -0.18 g/L) decreased regardless of age. However, the frequency of diabetes complications increased slightly, which can be partly explained by more frequent screening for these complications, and may also be due to longer life expectancy and a higher prevalence of diabetes.

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Monitoring of Recommended Examinations

Data on the follow-up of recommended tests for diabetes management are extracted from the National Inter-Regime Health Insurance Information System (Sniiram). People with diabetes receiving pharmacological treatment are identified based on reimbursements for antidiabetic treatments. Laboratory tests are selected according to the codes in the nomenclature of medical laboratory procedures, and clinical follow-up is based on the medical specialty of the healthcare professional performing the procedure. The frequency of glycemic control monitoring (3 annual HbA1c tests) has increased significantly since 2007, reaching 51% of patients in 2013 (+12 percentage points). Annual creatinine testing also increased (84% in 2013, +5 percentage points). A 4-point increase in the frequency of annual microalbuminuria testing was observed (30% in 2013) and a 3-point increase in lipid testing (74%). Annual dental visits also increased by 3 percentage points (36%). In contrast, cardiology follow-up (35%) and biannual ophthalmology visits (62%) had not increased since 2007. Socioeconomic disparities were relatively small regarding laboratory testing but more pronounced for clinical follow-up. Follow-up varied by region and type of examination. French Guiana and Limousin stood out from other regions with relatively low follow-up rates compared to national averages. Conversely, Réunion recorded better follow-up for most indicators.

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Diabetes and Obesity

The prevalence of obesity among people with type 2 diabetes (T2D) in mainland France in 2007, its trends between 2001 and 2007, and the characteristics of obese patients in 2007 were examined using data from the Entred studies conducted between 2001 and 2007. In 2007, the average age of treated T2D patients was 65 years; 41% were obese (body mass index, BMI ≥ 30 kg/m²), 46% of women and 37% of men, compared with 16.9% in the general population aged 18–74 years. The prevalence of obesity decreased with age, was higher among people with T2D treated with insulin (45% vs. 41%, p<0.001), among people born in France compared to those born in the Maghreb (42% vs. 33%, p< 0.001), and among individuals of lower socioeconomic status after adjusting for age, sex, and duration of diabetes. The prevalence of obesity increased between 2001 and 2007 (+7 percentage points) regardless of age, sex, ethnic origin, and socioeconomic status. This increase was greater among individuals treated with insulin compared to those not treated with insulin (+11 percentage points vs. +6 percentage points). Five percent were morbidly obese (BMI ≥ 40 kg/m²). Compared to people with T2D with a BMI below 25 kg/m² (underweight to normal weight), they had, after adjusting for age, sex, and duration of diabetes, significantly higher systolic blood pressure (137 vs. 131 mmHg) and HbA1c (7.5% vs. 7.0%), as well as a higher prevalence of suspected sleep apnea syndrome (35% vs. 9%). They were more likely to receive dietary consultations (35% vs. 16%), general practice care (41% vs. 24% for ≥12 visits), and podiatric care (26% vs. 23%), but were less likely to have three HbA1c tests within the year (42% vs. 45%) in the private sector. Furthermore, they were more likely to have received educational interventions. In conclusion, the prevalence of obesity has increased among treated T2D patients. Treated patients born in the Maghreb are less frequently obese, reflecting a higher genetic risk of diabetes at a lower level of obesity. Finally, while care increases with the level of obesity, it remains insufficient in the face of a higher cardiovascular risk.

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  • Slideshow "Epidemiology of Obesity Among People with Type 2 Diabetes in Metropolitan France – Entred 2007–2010"

  • Assogba F, Roudier C, Eschwege E, Fournier C, Ricci P, Weill A, Fagot-Campagna A, Druet C. Prevalence and trends in obesity among people with type 2 diabetes in mainland France. Entred 2001–2007. In: Congress of the Francophone Diabetes Society, Geneva, March 22–25, 2011. Diabetes Metabol 2011, 37 (suppl 1).

  • Assogba F, Roudier C, Druet C, Eschwège E, Fournier C, Ricci P, Weill A, Fagot-Campagna A. Prevalence and trends in obesity among people with type 2 diabetes in France. Between 2001 and 2007. In: Congress of the European Diabetes Epidemiology Group, Greece, May 16–18, 2010.

Foot complications

Data from the National Inter-Regime Health Insurance Information System (Sniiram), linked to the Medical Information Systems Program (PMSI), allow for estimating the frequency of hospitalizations for foot wounds and lower limb amputations among people with diabetes receiving pharmacological treatment (identified based on reimbursements for antidiabetic treatments). Hospitalizations for lower limb amputation (AMI) are selected based on procedures coded according to the Common Classification of Medical Procedures, and those for foot ulcers based on primary, related, and associated diagnoses. For foot ulcers and for the same individual, only the first hospital stay of the year is included. For LLA, only the hospitalization for the most proximal amputation is included. To enable comparisons by region or socioeconomic status, incidence rates are standardized to the 2010 European population age structure, limited to individuals aged 45 and older.

In 2013, in France, the incidence rates of hospitalizations for AMI and foot ulcers in the treated diabetic population were 252 per 100,000 and 668 per 100,000 people with diabetes, respectively. At the same age structure, the rate of diabetic men hospitalized for AMI was 2.6 times higher than that of women, and the rate of foot ulcers was 1.6 times higher. The rates were 1.5 and 1.4 times higher, respectively, among people with diabetes under the age of 60 who were beneficiaries of the complementary universal health coverage than among non-beneficiaries. It was 1.3 times higher among people residing in the most disadvantaged municipalities compared to those residing in the most advantaged municipalities. Regional disparities were very pronounced for these two complications.

Click here to view the detailed table of incidence data for lower limb amputation hospitalizations by region in 2013.

Click here to view the detailed table of incidence data for hospitalizations due to foot wounds by region in 2013.

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Cardiovascular Complications

Data extracted from the National Inter-Regime Health Insurance Information System (Sniiram), linked to the Medical Information Systems Program (PMSI), allow for the estimation of the frequency of hospitalizations for myocardial infarction (MI) and stroke among people with diabetes receiving pharmacological treatment (identified based on reimbursements for antidiabetic treatments). Hospitalizations for MI and stroke are selected based on the primary diagnosis. Rates standardized to the 2010 European population age structure are broken down by sex, socioeconomic status, and region, among individuals aged 45 and older.

In 2013, in France, the rate of people with diabetes hospitalized for MI was 382 per 100,000 people with diabetes, and the rate for stroke was 559 per 100,000. At the same age structure, the rate of men with diabetes hospitalized for MI was nearly twice as high as that of women, and the rate of stroke was 1.3 times higher among men. The rates were 1.3 and 1.6 times higher, respectively, among people with diabetes under 60 years of age who were beneficiaries of the complementary universal health coverage than among non-beneficiaries. These disparities were smaller according to a territorial index of social disadvantage. Certain regions, such as Limousin, had very high rates of people hospitalized for MI compared to the national rate. Conversely, the overseas departments (with the exception of Guadeloupe) were characterized by lower rates for MI but higher rates for strokes.

Click here to view the detailed table of hospitalization incidence data for myocardial infarction by region in 2013.

Click here to view the detailed table of hospitalization incidence data for stroke by region in 2013.

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End-stage chronic kidney disease treated in people with diabetes

The Epidemiology and Information Network in Nephrology (Rein) is an information system designed to contribute to the development and evaluation of health strategies aimed at improving the prevention and management of chronic kidney disease. Its overall objective is to describe the incidence and prevalence of renal replacement therapy for end-stage chronic kidney disease, the characteristics of the treated population, mortality, and treatment modalities through comprehensive and continuous recording of patient information.

In 2013, in France, 4,256 people with diabetes began renal replacement therapy for end-stage chronic kidney disease, representing an incidence rate of 142 per 100,000 people with diabetes. The median age of these people with diabetes was 71.6 years. With an identical age structure, 5 regions recorded high incidence rates compared to the national standardized incidence rate, and 5 others recorded much lower incidence rates. The standardized incidence of end-stage chronic kidney disease (ESCD) among people with diabetes has been trending upward since 2011. After accounting for the effects of aging and the growth of the general population, the residual portion accounts for 70% of the change in the number of new cases.

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Severe visual impairment among people with diabetes

The prevalence of severe visual impairment among people with diabetes was estimated using data from both components (households and institutions) of the Health and Disability Survey (HSM-HSI-Insee/Drees), conducted among 39,000 people of all ages in 2008 and 2009. This survey aimed to study physical and mental impairments and disabilities. Individuals were considered to have severe visual impairment if they were blind (or could only perceive light) or had low vision (a severe impairment without being blind), based on their own self-reports. The prevalence of severe visual impairment was estimated at 1.7% (blind: 0.18% and visually impaired: 1.56%) in the diabetic population (mean age: 75 years), which is 1.6 times higher than that of the non-diabetic population of equivalent age and sex. The cause of the visual impairment was unknown to the patients in 48% of cases (32% of cases among people with diabetes).

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  • Fosse S, Chatelus AL, Feldman-Billard S, Massin P, Druet C, Fagot-Campagna A. Prevalence of severe visual impairment (SVI) among people with diabetes in mainland France in 2008. Congress of the Francophone Diabetes Society, Nice, March 20–23, 2012. Diabetes Metabol 2012,38:A8.

Symptoms suggestive of obstructive sleep apnea-hypopnea syndrome (OSAHS)

The prevalence of OSAHS and the extent of underdiagnosis were estimated among people with type 2 diabetes based on the 2007 Entred study. Among people with type 2 diabetes, the prevalence of symptoms suggestive of OSAHS was 16%, and 28% of symptomatic individuals had previously undergone a sleep study.

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Other complications of diabetes

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