Diabetes complications cause major loss of quality of life

Patients with type 2 diabetes have moderately lower health-related quality of life scores than the general population of a similar age. This may be due to psychological effects associated with reduced general well-being, as well as effects on family relationships and social life. Furthermore, diabetics with complications have a lower quality of life than diabetics without complications. Loss of quality of life due to complications varies from sexual dysfunction, limb amputation and blindness, to the need for chronic kidney dialysis or kidney transplantation. Treatment with insulin is also associated with a lower quality of life (Koopmanschap, 2002).

Macrovascular complications include heart disease and diabetic foot

Cardiovascular disease (CVD) is the major complication of diabetes affecting larger blood vessels. 50% of people with diabetes die of cardiovascular disease, primarily heart disease and stroke (WHO, 2006a). The most important cardiovascular complications of diabetes are (WHO, 1999b; WHO, 2002e; WHO, 2003b;IDF, 2006a; EUDIP group, 2002):

• coronary heart disease (CHD) and cerebrovascular accident (CVA, including stroke): they occur when blood vessels are narrowed or blocked by fatty deposits (atheroslerotic plaques). High blood glucose levels promote atherogenesis and thrombosis through a range of biochemical pathways (Laakso, 1999).
• peripheral vascular disease (PVD, diabetic foot disease): in diabetic foot disease damage to blood vessels and nerves (see also diabetic neuropathy) causes ulcerations and infection which can necessitate amputation. Between 1 and 4% of the diabetic patients in Europe has to undergo amputation (IDF, 2006a).

Microvascular complications affect eye, kidney and nervous system

Complications of diabetes affecting the small blood vessels (WHO, 1999b; WHO, 2002e; WHO, 2003b; WHO, 2006a; IDF, 2006a; EUDIP group, 2002 )are:

• diabetic retinopathy: eye disease due to the damage of small blood vessels in the retina. After 20 years of diabetes almost all patients with diabetes type 1 and more than 60% of patients with diabetes type 2 are affected to some degree (EUDIP group, 2002). It can lead to severe visual disability and blindness. This affects 10 and 2% of patients respectively after 15 years of diabetes (WHO, 2002e).
• diabetic nephropathy: kidney disease and kidney failure may lead to chronic renal dialysis or kidney transplantation. About 10-20% of people with diabetes die of kidney failure (WHO, 2006a). According to the WHO guidelines an increase of serum creatinine ≥ 400 μmol/ll is considered as end stage renal failure where dialysis is imminent (EUDIP group, 2002).
• diabetic neuropathy: neuropathy can lead to sensory loss and damage to the limbs, increasing risk of foot ulcers (and ultimately amputation) and causing autonomic dysfunction, including sexual dysfunction (WHO, 1999b). Up to 50% of people with diabetes are affected (WHO, 2006a).

Certain risk factors increase risk of complications

Poor metabolic control (manifesting itself in hyperglycaemia) increases the risk for micro and macro vascular complications. Glycosylated haemoglobin (HbA1c) reflects metabolic control over the past 2-3 months with chronically high blood sugar levels resulting in an increased HbA1c. Above 7.5% the risk for complications is increased. Approximately half of diabetics have HbA1c above 7.5% (EUDIP group, 2002). Other risk factors for complications are: abnormal concentrations of total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides and presence of microalbuminuria, hypertension, smoking, overweight and obesity (EUDIP group, 2002).

Diabetes contributes to 1.6 - 6.6 % of total health care costs

The CODE-2 study has measured the health care costs of people with type 2 diabetes in 8 EU countries: Belgium, France, Germany, Italy, the Netherlands, Spain, Sweden and the UK (Jönsson, 2002). For these 8 countries the average annual costs per patient with type 2 diabetes were estimated at €2,834 in 1999. The health care costs of diabetes as a percentage of the total healthcare expenditures ranged from 1.6% in the Netherlands to 6.6 % in Italy. Hospitalisations accounted for the greatest proportion of costs (55%).

A Swedish study (Jonsson et al., 2000) observed that the cost profile during the natural history of diabetes is 'U' or 'J' shaped with relatively high costs immediately after diagnosis, followed by a fall and again a rise with the onset of complications (Jonsson et al., 2000). Indirect costs by diabetes due to loss of productivity may be as great or even greater than direct health care costs (WHO, 2002f).

Diabetes is among the leading causes of death and disability

In the WHO European Region diabetes accounts for an estimated 2.2 million DALYs in 2002. Diabetes ranked among the ten leading causes for the loss of healthy life years, expressed in DALYs, in Cyprus, Denmark, Greece, Italy, Malta and Portugal (WHO, 2005f).