Some things have changed for the better, but the cohort of emerging complications are going to create their own set of challenges.
Diabetes complications have changed over the last 20 years – and will continue to do so over the next 20.
That’s according to Professor Dianna Magliano, head of the diabetes and population health research theme at the Baker Heart and Diabetes Institute in Melbourne, after the epidemiologist gave a wide-ranging talk on this topic at the recent International Diabetes Federation Western Pacific Region Congress.
Diabetes complications have traditionally been classified as either microvascular or macrovascular in nature.
“The microvascular complications, these are complications which are described as pathognomonic of diabetes, meaning they are directly associated with prolonged hyperglycaemia,” said Professor Magliano.
“These include retinopathy [and] neuropathy.
“Macrovascular complications occur in people with and without diabetes. There are many factors involved in their aetiology, and optimal glucose control will only have some benefits. They include heart failure, myocardial infarction, stroke, and peripheral arterial disease.”
Better treatment of people with diabetes, courtesy of the development of new drugs and other improvements in how people with diabetes are managed, has led to improved survival in people with diabetes. But an increasing number of conditions have been linked to diabetes on the back of this improved survival.
“These include cancer, infections, functional disability, frailty, liver disease, cognitive disability and dementia, and affective disorders [like] depression and anxiety. And there’s probably more that you could add onto that list, like sleep apnoea even hearing loss,” Professor Magliano explained.
It’s not that these complications didn’t exist before, according to Professor Magliano. The trends and changes in diabetes complications were so much easier to see because it was easier to access large, population-level datasets – be those clinical registries or administrative health datasets – than it ever was before.
The good news is that the proportion of diabetes who died from cardiovascular disease in Australia decreased from 34% in 2005 to 25% in 2019.
However, the proportion of people with diabetes dying from cancer and dementia have both increased over the same timeframe (from 25% to 28% for cancer, and from 1% to 6% for dementia). Similar shifts were observed overseas, in Denmark, Sweden, Finland, Scotland, and South Korea.
In addition, the distribution of complications in people with diabetes that required hospitalisation has also changed.
While there have been decreases in the proportion of hospitalisations relating to heart failure, myocardial infarction, and hypoglycaemia, there have been increases in hospitalisations for hyperglycaemia and amputation.
“We took these excess causes of hospitalisations amongst people with diabetes compared to the general population, and we ranked the magnitude of excess annual hospitalisations,” said Professor Magliano.
“We thought the top 10 would all be traditional complications – but they weren’t.
“Only half of the top 10 were due to traditional complications, and then a few were due to emerging complications – depression, pneumonia, and some different kinds of infections.
“We also saw what we call ‘other’ complications, and some of these were quite novel. [For example,] people with diabetes have an excess risk of going to hospital for iron deficiency or anaemia – both in men and women.”
Related
One challenge with emerging complications in diabetes was understanding what links two previously separate conditions. The emerging association between diabetes and mental health was highlighted by a review in The Lancet Diabetes & Endocrinology earlier this year.
“It’s not fully understood why [diabetes and mental health are linked],” said Professor Magliano.
“[But] we know it’s a bidirectional relationship. We know that having diabetes is stressful [and] we know that mental health problems might increase your risk of developing diabetes.
“The pathways are not really well elucidated, but inflammation is probably going to have a major role. We also know that antipsychotic medications can cause weight gain… and then you might have a higher risk of developing diabetes.”
Professor Magliano concluded her talk by speculating about what she expected to occur in the coming years.
“We know we’re going to have an older population. Like all high-income countries, we are aging rapidly. We’re know were going to have more [people with] young onset type 2 diabetes. [And because people with diabetes] are getting older and surviving through the heart attacks, we will have a longer duration of diabetes,” she said.
“With the older population, we’ll get more dementia, more heart failure, more physical dysfunction and frailty. People with [a] longer duration of diabetes that will lead to more microvascular complications because [of] the exposure to hyperglycaemia will get obesity, liver disease, heart failure, [and] atrial fibrillation.
“We’re going to have lots of care challenges with insulin and technology and frailty. We have these really good medications… with greater use of SGLT-2s and GLPs, so we should get less renal disease, less heart failure, less MI, less stroke, and less liver disease. But with greater use of GLP-1s we’ll get more sarcopenia.”
The International Diabetes Federation Western Pacific Region Congress was held in Melbourne from 18 to 21 August 2026.
