New research from the University of Gothenburg has revealed a shift in the risk patterns for arterial disease among people with type 1 and type 2 diabetes.
While the risks of heart attack and stroke have decreased significantly, complications in more peripheral blood vessels are becoming relatively more common.
It is already well established that diabetes increases the likelihood of heart and brain-related events.
However, less is known about how diabetes affects more peripheral arteries, such as those in the legs or feet.
Two new studies published in *The Lancet Regional Health – Europe* shed light on this issue, showing long-term trends and identifying key risk factors.
The research team analyzed 20 years of health data from the Swedish National Diabetes Register. Their study involved over 34,000 individuals with type 1 diabetes and more than 655,000 with type 2 diabetes, compared against 2.7 million people without diabetes.
They examined complications in peripheral arteries such as calcification in the carotid and abdominal arteries, peripheral artery disease in the legs, and small vessel disease in the feet.
Results showed an overall decline in the number of these complications over time, especially among people with type 1 diabetes. For example, cases of small vessel disease in the feet dropped sharply from 814 to 77 per 100,000 people.
In type 2 diabetes, the drop was more modest—from 309 to 226. Similarly, calcification in the abdominal aorta and lower extremities fell by more than half in type 1 diabetes.
Despite this decline, the relative risk has shifted. Central arterial events like heart attacks and strokes have become less common, while peripheral complications now make up a larger share of the overall risk. This means more attention may need to be given to monitoring and preventing peripheral arterial disease in diabetes care.
The studies also highlighted how controlling modifiable risk factors can help. In people with type 1 diabetes, maintaining good control over long-term blood sugar and blood pressure could reduce the risk of many peripheral artery problems by 30–50%.
However, lowering levels of cholesterol, BMI, and improving kidney function provided minimal additional benefit.
In type 2 diabetes, high levels of LDL cholesterol and triglycerides were strongly linked to peripheral artery disease, especially in the carotid arteries. Yet, having triglyceride levels just above the guideline threshold did not appear to raise risk significantly.
Importantly, the researchers found that long-term blood sugar is the single most influential factor for developing peripheral arterial disease in both types of diabetes. This differs from central arterial disease, where a range of factors like cholesterol and blood pressure also play key roles.
Interestingly, elevated blood sugar was associated with lower risk of aneurysms and artery wall ruptures in the aorta, suggesting differing biological effects in different parts of the body’s vascular system.
Lead researcher Aidin Rawshani emphasized that early and intensive control of long-term blood sugar could offer substantial benefits: “We observed large differences in how cardiometabolic risk factors affect central and peripheral arteries. This means diabetes treatment may need to be tailored to the type of vascular risk involved.”
Key findings over 2001–2020 include: A drop in carotid artery calcification from 296 to 84 cases in type 1 diabetes, and from 170 to 84 in type 2. A slight rise in aneurysms, especially among those with type 1 diabetes (from 40 to 69 cases).
A sharp decline in lower body artery calcification: from 723 to 311 in type 1, and 338 to 190 in type 2. The most dramatic improvement was seen in small vessel disease in the feet among those with type 1 diabetes.
In type 1 diabetes, optimal control could nearly eliminate the risk of peripheral arterial disease. However, the risk of small vessel disease in the feet remained high even with good control—up to 2,944% higher than in those without diabetes.
In type 2 diabetes, the excess risk of artery calcification in the lower body was just 16% with optimal control, but jumped to over 600% with poor risk control. Aortic complications were actually lower in both types of diabetes compared to those without the condition.
These findings call for a more nuanced approach to managing diabetes, with a sharper focus on monitoring peripheral artery health and early intervention through blood sugar control.
The study is published in The Lancet Regional Health – Europe.
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