Evidence of improved cardiovascular risk for people with diabetes in England between 1994 and 2009

Vitruvian data man

This study evaluated trends in cardiovascular risk factors among people with diabetes. Data obtained as part of the Health Survey for England (HSE) between 1994 and 2009 were examined with particular focus on the differences between men and women and between social classes. It was important to investigate possible trends so that the impact of developments in service provision and health promotion could be assessed.

Research question

Among people with diabetes in England, have there been changes in cardiovascular risk factors between 1994 and 2009? Are there differences between men and women, and between different social classes in cardiovascular risk factors over the period of time studied?

The outcomes of interest were blood pressure (BP), cholesterol, smoking, BMI, and glycated haemoglobin (HbA1c).


A stethoscope on a keyboard

The HSE was carried out in 1994, 1998, 2003, 2006, 2008 and 2009

Participants in the HSE were recruited using a multistage cluster sampling technique.  This method can result in a sample which is more representative of the population in comparison to a sampling technique which does not refine the target sample.

Risk factors were measured using accepted units and equipment. However measurement methods changed over time in the case of cholesterol and HbA1c.


Across the surveys the mean age of participants ranged from 61.2 years to 64.5 years. The total sample size ranged from 12,197 in 1994 to 3840 in 2009. [S2] More women took part in each survey than men, and more non-manual than manual workers.

There was an increase in the prevalence of diabetes across the study period which was consistently higher among men and among manual workers.

Amongst pople with diabetes, significant improvements in levels of cardiovascular risk factors were found:

Risk factor Change from 1994 to 2009
Annual change  (95% CI )
Blood pressure Systolic BP: 148mmHg to 137 mmHgDiastolic BP: 80 mmHg to 70 mmHg -0.82 mmHg (-0.98 to -0.67)-0.64 mmHg (-0.73 to -0.55)
Mean total cholesterol 6.1mmol/L to 4.5mmol/L -0.12 mmol/l (-0.13 to -0.11)
Smoking  17.5% to 13.4% Odds of smoking per year:  0.97 (0.95 to 0.99)
BMI 27.7 kg/m2 to 31.6 kg/m2 0.24, 0.2 to 0.28
HbA1c Ranged between 7.3% and 7.5% DNA

There was no significant change in the proportion of patients reaching target HbA1c.



The findings showed significant improvements in blood pressure and total cholesterol amongst people with diabetes

This high quality study shows that substantial gains have been achieved in terms of cardiovascular risk factors among people with diabetes in England.  The reductions in blood pressure and cholesterol across the sample and in smoking among women and  non-manual social classes may protect people with diabetes from cardiovascular disease.

Although difficult to achieve, this sample has maintained very respectable mean HbA1c values which indicates individuals are performing self-management very well.

Increases in BMI stand out as the greatest threat to cardiovascular health among people with diabetes.


  • The diagnostic threshold for diabetes was changed in England in 2000. The increased prevalence of diabetes and reduction in cardiovascular risk factors may be influenced by increased detection amongst “healthier” patients.
  • Response rates to the HSE declined over the study period
  • The age range of the sample is quite narrow
  • We don’t know how many participants had type 1 diabetes or type 2 diabetes
  • Since this sample can be considered highly representative of the population in England, the results are likely to reflect local populations of older adults with diabetes
  • Awareness of areas where gains have been made, such as improvements in cholesterol levels as well as problem areas, BMI in this case, can inform local service provision and policy making related to healthy eating and physical activity for weight loss.


Samaranayaka S & Gulliford MC.  Trends in cardiovascular risk factors among people with diabetes in a population based study, Health Survey for England 1994–2009.  Primary Care Diabetes 2013; 7:193-8.

Most recent data for the Health Survey for England 2011 can be found on the Health and Social Care Information Centre.

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Lisa Hynes

Lisa Hynes
Lisa is a PhD candidate in the psychology & health research cluster at the National University of Ireland, Galway. She completed a degree in psychology and a masters degree in health psychology also at NUI, Galway. She has worked as a research assistant in the Department of Epidemiology & Preventive Medicine, Monash University, Melbourne and as a tutor in a pre-school for children with Autism Spectrum Disorder. Lisa is currently working on developing a complex health behaviour change intervention to improve clinic attendance among young adults with Type 1 Diabetes. She is interested in public health promotion, particularly research to understand and improve health behaviours such as exercise and healthy eating.

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