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Miller V, Jenkins DA, Dehghan M, Srichaikul K, Rangarajan S, Mente A, Mohan V, Swaminathan S, Ismail R, Luz Diaz M, Ravindran RM, Zatonska K, Bahonar A, Altuntas Y, Khatib R, Lopez-Jaramillo P, Yusufali A, Yeates K, Chifamba J, Iqbal R, Yusuf R, Catherina Swart E, Bo H, Han G, Li X, Alhabib KF, Rosengren A, Avezum A, Lanas F, Yusuf S. Associations of the glycaemic index and the glycaemic load with risk of type 2 diabetes in 127 594 people from 20 countries (PURE): a prospective cohort study. Lancet Diabetes Endocrinol 2024; 12:330-338. [PMID: 38588684 DOI: 10.1016/s2213-8587(24)00069-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/25/2024] [Accepted: 02/26/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The association between the glycaemic index and the glycaemic load with type 2 diabetes incidence is controversial. We aimed to evaluate this association in an international cohort with diverse glycaemic index and glycaemic load diets. METHODS The PURE study is a prospective cohort study of 127 594 adults aged 35-70 years from 20 high-income, middle-income, and low-income countries. Diet was assessed at baseline using country-specific validated food frequency questionnaires. The glycaemic index and the glycaemic load were estimated on the basis of the intake of seven categories of carbohydrate-containing foods. Participants were categorised into quintiles of glycaemic index and glycaemic load. The primary outcome was incident type 2 diabetes. Multivariable Cox Frailty models with random intercepts for study centre were used to calculate hazard ratios (HRs). FINDINGS During a median follow-up of 11·8 years (IQR 9·0-13·0), 7326 (5·7%) incident cases of type 2 diabetes occurred. In multivariable adjusted analyses, a diet with a higher glycaemic index was significantly associated with a higher risk of diabetes (quintile 5 vs quintile 1; HR 1·15 [95% CI 1·03-1·29]). Participants in the highest quintile of the glycaemic load had a higher risk of incident type 2 diabetes compared with those in the lowest quintile (HR 1·21, 95% CI 1·06-1·37). The glycaemic index was more strongly associated with diabetes among individuals with a higher BMI (quintile 5 vs quintile 1; HR 1·23 [95% CI 1·08-1·41]) than those with a lower BMI (quintile 5 vs quintile 1; 1·10 [0·87-1·39]; p interaction=0·030). INTERPRETATION Diets with a high glycaemic index and a high glycaemic load were associated with a higher risk of incident type 2 diabetes in a multinational cohort spanning five continents. Our findings suggest that consuming low glycaemic index and low glycaemic load diets might prevent the development of type 2 diabetes. FUNDING Full funding sources are listed at the end of the Article.
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Affiliation(s)
- Victoria Miller
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada.
| | - David A Jenkins
- Department of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Toronto, ON, Canada; Clinical Nutrition Risk Factor Modification Centre, St Michael's Hospital, Toronto, ON, Canada; Division of Endocrinology and Metabolism, St Michael's Hospital, Toronto, ON, Canada
| | - Mahshid Dehghan
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Kristie Srichaikul
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Andrew Mente
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Viswanathan Mohan
- Department of Diabetology, Madras Diabetes Research Foundation & Dr Mohan's Diabetes Specialties Centre, Chennai, India
| | - Sumathi Swaminathan
- St John's Research Institute, St John's National Academy of Health Sciences, Bangalore, India
| | - Rosnah Ismail
- Department of Public Health Medicine, Faculty of Medicine, Universiti Kebangsaan, Kuala Lumpur, Malaysia
| | | | - Rekha M Ravindran
- Department of Health Sciences, Government of Kerala, Kerala, India; Health Action by People, Trivandrum, Kerala, India
| | | | - Ahmad Bahonar
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Yuksel Altuntas
- University of Health Sciences Turkey, Faculty of Medicine, Istanbul Sisli Hamidiye Etfal Health Training Research Hospital, Clinic of Endocrinology and Metabolism, Sisli/Istabul, Türkiye
| | - Rasha Khatib
- Advocate Aurora Research Institute, Milwaukee, WI, USA; Institute of Community and Public Health, Birzeit University, Birzeit, Palestine
| | | | | | - Karen Yeates
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Jephat Chifamba
- Department of Biomedical Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Romaina Iqbal
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Rita Yusuf
- Center for Health, Population and Development, Independent University, Dhaka, Bangladesh
| | | | - Hu Bo
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Guoliang Han
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaocong Li
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University Medical City, King Saud University, Riyaadh, Saudi Arabia
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Alvaro Avezum
- International Research Center, Hospital Alemão-Oswaldo Cruz & UNISA, São Paulo, SP Brazil
| | | | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
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Wang X, Liu X, O'Donnell MJ, McQueen M, Sniderman A, Pare G, Hankey GJ, Rangarajan S, Chin SL, Rao-Melacini P, Ferguson J, Xavier D, Zhang H, Liu L, Pais P, Lopez-Jaramillo P, Damasceno A, Langhorne P, Rosengren A, Dans AL, Elsayed A, Avezum A, Mondo C, Judge C, Diener HC, Ryglewicz D, Czlonkowska A, Pogosova N, Weimar C, Iqbal R, Diaz R, Yusoff K, Yusufali A, Oguz A, Penaherrera E, Lanas F, Ogah OS, Ogunniyi A, Iversen HK, Malaga G, Rumboldt Z, Oveisgharan S, Al Hussain F, Nilanont Y, Yusuf S. Tobacco use and risk of acute stroke in 32 countries in the INTERSTROKE study: a case-control study. EClinicalMedicine 2024; 70:102515. [PMID: 38516107 PMCID: PMC10955659 DOI: 10.1016/j.eclinm.2024.102515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 03/23/2024] Open
Abstract
Background Smoking is a major risk factor for the global burden of stroke. We have previously reported a global population attributable risk (PAR) of stroke of 12.4% associated with current smoking. In this study we aimed to explore the association of current tobacco use with different types of tobacco exposure and environmental tobacco smoke (ETS) exposure on the risk of stroke and stroke subtypes, and by regions and country income levels. Methods The INTERSTROKE study is a case-control study of acute first stroke and was undertaken with 13,462 stroke cases and 13,488 controls recruited between January 11, 2007 and August 8, 2015 in 32 countries worldwide. Association of risk of tobacco use and ETS exposure were analysed with overall stroke, ischemic and intracerebral hemorrhage (ICH), and with TOAST etiological stroke subtypes (large vessel, small vessel, cardioembolism, and undetermined). Findings Current smoking was associated with an increased risk of all stroke (odds ratio [OR] 1.64, 95% CI 1.46-1.84), and had a stronger association with ischemic stroke (OR 1.85, 95% CI 1.61-2.11) than ICH (OR 1.19 95% CI 1.00-1.41). The OR and PAR of stroke among current smokers varied significantly between regions and income levels with high income countries (HIC) having the highest odds (OR 3.02 95% CI 2.24-4.10) and PAR (18.6%, 15.1-22.8%). Among etiological subtypes of ischemic stroke, the strongest association of current smoking was seen for large vessel stroke (OR 2.16, 95% CI 1.63-2.87) and undetermined cause (OR 1.97, 95% CI 1.55-2.50). Both filtered (OR 1.73, 95% CI 1.50-1.99) and non-filtered (OR 2.59, 95% CI 1.79-3.77) cigarettes were associated with stroke risk. ETS exposure increased the risk of stroke in a dose-dependent manner, exposure for more than 10 h per week increased risk for all stroke (OR 1.95, 95% CI 1.69-2.27), ischemic stroke (OR 1.89, 95% CI 1.59-2.24) and ICH (OR 2.00, 95% CI 1.60-2.50). Interpretation There are significant variations in the magnitude of risk and PAR of stroke according to the types of tobacco used, active and ETS exposure, and countries with different income levels. Specific strategies to discourage tobacco use by any form and to build a smoke free environment should be implemented to ease the global burden of stroke. Funding The Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland, and through unrestricted grants from several pharmaceutical companies with major contributions from Astra Zeneca, Boehringer Ingelheim (Canada), Pfizer (Canada), MERCK, Sharp and Dohme, Swedish Heart and Lung Foundation, UK Chest, and UK Heart and Stroke.
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Affiliation(s)
- Xingyu Wang
- Beijing Hypertension League Institute, Beijing, China
- National Genetic Resources Research Center, National Research Institute for Family Planning, Beijing, China
| | - Xin Liu
- Beijing Hypertension League Institute, Beijing, China
- National Genetic Resources Research Center, National Research Institute for Family Planning, Beijing, China
| | - Martin J. O'Donnell
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
- NUI Galway, Galway, Ireland
| | - Matthew McQueen
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | | | - Guillaume Pare
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Graeme J. Hankey
- St John's Medical College and Research Institute, Bangalore, India
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Siu Lim Chin
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Purnima Rao-Melacini
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | | | - Denis Xavier
- Fundacion Oftalmologica de Santander-Clinica Carlos Ardila Lulle (FOSCAL), Bucaramanga, Colombia
| | - Hongye Zhang
- Beijing Hypertension League Institute, Beijing, China
| | - Lisheng Liu
- Beijing Hypertension League Institute, Beijing, China
| | - Prem Pais
- St John's Medical College and Research Institute, Bangalore, India
| | - Patricio Lopez-Jaramillo
- Fundacion Oftalmologica de Santander-Clinica Carlos Ardila Lulle (FOSCAL), Bucaramanga, Colombia
| | | | - Peter Langhorne
- Glasgow Royal Infirmary, University of Glasgow, Glasgow, Scotland, UK
| | - Annika Rosengren
- Sahlgrenska Academy and University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Antonio L. Dans
- College of Medicine, University of Philippines, Manila, Philippines
| | | | - Alvaro Avezum
- Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Charles Mondo
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda
| | | | | | | | | | - Nana Pogosova
- National Research Center for Preventive Medicine of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | | | - Romana Iqbal
- Department of Medicine, Aga Khan University Hospitals in Karachi, Pakistan
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica, Rosario, Argentina
| | - Khalid Yusoff
- UCSI University, Cheras, Kuala Lumpur 56000, Malaysia
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Health Authority/Dubai Medical College, Dubai, United Arab Emirates
| | - Aytekin Oguz
- Istanbul Medeniyet Üniversitesi, Istanbul, Turkey
| | | | - Fernando Lanas
- Faculty of Medicine, Universidad de La Frontera, Temuco, Chile
| | - Okechukwu S. Ogah
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan PMB 5116, Nigeria
| | - A. Ogunniyi
- Department of Medicine, University College Hospital, Ibadan PMB 5116, Nigeria
| | | | | | | | | | | | - Yongchai Nilanont
- Neurology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - INTERSTROKE Investigators
- Beijing Hypertension League Institute, Beijing, China
- National Genetic Resources Research Center, National Research Institute for Family Planning, Beijing, China
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
- NUI Galway, Galway, Ireland
- McGill University Health Centre, Montreal, QC, Canada
- St John's Medical College and Research Institute, Bangalore, India
- Fundacion Oftalmologica de Santander-Clinica Carlos Ardila Lulle (FOSCAL), Bucaramanga, Colombia
- Eduardo Mondlane University, Maputo, Mozambique
- Glasgow Royal Infirmary, University of Glasgow, Glasgow, Scotland, UK
- Sahlgrenska Academy and University Hospital, University of Gothenburg, Gothenburg, Sweden
- College of Medicine, University of Philippines, Manila, Philippines
- Al Shaab Teaching Hospital, Khartoum, Sudan
- Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda
- Department of Neurology, University Hospital, Essen, Germany
- Institute of Psychiatry and Neurology, Warsaw, Poland
- National Research Center for Preventive Medicine of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
- Department of Medicine, Aga Khan University Hospitals in Karachi, Pakistan
- Estudios Clinicos Latinoamerica, Rosario, Argentina
- UCSI University, Cheras, Kuala Lumpur 56000, Malaysia
- Hatta Hospital, Dubai Health Authority/Dubai Medical College, Dubai, United Arab Emirates
- Istanbul Medeniyet Üniversitesi, Istanbul, Turkey
- Department of Cardiology, Hospital Luis Vernaza, Guayaquil, Ecuador
- Faculty of Medicine, Universidad de La Frontera, Temuco, Chile
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan PMB 5116, Nigeria
- Department of Medicine, University College Hospital, Ibadan PMB 5116, Nigeria
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Universidad Peruana Cayetano Heredia, Lima, Peru
- University of Split, Croatia
- Rush Alzheimer Disease Research Center in Chicago, Chicago, IL, USA
- University of Limpopo, Pretoria, South Africa
- Neurology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Mente A, Dehghan M, Rangarajan S, O'Donnell M, Hu W, Dagenais G, Wielgosz A, Lear SA, Wei L, Diaz R, Avezum A, Lopez-Jaramillo P, Lanas F, Swaminathan S, Kaur M, Vijayakumar K, Mohan V, Gupta R, Szuba A, Iqbal R, Yusuf R, Mohammadifard N, Khatib R, Nasir NM, Karsidag K, Rosengren A, Yusufali A, Wentzel-Viljoen E, Chifamba J, Dans A, Alhabib KF, Yeates K, Teo K, Gerstein HC, Yusuf S. Diet, cardiovascular disease, and mortality in 80 countries. Eur Heart J 2023:ehad269. [PMID: 37414411 PMCID: PMC10361015 DOI: 10.1093/eurheartj/ehad269] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 03/31/2023] [Accepted: 04/25/2023] [Indexed: 07/08/2023] Open
Abstract
AIMS To develop a healthy diet score that is associated with health outcomes and is globally applicable using data from the Prospective Urban Rural Epidemiology (PURE) study and replicate it in five independent studies on a total of 245 000 people from 80 countries. METHODS AND RESULTS A healthy diet score was developed in 147 642 people from the general population, from 21 countries in the PURE study, and the consistency of the associations of the score with events was examined in five large independent studies from 70 countries. The healthy diet score was developed based on six foods each of which has been associated with a significantly lower risk of mortality [i.e. fruit, vegetables, nuts, legumes, fish, and dairy (mainly whole-fat); range of scores, 0-6]. The main outcome measures were all-cause mortality and major cardiovascular events [cardiovascular disease (CVD)]. During a median follow-up of 9.3 years in PURE, compared with a diet score of ≤1 points, a diet score of ≥5 points was associated with a lower risk of mortality [hazard ratio (HR) 0.70; 95% confidence interval (CI) 0.63-0.77)], CVD (HR 0.82; 0.75-0.91), myocardial infarction (HR 0.86; 0.75-0.99), and stroke (HR 0.81; 0.71-0.93). In three independent studies in vascular patients, similar results were found, with a higher diet score being associated with lower mortality (HR 0.73; 0.66-0.81), CVD (HR 0.79; 0.72-0.87), myocardial infarction (HR 0.85; 0.71-0.99), and a non-statistically significant lower risk of stroke (HR 0.87; 0.73-1.03). Additionally, in two case-control studies, a higher diet score was associated with lower first myocardial infarction [odds ratio (OR) 0.72; 0.65-0.80] and stroke (OR 0.57; 0.50-0.65). A higher diet score was associated with a significantly lower risk of death or CVD in regions with lower than with higher gross national incomes (P for heterogeneity <0.0001). The PURE score showed slightly stronger associations with death or CVD than several other common diet scores (P < 0.001 for each comparison). CONCLUSION A diet comprised of higher amounts of fruit, vegetables, nuts, legumes, fish, and whole-fat dairy is associated with lower CVD and mortality in all world regions, especially in countries with lower income where consumption of these foods is low.
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Affiliation(s)
- Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, 2nd Floor, Room C2-105, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, Ontario L8S 4L8, Canada
| | - Mahshid Dehghan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, 2nd Floor, Room C2-105, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, 2nd Floor, Room C2-105, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
| | - Martin O'Donnell
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- HRB-Clinical Research Facility, University of Galway, Galway, Connacht, Ireland
| | - Weihong Hu
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, 2nd Floor, Room C2-105, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
| | - Gilles Dagenais
- Department of Medicine, Université Laval Institut universitaire de cardiologie et de pneumologie de Québec, Quebec City G1V 4G5, Canada
| | - Andreas Wielgosz
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Scott A Lear
- Faculty of Health Sciences, and Department of Biomedical Physiology & Kinesiology, Simon Fraser University Vancouver, Burnaby, British Columbia, Canada
| | - Li Wei
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, Xicheng District, China
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica ECLA, Universidad Nacional de Rosario, Rosario, Santa Fe, Argentina
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz & UNISA, Sao Paulo, São Paulo estado, SP Brazil
| | - Patricio Lopez-Jaramillo
- Masira Research Institute, Medical School, Universidad de Santander (UDES), Bucaramanga, Santander, Colombia
| | - Fernando Lanas
- Francisco Salazar, Universidad de La Frontera, Temuco, Araucanía, Chile
| | - Sumathi Swaminathan
- Division of Nutrition, St John's Research Institute, Koramangala, Bangalore, Karnataka, India
| | - Manmeet Kaur
- Postgraduate Institute of Medical Education and Research, School of Public Health, Chandigarh, Punjab and Haryana, India
| | - K Vijayakumar
- Health Action by People, Amrita Institute of Medical Sciences, Trivandrum, Kerala, India
| | - Viswanathan Mohan
- Director and Chief of Diabetes Research, Madras Diabetes Research Foundation and Dr. Mohan's Diabetes Specialities Centre, Chennai, Tamil Nadu, India
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Rajasthan University of Health Sciences, Jaipur, Rajasthan, India
| | - Andrzej Szuba
- Department of Internal Medicine, Wroclaw Medical University, 4th Military Hospital, Wroclaw, Lower Silesian Voivodeship, Poland
| | - Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Sindh, Pakistan
| | - Rita Yusuf
- Department of Life Sciences, Independent University, Bangladesh, Bashundhara, Dhaka, Dhaka District, Bangladesh
| | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Isfahan Province, Iran
| | - Rasha Khatib
- Departments of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nafiza Mat Nasir
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Teknologi MARA (UiTM), Shah Alam, Selangor, Malaysia
| | - Kubilay Karsidag
- Department of Internal Medicine, Division of Endocrinology, Medical Faculty of Istanbul University, Istanbul, Istanbul Province, Turkey
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital/Östra Hospital, Gothenburg, Västergötland, Sweden
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Health Authority, Dubai Medical University, Dubai, United Arab Emirates
| | - Edelweiss Wentzel-Viljoen
- Faculty of Health Sciences, Centre of Excellence for Nutrition, Potchefstroom, North West Province, South Africa
| | - Jephat Chifamba
- College of Health Sciences, Physiology Department, University of Zimbabwe, Harare, Harare Metropolitan Province, Zimbabwe
| | - Antonio Dans
- Department of Medicine, University of the Philippines, Ermita, Manila, Metro Manila, Philippines
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Riyadh Province, Saudi Arabia
| | - Karen Yeates
- Department of Medicine, Queen's University, 94 Stuart Street, Etherington Hall, Kingston, Ontario, Canada
| | - Koon Teo
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, 2nd Floor, Room C2-105, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, Ontario L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Hertzel C Gerstein
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, 2nd Floor, Room C2-105, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, Ontario L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, 2nd Floor, Room C2-105, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, Ontario L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Lopez-Jaramillo P, Gomez-Arbelaez D, Martinez-Bello D, Abat MEM, Alhabib KF, Avezum Á, Barbarash O, Chifamba J, Diaz ML, Gulec S, Ismail N, Iqbal R, Kelishadi R, Khatib R, Lanas F, Levitt NS, Li Y, Mohan V, Mony PK, Poirier P, Rosengren A, Soman B, Wang C, Wang Y, Yeates K, Yusuf R, Yusufali A, Zatonska K, Rangarajan S, Yusuf S. Association of the triglyceride glucose index as a measure of insulin resistance with mortality and cardiovascular disease in populations from five continents (PURE study): a prospective cohort study. Lancet Healthy Longev 2023; 4:e23-e33. [PMID: 36521498 DOI: 10.1016/s2666-7568(22)00247-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 10/15/2022] [Accepted: 10/18/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The triglyceride glucose (TyG) index is an easily accessible surrogate marker of insulin resistance, an important pathway in the development of type 2 diabetes and cardiovascular diseases. However, the association of the TyG index with cardiovascular diseases and mortality has mainly been investigated in Asia, with few data available from other regions of the world. We assessed the association of insulin resistance (as determined by the TyG index) with mortality and cardiovascular diseases in individuals from five continents at different levels of economic development, living in urban or rural areas. We also examined whether the associations differed according to the country's economical development. METHODS We used the TyG index as a surrogate measure for insulin resistance. Fasting triglycerides and fasting plasma glucose were measured at the baseline visit in 141 243 individuals aged 35-70 years from 22 countries in the Prospective Urban Rural Epidemiology (PURE) study. The TyG index was calculated as Ln (fasting triglycerides [mg/dL] x fasting plasma glucose [mg/dL]/2). We calculated hazard ratios (HRs) using a multivariable Cox frailty model with random effects to test the associations between the TyG index and risk of cardiovascular diseases and mortality. The primary outcome of this analysis was the composite of mortality or major cardiovascular events (defined as death from cardiovascular causes, and non-fatal myocardial infarction, or stroke). Secondary outcomes were non-cardiovascular mortality, cardiovascular mortality, all myocardial infarctions, stroke, and incident diabetes. We also did subgroup analyses to examine the magnitude of associations between insulin resistance (ie, the TyG index) and outcome events according to the income level of the countries. FINDINGS During a median follow-up of 13·2 years (IQR 11·9-14·6), we recorded 6345 composite cardiovascular diseases events, 2030 cardiovascular deaths, 3038 cases of myocardial infarction, 3291 cases of stroke, and 5191 incident cases of type 2 diabetes. After adjusting for all other variables, the risk of developing cardiovascular diseases increased across tertiles of the baseline TyG index. Compared with the lowest tertile of the TyG index, the highest tertile (tertile 3) was associated with a greater incidence of the composite outcome (HR 1·21; 95% CI 1·13-1·30), myocardial infarction (1·24; 1·12-1·38), stroke (1·16; 1·05-1·28), and incident type 2 diabetes (1·99; 1·82-2·16). No significant association of the TyG index was seen with non-cardiovascular mortality. In low-income countries (LICs) and middle-income countries (MICs), the highest tertile of the TyG index was associated with increased hazards for the composite outcome (LICs: HR 1·31; 95% CI 1·12-1·54; MICs: 1·20; 1·11-1·31; pinteraction=0·01), cardiovascular mortality (LICs: 1·44; 1·15-1·80; pinteraction=0·01), myocardial infarction (LICs: 1·29; 1·06-1·56; MICs: 1·26; 1·10-1·45; pinteraction=0·08), stroke (LICs: 1·35; 1·02-1·78; MICs: 1·17; 1·05-1·30; pinteraction=0·19), and incident diabetes (LICs: 1·64; 1·38-1·94; MICs: 2·68; 2·40-2·99; pinteraction <0·0001). In contrast, in high-income countries, higher TyG index tertiles were only associated with an increased hazard of incident diabetes (2·95; 2·25-3·87; pinteraction <0·0001), but not of cardiovascular diseases or mortality. INTERPRETATION The TyG index is significantly associated with future cardiovascular mortality, myocardial infarction, stroke, and type 2 diabetes, suggesting that insulin resistance plays a promoting role in the pathogenesis of cardiovascular and metabolic diseases. Potentially, the association between the TyG index and the higher risk of cardiovascular diseases and type 2 diabetes in LICs and MICs might be explained by an increased vulnerability of these populations to the presence of insulin resistance. FUNDING Full funding sources are listed at the end of the paper (see Acknowledgments).
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Affiliation(s)
| | | | | | - Marc Evans M Abat
- Division of Adult Medicine, Department of Medicine, Philippine General Hospital, Manila, Philippines
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Álvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Olga Barbarash
- Federal State Budgetary Institution Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - Jephat Chifamba
- Physiology Unit, Department of Biomedical Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Maria L Diaz
- Estudios Clínicos Latinoamérica and Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Sadi Gulec
- Cardiology Department, Ankara University School of Medicine, Ankara, Türkiye
| | - Noorhassim Ismail
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Romaina Iqbal
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Roya Kelishadi
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Rasha Khatib
- Advocate Aurora Research Institute, Advocate Aurora Health, Downers Grove, IL, USA; Institute of Community and Public Health, Birzeit University, Birzeit, Palestine
| | | | - Naomi S Levitt
- Chronic Disease Initiative for Africa, University of Cape Town, Cape Town, South Africa
| | - Yang Li
- Medical Research & Biometrics Center, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation, and Dr Mohan's Diabetes Specialities Centre, Chennai, India
| | - Prem K Mony
- Division of Epidemiology & Population Health, St John's Medical College & Research Institute, Bangalore, India
| | - Paul Poirier
- Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, QC, Canada
| | - Annika Rosengren
- Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Biju Soman
- Health Action by People, Medical College, and Sree Chitra Tirunal Institute for Medical Sciences and Technology, Kerala, India
| | - Chuangshi Wang
- Medical Research & Biometrics Center, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Wang
- Medical Research & Biometrics Center, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Rita Yusuf
- Independent University, Dhaka, Bangladesh
| | | | - Katarzyna Zatonska
- Department of Population Health, Wroclaw Medical University, Wroclaw, Poland
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada
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5
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Eikelboom JW, Jolly SS, Belley-Cote EP, Whitlock RP, Rangarajan S, Xu L, Heenan L, Bangdiwala SI, Luz Diaz M, Diaz R, Yusufali A, Kumar Sharma S, Tarhuni WM, Hassany M, Avezum A, Harper W, Wasserman S, Almas A, Drapkina O, Felix C, Lopes RD, Berwanger O, Lopez-Jaramillo P, Anand SS, Bosch J, Choudhri S, Farkouh ME, Loeb M, Yusuf S. Colchicine and the combination of rivaroxaban and aspirin in patients hospitalised with COVID-19 (ACT): an open-label, factorial, randomised, controlled trial. Lancet Respir Med 2022; 10:1169-1177. [PMID: 36228641 PMCID: PMC9635892 DOI: 10.1016/s2213-2600(22)00298-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/03/2022] [Accepted: 08/04/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND COVID-19 disease is accompanied by a dysregulated immune response and hypercoagulability. The Anti-Coronavirus Therapies (ACT) inpatient trial aimed to evaluate anti-inflammatory therapy with colchicine and antithrombotic therapy with the combination of rivaroxaban and aspirin for prevention of disease progression in patients hospitalised with COVID-19. METHODS The ACT inpatient, open-label, 2 × 2 factorial, randomised, controlled trial was done at 62 clinical centres in 11 countries. Patients aged at least 18 years with symptomatic, laboratory confirmed COVID-19 who were within 72 h of hospitalisation or worsening clinically if already hospitalised were randomly assigned (1:1) to receive colchicine 1·2 mg followed by 0·6 mg 2 h later and then 0·6 mg twice daily for 28 days versus usual care; and in a second (1:1) randomisation, to the combination of rivaroxaban 2·5 mg twice daily plus aspirin 100 mg once daily for 28 days versus usual care. Investigators and patients were not masked to treatment allocation. The primary outcome, assessed at 45 days in the intention-to-treat population, for the colchicine randomisation was the composite of the need for high-flow oxygen, mechanical ventilation, or death; and for the rivaroxaban plus aspirin randomisation was the composite of major thrombosis (myocardial infarction, stroke, acute limb ischaemia, or pulmonary embolism), the need for high-flow oxygen, mechanical ventilation, or death. The trial is registered at www. CLINICALTRIALS gov, NCT04324463 and is ongoing. FINDINGS Between Oct 2, 2020, and Feb 10, 2022, at 62 sites in 11 countries, 2749 patients were randomly assigned to colchicine or control and the combination of rivaroxaban and aspirin or to the control. 2611 patients were included in the analysis of colchicine (n=1304) versus control (n=1307); 2119 patients were included in the analysis of rivaroxaban and aspirin (n=1063) versus control (n=1056). Follow-up was more than 98% complete. Overall, 368 (28·2%) of 1304 patients allocated to colchicine and 356 (27·2%) of 1307 allocated to control had a primary outcome (hazard ratio [HR] 1·04, 95% CI 0·90-1·21, p=0·58); and 281 (26·4%) of 1063 patients allocated to the combination of rivaroxaban and aspirin and 300 (28·4%) of 1056 allocated to control had a primary outcome (HR 0·92, 95% CI 0·78-1·09, p=0·32). Results were consistent in subgroups defined by vaccination status, disease severity at baseline, and timing of randomisation in relation to onset of symptoms. There was no increase in the number of patients who had at least one serious adverse event for colchicine versus control groups (87 [6·7%] of 1304 vs 90 [6·9%] of 1307) or with rivaroxaban and aspirin versus control groups (85 [8·0%] vs 91 [8·6%]). Among patients assigned to colchicine, 8 (0·61%) had adverse events that led to discontinuation of study drug, mostly gastrointestinal in nature. 17 (1·6%) patients assigned to the combination of rivaroxaban and aspirin had bleeding compared with seven (0·66%) of those allocated to control (p=0·042); the number of serious bleeding events was two (0·19%) versus six (0·57%), respectively (p=0·18). No patients assigned to rivaroxaban and aspirin had serious adverse events that led to discontinuation of study drug. INTERPRETATION Among patients hospitalised with COVID-19, neither colchicine nor the combination of rivaroxaban and aspirin prevent disease progression or death. FUNDING Canadian Institutes for Health Research, Bayer, Population Health Research Institute, Hamilton Health Sciences Research Institute, Thistledown Foundation. TRANSLATIONS For the Portuguese, Russian and Spanish translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- John W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada,Correspondence to: Prof John W Eikelboom, Population Health Research Institute, Hamilton, ON L8L 2X2, Canada
| | - Sanjit S Jolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Emilie P Belley-Cote
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Richard P Whitlock
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada
| | - Lizhen Xu
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada
| | - Laura Heenan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada
| | - Shrikant I Bangdiwala
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada
| | - Maria Luz Diaz
- Estudios Clínicos Latino América, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Rafael Diaz
- Estudios Clínicos Latino América, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates
| | | | - Wadea M Tarhuni
- Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada,Department of Medicine, Western University, Clinical Skills Building London, ON, Canada,Windsor Cardiac Centre, Windsor, ON, Canada
| | - Mohamed Hassany
- National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - William Harper
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa,Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Aysha Almas
- Section of Internal Medicine, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Oxana Drapkina
- National Medical Research Center for Therapy and Preventive Medicine, Moscow, Russia
| | - Camilo Felix
- Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Ecuador
| | - Renato D Lopes
- Division of Cardiology, Duke University Medical Center, Duke Clinical Research Institute, NC, USA
| | | | | | - Sonia S Anand
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jackie Bosch
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | | | - Michael E Farkouh
- Peter Munk Cardiac Centre, University of Toronto, Toronto, ON, Canada
| | - Mark Loeb
- Departments of Pathology and Molecular Medicine and Health Evidence Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Surgery, McMaster University, Hamilton, ON, Canada
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6
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Eikelboom JW, Jolly SS, Belley-Cote EP, Whitlock RP, Rangarajan S, Xu L, Heenan L, Bangdiwala SI, Tarhuni WM, Hassany M, Kontsevaya A, Harper W, Sharma SK, Lopez-Jaramillo P, Dans AL, Palileo-Villanueva LM, Avezum A, Pais P, Xavier D, Felix C, Yusufali A, Lopes RD, Berwanger O, Ali Z, Wasserman S, Anand SS, Bosch J, Choudhri S, Farkouh ME, Loeb M, Yusuf S. Colchicine and aspirin in community patients with COVID-19 (ACT): an open-label, factorial, randomised, controlled trial. Lancet Respir Med 2022; 10:1160-1168. [PMID: 36228639 PMCID: PMC9635862 DOI: 10.1016/s2213-2600(22)00299-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/28/2022] [Accepted: 08/02/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The large number of patients worldwide infected with the SARS-CoV-2 virus has overwhelmed health-care systems globally. The Anti-Coronavirus Therapies (ACT) outpatient trial aimed to evaluate anti-inflammatory therapy with colchicine and antithrombotic therapy with aspirin for prevention of disease progression in community patients with COVID-19. METHODS The ACT outpatient, open-label, 2 × 2 factorial, randomised, controlled trial, was done at 48 clinical sites in 11 countries. Patients in the community aged 30 years and older with symptomatic, laboratory confirmed COVID-19 who were within 7 days of diagnosis and at high risk of disease progression were randomly assigned (1:1) to receive colchicine 0·6 mg twice daily for 3 days and then 0·6 mg once daily for 25 days versus usual care, and in a second (1:1) randomisation to receive aspirin 100 mg once daily for 28 days versus usual care. Investigators and patients were not masked to treatment allocation. The primary outcome was assessed at 45 days in the intention-to-treat population; for the colchicine randomisation it was hospitalisation or death, and for the aspirin randomisation it was major thrombosis, hospitalisation, or death. The ACT outpatient trial is registered at ClinicalTrials.gov, NCT04324463 and is ongoing. FINDINGS Between Aug 27, 2020, and Feb 10, 2022, 3917 patients were randomly assigned to colchicine or control and to aspirin or control; after excluding 36 patients due to administrative reasons 3881 individuals were included in the analysis (n=1939 colchicine vs n=1942 control; n=1945 aspirin vs 1936 control). Follow-up was more than 99% complete. Overall event rates were 5 (0·1%) of 3881 for major thrombosis, 123 (3·2%) of 3881 for hospitalisation, and 23 (0·6%) of 3881 for death; 66 (3·4%) of 1939 patients allocated to colchicine and 65 (3·3%) of 1942 patients allocated to control experienced hospitalisation or death (hazard ratio [HR] 1·02, 95% CI 0·72-1·43, p=0·93); and 59 (3·0%) of 1945 of patients allocated to aspirin and 73 (3·8%) of 1936 patients allocated to control experienced major thrombosis, hospitalisation, or death (HR 0·80, 95% CI 0·57-1·13, p=0·21). Results for the primary outcome were consistent in all prespecified subgroups, including according to baseline vaccination status, timing of randomisation in relation to onset of symptoms (post-hoc analysis), and timing of enrolment according to the phase of the pandemic (post-hoc analysis). There were more serious adverse events with colchicine than with control (34 patients [1·8%] of 1939 vs 27 [1·4%] of 1942) but none in either group that led to discontinuation of study interventions. There was no increase in serious adverse events with aspirin versus control (31 [1·6%] vs 31 [1·6%]) and none that led to discontinuation of study interventions. INTERPRETATION The results provide no support for the use of colchicine or aspirin to prevent disease progression or death in outpatients with COVID-19. FUNDING Canadian Institutes for Health Research, Bayer, Population Health Research Institute, Hamilton Health Sciences Research Institute, and Thistledown Foundation. TRANSLATIONS For the Portuguese, Russian and Spanish translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- John W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada.
| | - Sanjit S Jolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Emilie P Belley-Cote
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Richard P Whitlock
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada
| | - Lizhen Xu
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada
| | - Laura Heenan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada
| | - Shrikant I Bangdiwala
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Wadea M Tarhuni
- Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada,Department of Medicine, Western University, Clinical Skills Building London, ON, Canada,Windsor Cardiac Centre, Windsor, ON, Canada
| | - Mohamed Hassany
- National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | - Anna Kontsevaya
- National Medical Research Center for Therapy and Preventive Medicine, Moscow, Russia
| | - William Harper
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | - Antonio L Dans
- UP College of Medicine, University of the Philippines Manila, Manila, Philippines
| | | | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Prem Pais
- St John's Research Institute, Bangalore, India
| | - Denis Xavier
- St John's Medical College, St John's Research Institute, Bangalore, India
| | - Camilo Felix
- Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Ecuador
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates
| | - Renato D Lopes
- Division of Cardiology, Duke University Medical Center, Duke Clinical Research Institute, NC, USA
| | | | - Zeeshan Ali
- Jinnah Sindh Medical University and Jinnah Postgraduate Medical Center, Karachi, Pakistan
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa,Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Sonia S Anand
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jackie Bosch
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | | | - Michael E Farkouh
- Peter Munk Cardiac Centre, University of Toronto, Toronto, ON, Canada
| | - Mark Loeb
- Departments of Pathology and Molecular Medicine and Health Evidence Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
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7
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Li S, Lear SA, Rangarajan S, Hu B, Yin L, Bangdiwala SI, Alhabib KF, Rosengren A, Gupta R, Mony PK, Wielgosz A, Rahman O, Mazapuspavina MY, Avezum A, Oguz A, Yeates K, Lanas F, Dans A, Abat MEM, Yusufali A, Diaz R, Lopez-Jaramillo P, Leach L, Lakshmi PVM, Basiak-Rasala A, Iqbal R, Kelishadi R, Chifamba J, Khatib R, Li W, Yusuf S. Association of Sitting Time With Mortality and Cardiovascular Events in High-Income, Middle-Income, and Low-Income Countries. JAMA Cardiol 2022; 7:796-807. [PMID: 35704349 DOI: 10.1001/jamacardio.2022.1581] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance High amounts of sitting time are associated with increased risks of cardiovascular disease (CVD) and mortality in high-income countries, but it is unknown whether risks also increase in low- and middle-income countries. Objective To investigate the association of sitting time with mortality and major CVD in countries at different economic levels using data from the Prospective Urban Rural Epidemiology study. Design, Setting, and Participants This population-based cohort study included participants aged 35 to 70 years recruited from January 1, 2003, and followed up until August 31, 2021, in 21 high-income, middle-income, and low-income countries with a median follow-up of 11.1 years. Exposures Daily sitting time measured using the International Physical Activity Questionnaire. Main Outcomes and Measures The composite of all-cause mortality and major CVD (defined as cardiovascular death, myocardial infarction, stroke, or heart failure). Results Of 105 677 participants, 61 925 (58.6%) were women, and the mean (SD) age was 50.4 (9.6) years. During a median follow-up of 11.1 (IQR, 8.6-12.2) years, 6233 deaths and 5696 major cardiovascular events (2349 myocardial infarctions, 2966 strokes, 671 heart failure, and 1792 cardiovascular deaths) were documented. Compared with the reference group (<4 hours per day of sitting), higher sitting time (≥8 hours per day) was associated with an increased risk of the composite outcome (hazard ratio [HR], 1.19; 95% CI, 1.11-1.28; Pfor trend < .001), all-cause mortality (HR, 1.20; 95% CI, 1.10-1.31; Pfor trend < .001), and major CVD (HR, 1.21; 95% CI, 1.10-1.34; Pfor trend < .001). When stratified by country income levels, the association of sitting time with the composite outcome was stronger in low-income and lower-middle-income countries (≥8 hours per day: HR, 1.29; 95% CI, 1.16-1.44) compared with high-income and upper-middle-income countries (HR, 1.08; 95% CI, 0.98-1.19; P for interaction = .02). Compared with those who reported sitting time less than 4 hours per day and high physical activity level, participants who sat for 8 or more hours per day experienced a 17% to 50% higher associated risk of the composite outcome across physical activity levels; and the risk was attenuated along with increased physical activity levels. Conclusions and Relevance High amounts of sitting time were associated with increased risk of all-cause mortality and CVD in economically diverse settings, especially in low-income and lower-middle-income countries. Reducing sedentary time along with increasing physical activity might be an important strategy for easing the global burden of premature deaths and CVD.
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Affiliation(s)
- Sidong Li
- National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Scott A Lear
- Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences & McMaster University, Hamilton, Ontario, Canada
| | - Bo Hu
- National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lu Yin
- National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shrikant I Bangdiwala
- Population Health Research Institute, Hamilton Health Sciences & McMaster University, Hamilton, Ontario, Canada
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Annika Rosengren
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Jawahar Circle, Jaipur, India
| | - Prem K Mony
- St John's Medical College & Research Institute, Bangalore, India
| | - Andreas Wielgosz
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Omar Rahman
- University of Liberal Arts, Dhaka, Bangladesh
| | - M Y Mazapuspavina
- Department of Primary Care Medicine, Faculty of Medicine UiTM Sg Buloh Campus, University Teknologi MARA UiTM, Malaysia
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz and UNISA, São Paulo, Brazil
| | - Aytekin Oguz
- Faculty of Medicine, Department of Internal Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | | | - Antonio Dans
- Department of Medicine, University of the Philippines, Manila, Philippines
| | - Marc Evans M Abat
- Division of Adult Medicine, Department of Medicine, Philippine General Hospital, Ermita, Manila, Philippines
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Health Authority/Dubai Medical College, Dubai, United Arab Emirates
| | - Rafael Diaz
- Estudios Clínicos Latino América, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | | | - Lloyd Leach
- University of the Western Cape, Bellville, Cape Town, South Africa
| | - P V M Lakshmi
- Department of Community Medicine and School of Public Health, PGIMER, Chandigarh, India
| | | | - Romaina Iqbal
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Roya Kelishadi
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Jephat Chifamba
- Department of Biomedical Sciences Physiology Unit, University of Zimbabwe, Harare, Zimbabwe
| | - Rasha Khatib
- Advocate Aurora Research Institute, Advocate Aurora Health, Downers Grove, Illinois.,Institute of Community and Public Health, Birzeit University, Birzeit, Palestine
| | - Wei Li
- National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences & McMaster University, Hamilton, Ontario, Canada
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8
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O’Donnell MJ, McQueen M, Sniderman A, Pare G, Wang X, Hankey GJ, Rangarajan S, Chin SL, Rao-Melacini P, Ferguson J, Xavier D, Lisheng L, Zhang H, Pais P, Lopez-Jaramillo P, Damasceno A, Langhorne P, Rosengren A, Dans AL, Elsayed A, Avezum A, Mondo C, Judge C, Diener HC, Ryglewicz D, Czlonkowska A, Pogosova N, Weimar C, Iqbal R, Diaz R, Yusoff K, Yusufali A, Oguz A, Penaherrera E, Lanas F, Ogah OS, Ogunniyi A, Iversen HK, Malaga G, Rumboldt Z, Oveisgharan S, Al Hussain F, Nilanont Y, Yusuf S. Association of Lipids, Lipoproteins, and Apolipoproteins with Stroke Subtypes in an International Case Control Study (INTERSTROKE). J Stroke 2022; 24:224-235. [PMID: 35677977 PMCID: PMC9194539 DOI: 10.5853/jos.2021.02152] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 04/11/2022] [Indexed: 11/11/2022] Open
Abstract
Background and Purpose The association of dyslipidemia with stroke has been inconsistent, which may be due to differing associations within etiological stroke subtypes. We sought to determine the association of lipoproteins and apolipoproteins within stroke subtypes.Methods Standardized incident case-control STROKE study in 32 countries. Cases were patients with acute hospitalized first stroke, and matched by age, sex and site to controls. Concentrations of total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), apolipoprotein A1 (apoA1), and apoB were measured. Non-HDL-C was calculated. We estimated multivariable odds ratio (OR) and population attributable risk percentage (PAR%). Outcome measures were all stroke, ischemic stroke (and subtypes), and intracerebral hemorrhage (ICH).Results Our analysis included 11,898 matched case-control pairs; 77.3% with ischemic stroke and 22.7% with ICH. Increasing apoB (OR, 1.10; 95% confidence interval [CI], 1.06 to 1.14 per standard deviation [SD]) and LDL-C (OR, 1.06; 95% CI, 1.02 to 1.10 per SD) were associated with an increase in risk of ischemic stroke, but a reduced risk of ICH. Increased apoB was significantly associated with large vessel stroke (PAR 13.4%; 95% CI, 5.6 to 28.4) and stroke of undetermined cause. Higher HDL-C (OR, 0.75; 95% CI, 0.72 to 0.78 per SD) and apoA1 (OR, 0.63; 95% CI, 0.61 to 0.66 per SD) were associated with ischemic stroke (and subtypes). While increasing HDL-C was associated with an increased risk of ICH (OR, 1.20; 95% CI, 1.14 to 1.27 per SD), apoA1 was associated with a reduced risk (OR, 0.80; 95% CI, 0.75 to 0.85 per SD). ApoB/A1 (OR, 1.38; 95% CI, 1.32 to 1.44 per SD) had a stronger magnitude of association than the ratio of LDL-C/HDL-C (OR, 1.26; 95% CI, 1.21 to 1.31 per SD) with ischemic stroke (<i>P</i><0.0001). Conclusions The pattern and magnitude of association of lipoproteins and apolipoproteins with stroke varies by etiological stroke subtype. While the directions of association for LDL, HDL, and apoB were opposing for ischemic stroke and ICH, apoA1 was associated with a reduction in both ischemic stroke and ICH. The ratio of apoB/A1 was the best lipid predictor of ischemic stroke risk.
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Affiliation(s)
- Martin J. O’Donnell
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
- Department of Medicine, HRB-Clinical Research Facility, NUI Galway, Galway, Ireland
- Correspondence: Martin J. O’Donnell Department of Medicine, HRB-Clinical Research Facility, NUI Galway, Newcastle Rd., Galway, Ireland Tel: +353-91-494-098 Fax: +353-905-297-3781 E-mail:
| | - Matthew McQueen
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Allan Sniderman
- Division of Cardiology, McGill University Health Center, Montreal, QC, Canada
| | - Guillaume Pare
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Xingyu Wang
- National Center of Cardiovascular Disease, Beijing, China
| | - Graeme J. Hankey
- School of Medicine and Pharmacology, The University of Western Australia, Perth, Australia
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Siu Lim Chin
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Purnima Rao-Melacini
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - John Ferguson
- Department of Medicine, HRB-Clinical Research Facility, NUI Galway, Galway, Ireland
| | - Denis Xavier
- St John’s Medical College and Research Institute, Bangalore, India
| | - Liu Lisheng
- National Center of Cardiovascular Disease, Beijing, China
| | - Hongye Zhang
- Beijing Hypertension League Institute, Beijing, China
| | - Prem Pais
- St John’s Medical College and Research Institute, Bangalore, India
| | - Patricio Lopez-Jaramillo
- Fundacion Oftalmologica de Santander-Clinica Carlos Ardila Lulle (FOSCAL), Bucaramanga, Colombia
| | | | - Peter Langhorne
- Department of Geriatric Medicine, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy and University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Antonio L. Dans
- College of Medicine, University of Philippines, Manila, Philippines
| | - Ahmed Elsayed
- Department of Surgery, Al Shaab Teaching Hospital, Khartoum, Sudan
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
| | - Charles Mondo
- Department of Cardiology, Kiruddu National Referral Hospital, Kampala, Uganda
| | - Conor Judge
- Department of Medicine, HRB-Clinical Research Facility, NUI Galway, Galway, Ireland
| | - Hans-Christoph Diener
- Institute for Medical Informatics, Department of Biometry and Epidemiology, University of Duisburg-Essen, Essen, Germany
| | | | - Anna Czlonkowska
- Department of Neurology, Military Institute of Aviation Medicine, Warsaw, Poland
| | - Nana Pogosova
- National Research Center for Preventive Medicine, Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Christian Weimar
- Institute for Medical Informatics, Department of Biometry and Epidemiology, University of Duisburg-Essen, Essen, Germany
| | - Romana Iqbal
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Rafael Diaz
- Estudios Clínicos Latino America (ECLA), Instituto Cardiovascular de Rosario (ICR), Rosario, Argentina
| | - Khalid Yusoff
- University College Sedaya International (UCSI) University, Kuala Lumpur, Malaysia
| | - Afzalhussein Yusufali
- Department of Medicine, Hatta Hospital, Dubai Health Authority, Dubai Medical College, Dubai, United Arab Emirates
| | - Aytekin Oguz
- Department of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | | | - Fernando Lanas
- Faculty of Medicine, University of La Frontera, Temuco, Chile
| | - Okechukwu S. Ogah
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Adesola Ogunniyi
- Department of Medicine, University College Hospital, Ibadan, Nigeria
| | | | | | | | | | | | - Yongchai Nilanont
- Neurology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
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9
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Wang C, Hu B, Rangarajan S, Bangdiwala SI, Gulec S, Lear SA, Mohan V, Gupta R, Alhabib KF, Soman B, Abat MEM, Rosengren A, Lanas F, Avezum A, Lopez-Jaramillo P, Diaz R, Yusoff K, Iqbal R, Chifamba J, Yeates K, Zatońska K, Kruger IM, Bahonar A, Yusufali A, Li W, Yusuf S. 'Corrigendum to "Association of bedtime with mortality and major cardiovascular events: an analysis of 112,198 individuals from 21 countries in the PURE study" [Sleep Medicine 80 (2021) 265-272]'. Sleep Med 2022; 92:108. [PMID: 34996707 DOI: 10.1016/j.sleep.2021.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Chuangshi Wang
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Bo Hu
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | | | - Sadi Gulec
- Ankara University School of Medicine, Ankara, Turkey
| | - Scott A Lear
- Faculty of Health Sciences, Simon Fraser University, Canada
| | - Viswanathan Mohan
- Dr.Mohan's Diabetes Specialities Centre, No. 6, Conran Smith Road, Gopalapuram, Chennai, 600086, India
| | - Rajeev Gupta
- Eternal Heart Care Centre & Research Institute, Jawahar Circle, Jaipur, 302017, India
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, 11472, Saudi Arabia
| | - Biju Soman
- Health Action By People, Navarangam Lane, Opp. Men's Hostel-3, Medical College, Trivandrum, 695011, Kerala, India; Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, 695011, Kerala, India
| | - Marc Evans M Abat
- Division of Adult Medicine, Department of Medicine, Philippine General Hospital, Philippines
| | - Annika Rosengren
- Sahlgrenska University Hospital/Östra Hospital, Diagnosvägen 11, SE 416 85, Göteborg, Sweden
| | | | - Alvaro Avezum
- Hospital Alemão Oswaldo Cruz and UNISA, Rua 13 de Maio, 1975, São Paulo, SP, Brazil
| | | | - Rafael Diaz
- Instituto Cardiovascular de Rosario, ECLA, Paraguay 160, 2000 Rosario, Argentina
| | - Khalid Yusoff
- Universiti Teknologi MARA, Jalan Prima Selayang 7, 68100, Batu Caves, Selangor, Malaysia; UCSI University, 1 Jalan Menara Gading, Taman Connaught, 56000, Cheras, Kuala Lumpur, Malaysia
| | - Romaina Iqbal
- Department of Community Health Sciences, The Aga Khan University, P.O. Box 3500 Stadium Road, Karachi, 74800, Pakistan
| | - Jephat Chifamba
- University of Zimbabwe, Department of Physiology, P.O.Box MP167 Harare, Zimbabwe
| | - Karen Yeates
- Queen's University, Department of Medicine, Kingston, Ontario, Canada
| | - Katarzyna Zatońska
- Faculty of Medicine, Head of Social Medicine Department, Wroclaw Medical University, Bujwida 44 St, 50-345, Wroclaw, EU, Poland
| | - Iolanthé M Kruger
- Africa Unit for Transdisciplinary Health Research (AUTHeR), North-West University, Potchefstroom Campus, Private Bag X6001, Potchefstroom, 2520, South Africa
| | - Ahmad Bahonar
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates
| | - Wei Li
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
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10
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Khetan AK, Leong DP, Gupta R, Zhu Y, Li S, Liu W, Kruger IM, Teo KK, Wielgosz A, Yusuf R, Noor Khan NAM, Khatib R, Alhabib KF, Karsidag K, Chifamba J, Mohammadifard N, Serón P, Lopez-Jaramillo P, Orlandini A, Szuba A, Yusufali A, Nair S, Rosengren A, Yeates K, Dans AM, Iqbal R, Avezum Á, Rangarajan S, Yusuf S. Variations in the association of height with mortality, cardiovascular disease and cancer in low-, middle- and high-income countries. Int J Epidemiol 2021; 51:1304-1316. [PMID: 34939099 DOI: 10.1093/ije/dyab268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 12/13/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Final adult height is a useful proxy measure of childhood nutrition and disease burden. Tall stature has been previously associated with decreased risk of all-cause mortality, decreased risk of major cardiovascular events and an increased risk of cancer. However, these associations have primarily been derived from people of European and East Asian backgrounds, and there are sparse data from other regions of the world. METHODS The Prospective Urban-Rural Epidemiology study is a large, longitudinal population study done in 21 countries of varying incomes and sociocultural settings. We enrolled an unbiased sample of households, which were eligible if at least one household member was aged 35-70 years. Height was measured in a standardized manner, without shoes, to the nearest 0.1 cm. During a median follow-up of 10.1 years (interquartile range 8.3-12.0), we assessed the risk of all-cause mortality, major cardiovascular events and cancer. RESULTS A total of 154 610 participants, enrolled since January 2003, with known height and vital status, were included in this analysis. Follow-up event data until March 2021 were used; 11 487 (7.4%) participants died, whereas 9291 (6.0%) participants had a major cardiovascular event and 5873 (3.8%) participants had a new diagnosis of cancer. After adjustment, taller individuals had lower hazards of all-cause mortality [hazard ratio (HR) per 10-cm increase in height 0.93, 95% confidence interval (CI) 0.90-0.96] and major cardiovascular events (HR 0.97, 95% CI 0.94-1.00), whereas the hazard of cancer was higher in taller participants (HR 1.23, 95% CI 1.18-1.28). The interaction p-values between height and country-income level for all three outcomes were <0.001, suggesting that the association with height varied by country-income level for these outcomes. In low-income countries, height was inversely associated with all-cause mortality (HR 0.88, 95% CI 0.84-0.92) and major cardiovascular events (HR 0.87, 95% CI 0.82-0.93). There was no association of height with these outcomes in middle- and high-income countries. The respective HRs for cancer in low-, middle- and high-income countries were 1.14 (95% CI 0.99-1.32), 1.12 (95% CI 1.04-1.22) and 1.20 (95% CI 1.14-1.26). CONCLUSIONS Unlike high- and middle-income countries, tall stature has a strong inverse association with all-cause mortality and major cardiovascular events in low-income countries. Improved childhood physical development and advances in population-wide cardiovascular treatments in high- and middle-income countries may contribute to this gap. From a life-course perspective, we hypothesize that optimizing maternal and child health in low-income countries may improve rates of premature mortality and cardiovascular events in these countries, at a population level.
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Affiliation(s)
- Aditya K Khetan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Darryl P Leong
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Rajeev Gupta
- Eternal Heart Care Center and Research Institute, Jaipur, India
| | - Yibing Zhu
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, P. R. China
| | - Sidong Li
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, P. R. China
| | - Weida Liu
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, P. R. China
| | - Iolanthé M Kruger
- Africa Unit for Transdisciplinary Health Research (AUTHeR), North-West University, Potchefstroom Campus, South Africa
| | - Koon K Teo
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | | | - Rita Yusuf
- Independent University, Dhaka, Bangladesh
| | | | - Rasha Khatib
- Institute for Community and Public Health, Birzeit University, Birzeit, Palestine; Advocate Aurora Health, Downers Grove, IL, USA
| | - Khalid F Alhabib
- King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Kubilay Karsidag
- Department of Internal Medicine, Medical Faculty of Istanbul University, Istanbul, Turkey
| | - Jephat Chifamba
- Department of Biomedical Sciences, Physiology Unit, Faculty of Medicine and Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Pamela Serón
- Faculty of Medicine, Universidad de La Frontera, Claro Solar, Temuco, Chile
| | - Patricio Lopez-Jaramillo
- Masira Research Institute, Medical School, Universidad de Santander (UDES), Bucaramanga, Colombia
| | - Andres Orlandini
- ECLA (Estudios Clínicos Latino America), Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Andrzej Szuba
- Department of Angiology, Hypertension and Diabetology, Wroclaw Medical University, Wroclaw, Poland
| | | | - Sanjeev Nair
- Health Action by People, Trivandrum and Government Medical College, Thrissur, India
| | - Annika Rosengren
- Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, VGR Region, Gothenburg, Sweden
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | | | - Romaina Iqbal
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Álvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
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11
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Narula N, Wong ECL, Dehghan M, Mente A, Rangarajan S, Lanas F, Lopez-Jaramillo P, Rohatgi P, Lakshmi PVM, Varma RP, Orlandini A, Avezum A, Wielgosz A, Poirier P, Almadi MA, Altuntas Y, Ng KK, Chifamba J, Yeates K, Puoane T, Khatib R, Yusuf R, Boström KB, Zatonska K, Iqbal R, Weida L, Yibing Z, Sidong L, Dans A, Yusufali A, Mohammadifard N, Marshall JK, Moayyedi P, Reinisch W, Yusuf S. Association of ultra-processed food intake with risk of inflammatory bowel disease: prospective cohort study. BMJ 2021; 374:n1554. [PMID: 34261638 PMCID: PMC8279036 DOI: 10.1136/bmj.n1554] [Citation(s) in RCA: 109] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To evaluate the relation between intake of ultra-processed food and risk of inflammatory bowel disease (IBD). DESIGN Prospective cohort study. SETTING 21 low, middle, and high income countries across seven geographical regions (Europe and North America, South America, Africa, Middle East, south Asia, South East Asia, and China). PARTICIPANTS 116 087 adults aged 35-70 years with at least one cycle of follow-up and complete baseline food frequency questionnaire (FFQ) data (country specific validated FFQs were used to document baseline dietary intake). Participants were followed prospectively at least every three years. MAIN OUTCOME MEASURES The main outcome was development of IBD, including Crohn's disease or ulcerative colitis. Associations between ultra-processed food intake and risk of IBD were assessed using Cox proportional hazard multivariable models. Results are presented as hazard ratios with 95% confidence intervals. RESULTS Participants were enrolled in the study between 2003 and 2016. During the median follow-up of 9.7 years (interquartile range 8.9-11.2 years), 467 participants developed incident IBD (90 with Crohn's disease and 377 with ulcerative colitis). After adjustment for potential confounding factors, higher intake of ultra-processed food was associated with a higher risk of incident IBD (hazard ratio 1.82, 95% confidence interval 1.22 to 2.72 for ≥5 servings/day and 1.67, 1.18 to 2.37 for 1-4 servings/day compared with <1 serving/day, P=0.006 for trend). Different subgroups of ultra-processed food, including soft drinks, refined sweetened foods, salty snacks, and processed meat, each were associated with higher hazard ratios for IBD. Results were consistent for Crohn's disease and ulcerative colitis with low heterogeneity. Intakes of white meat, red meat, dairy, starch, and fruit, vegetables, and legumes were not associated with incident IBD. CONCLUSIONS Higher intake of ultra-processed food was positively associated with risk of IBD. Further studies are needed to identify the contributory factors within ultra-processed foods. STUDY REGISTRATION ClinicalTrials.gov NCT03225586.
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Affiliation(s)
- Neeraj Narula
- Department of Medicine (Division of Gastroenterology) and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Emily C L Wong
- Department of Medicine (Division of Gastroenterology) and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Mahshid Dehghan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Andrew Mente
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Fernando Lanas
- Department of Internal Medicine, Universidad de La Frontera, Temuco, Chile
| | - Patricio Lopez-Jaramillo
- Masira Research Institute, Universidad de Santander (UDES) Fundación Oftalmológica de Santander-FOSCAL-Bucaramanga, Colombia
| | - Priyanka Rohatgi
- Department of Nutrition and Dietetics, Apollo Hospitals, Bangalore, India
| | - P V M Lakshmi
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ravi Prasad Varma
- Achutha Menon Centre for Health Science Studies, SCTIMST and Health Action by People, Thiruvananthapuram, India
| | - Andres Orlandini
- Department of Cardiology, Estudios Clinicos Latinoamerica ECLA Rosario, Santa Fe, Argentina
| | - Alvaro Avezum
- International Research Centre, Hospital Alemao Oswaldo Cruz, Sao Paulo, Brazil, Universidade Santo Amaro (UNISA), Sao Paulo, Brazil
| | - Andreas Wielgosz
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Paul Poirier
- Faculté de pharmacie, Université Laval Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Canada
| | - Majid A Almadi
- Department of Medicine, Division of Gastroenterology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Yuksel Altuntas
- University of Health Sciences, Faculty of Medicine, Istanbul Sisli Hamidiye Etfal Health Training and Research Hospital, Clinic of Endocrinology and Metabolism Sisli/Istanbul, Turkey
| | - Kien Keat Ng
- Faculty of Medicine and Defence Health, National Defence University of Malaysia, Kuala Lumpur, Malaysia
| | - Jephat Chifamba
- Department of Physiology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Thandi Puoane
- School of Public Health, University of the Western Cape, Bellville. South Africa
| | - Rasha Khatib
- Institute for Community and Public Health, Birzeit University, Birzeit, Palestine
| | - Rita Yusuf
- Advocate Research Institute, Advocate Health Care, IL, USA
- School of Life Sciences, Independent University, Bangladesh Bashundhara, Dhaka, Bangladesh
| | - Kristina Bengtsson Boström
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Katarzyna Zatonska
- Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Romaina Iqbal
- Department of Community Health Sciences, The Aga Khan University, Karachi, Pakistan
| | - Liu Weida
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences Mentougou District, Beijing, China
| | - Zhu Yibing
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences Mentougou District, Beijing, China
| | - Li Sidong
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences Mentougou District, Beijing, China
| | - Antonio Dans
- Section of Adult Medicine and Medical Research Unit, University of Philippines, Manila, Philippines
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Medical University, Dubai Health Authority, Dubai, United Arab Emirates
| | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - John K Marshall
- Department of Medicine (Division of Gastroenterology) and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Paul Moayyedi
- Department of Medicine (Division of Gastroenterology) and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Walter Reinisch
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
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12
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Naito R, Leong DP, Bangdiwala SI, McKee M, Subramanian SV, Rangarajan S, Islam S, Avezum A, Yeates KE, Lear SA, Gupta R, Yusufali A, Dans AL, Szuba A, Alhabib KF, Kaur M, Rahman O, Seron P, Diaz R, Puoane T, Liu W, Zhu Y, Sheng Y, Lopez-Jaramillo P, Chifamba J, Rosnah I, Karsidag K, Kelishadi R, Rosengren A, Khatib R, K R LIA, Azam SI, Teo K, Yusuf S. Impact of social isolation on mortality and morbidity in 20 high-income, middle-income and low-income countries in five continents. BMJ Glob Health 2021; 6:bmjgh-2020-004124. [PMID: 33753400 PMCID: PMC7986654 DOI: 10.1136/bmjgh-2020-004124] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/26/2020] [Accepted: 01/20/2021] [Indexed: 12/26/2022] Open
Abstract
Objective To examine the association between social isolation and mortality and incident diseases in middle-aged adults in urban and rural communities from high-income, middle-income and low-income countries. Design Population-based prospective observational study. Setting Urban and rural communities in 20 high income, middle income and low income. Participants 119 894 community-dwelling middle-aged adults. Main outcome measures Associations of social isolation with mortality, cardiovascular death, non-cardiovascular death and incident diseases. Results Social isolation was more common in middle-income and high-income countries compared with low-income countries, in urban areas than rural areas, in older individuals and among women, those with less education and the unemployed. It was more frequent among smokers and those with a poorer diet. Social isolation was associated with greater risk of mortality (HR of 1.26, 95% CI: 1.17 to 1.36), incident stroke (HR: 1.23, 95% CI: 1.07 to 1.40), cardiovascular disease (HR: 1.15, 95% CI: 1.05 to 1.25) and pneumonia (HR: 1.22, 95% CI: 1.09 to 1.37), but not cancer. The associations between social isolation and mortality were observed in populations in high-income, middle-income and low-income countries (HR (95% CI): 1.69 (1.32 to 2.17), 1.27 (1.15 to 1.40) and 1.47 (1.25 to 1.73), respectively, interaction p=0.02). The HR associated with social isolation was greater in men than women and in younger than older individuals. Mediation analyses for the association between social isolation and mortality showed that unhealthy behaviours and comorbidities may account for about one-fifth of the association. Conclusion Social isolation is associated with increased risk of mortality in countries at different economic levels. The increasing share of older people in populations in many countries argues for targeted strategies to mitigate its adverse effects.
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Affiliation(s)
- Ryo Naito
- Population Health Research Institute, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Darryl P Leong
- Population Health Research Institute, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Shrikant Ishver Bangdiwala
- Population Health Research Institute, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | - S V Subramanian
- Harvard Center for Population and Development Studies and Department of Society and Human Development, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Shofiqul Islam
- Population Health Research Institute, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Karen E Yeates
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Scott A Lear
- Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Rajeev Gupta
- Eternal Heart Care Centre & Research Institute, Jaipur, India
| | | | - Antonio L Dans
- Adult Medicine Research Unit, Philippine General Hospital, Manila, Philippines
| | - Andrzej Szuba
- Department of Angiology, Hypertension and Diabetology, Wroclaw Medical University, Wroclaw, Dolnoslaskie, Poland
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Manmeet Kaur
- School of Public Health, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Omar Rahman
- University of Liberal Arts Bangladesh, Dhaka, Dhaka District, Bangladesh
| | | | - Rafael Diaz
- ECLA - Academic Research Organization, Rosario, Argentina
| | - Thandi Puoane
- School of Public Health, University of Western Cape, Cape Town, Western Cape, South Africa
| | - Weida Liu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Xicheng District, Beijing, China
| | - Yibing Zhu
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Beijing, China
| | - Yundong Sheng
- Jiangxinzhou Community Health Service Center, Nanjing, China
| | | | - Jephat Chifamba
- Department of Physiology, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
| | - Ismail Rosnah
- Community Health Department, Faculty of Medicine, Universiti Kebangsaan Malaysia, Malaysia, Malaysia
| | - Kubilay Karsidag
- Division of Endocrinology, Medical Faculty of Istanbul University, Fatih, Turkey
| | - Roya Kelishadi
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, and Region Västra Götaland, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Rasha Khatib
- Advocate Aurora Research Institute, Downers Grove, Illinois, USA.,Institute of Community and Public Health, Birzeit University, Birzeit, Palestine
| | - Leela Itty Amma K R
- Health Action by People, Thiruvananthapuram, Kerala, India.,Department of Community Medicine, Sree Mookambika Institute of Medical Sciences, Kulasekharam, India
| | - Syed Iqbal Azam
- Community Health Sciences (CHS) department, The Aga Khan University, Karachi, Pakistan
| | - Koon Teo
- Population Health Research Institute, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton, Ontario, Canada .,Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
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13
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Chow CK, Nguyen TN, Marschner S, Diaz R, Rahman O, Avezum A, Lear SA, Teo K, Yeates KE, Lanas F, Li W, Hu B, Lopez-Jaramillo P, Gupta R, Kumar R, Mony PK, Bahonar A, Yusoff K, Khatib R, Kazmi K, Dans AL, Zatonska K, Alhabib KF, Kruger IM, Rosengren A, Gulec S, Yusufali A, Chifamba J, Rangarajan S, McKee M, Yusuf S. Availability and affordability of medicines and cardiovascular outcomes in 21 high-income, middle-income and low-income countries. BMJ Glob Health 2021; 5:bmjgh-2020-002640. [PMID: 33148540 PMCID: PMC7640501 DOI: 10.1136/bmjgh-2020-002640] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 09/06/2020] [Accepted: 09/10/2020] [Indexed: 01/23/2023] Open
Abstract
Objectives We aimed to examine the relationship between access to medicine for cardiovascular disease (CVD) and major adverse cardiovascular events (MACEs) among people at high risk of CVD in high-income countries (HICs), upper and lower middle-income countries (UMICs, LMICs) and low-income countries (LICs) participating in the Prospective Urban Rural Epidemiology (PURE) study. Methods We defined high CVD risk as the presence of any of the following: hypertension, coronary artery disease, stroke, smoker, diabetes or age >55 years. Availability and affordability of blood pressure lowering drugs, antiplatelets and statins were obtained from pharmacies. Participants were categorised: group 1—all three drug types were available and affordable, group 2—all three drugs were available but not affordable and group 3—all three drugs were not available. We used multivariable Cox proportional hazard models with nested clustering at country and community levels, adjusting for comorbidities, sociodemographic and economic factors. Results Of 163 466 participants, there were 93 200 with high CVD risk from 21 countries (mean age 54.7, 49% female). Of these, 44.9% were from group 1, 29.4% from group 2 and 25.7% from group 3. Compared with participants from group 1, the risk of MACEs was higher among participants in group 2 (HR 1.19, 95% CI 1.07 to 1.31), and among participants from group 3 (HR 1.25, 95% CI 1.08 to 1.50). Conclusion Lower availability and affordability of essential CVD medicines were associated with higher risk of MACEs and mortality. Improving access to CVD medicines should be a key part of the strategy to lower CVD globally.
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Affiliation(s)
- Clara Kayei Chow
- Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Tu Ngoc Nguyen
- Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Simone Marschner
- Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Rafael Diaz
- Estudios Clinicos Latino America, Rosario, Argentina
| | - Omar Rahman
- Independent University, Dhaka, Dhaka District, Bangladesh
| | - Alvaro Avezum
- International Research Centre, Hospital Alemao Oswaldo Cruz, Sao Paulo, Brazil
| | - Scott A Lear
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Koon Teo
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Karen E Yeates
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | | | - Wei Li
- Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Fuwai Hospital, Xicheng District, Beijing, China
| | - Bo Hu
- Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Fuwai Hospital, Xicheng District, Beijing, China
| | | | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Jaipur, India
| | - Rajesh Kumar
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Prem K Mony
- St John's Medical College, Bangalore, Karnataka, India
| | - Ahmad Bahonar
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (the Islamic Republic of)
| | - Khalid Yusoff
- Faculty of Medicine and Health Sciences, UCSI University, Kuala Lumpur, Wilayah Persekutuan, Malaysia.,Centre for Translational Research & Epidemiology, Faculty of Medicine, University Teknologi MARA, Shah Alam, Selangor, Malaysia
| | - Rasha Khatib
- Institute for Community and Public Health, Birzeit University, Birzeit, Illinois, Palestine.,Advocate Research Institute, Advocate Health Care, Hinsdale, Illinois, USA
| | - Khawar Kazmi
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Antonio L Dans
- Section of Adult Medicine & Medical Research Unit, University of the Philippines, Manila, Philippines
| | - Katarzyna Zatonska
- Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Iolanthe Marike Kruger
- Africa Unit for Transdisciplinary Health Research, North-West University, Potchefstroom, South Africa
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, University of Gothenburg and Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sadi Gulec
- Cardiology Department, Ankara University School of Medicine, Ankara, Turkey
| | | | - Jephat Chifamba
- Physiology Department, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Martin McKee
- Centre for Global Chronic Conditions, London School of Hygiene & Tropical Medicine, London, UK
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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14
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Tse LA, Wang C, Rangarajan S, Liu Z, Teo K, Yusufali A, Avezum Á, Wielgosz A, Rosengren A, Kruger IM, Chifamba J, Calik KBT, Yeates K, Zatońska K, AlHabib KF, Yusoff K, Kaur M, Ismail N, Seron P, Lopez-Jaramillo P, Poirier P, Gupta R, Khatib R, Kelishadi R, Lear SA, Choudhury T, Mohan V, Li W, Yusuf S. Timing and Length of Nocturnal Sleep and Daytime Napping and Associations With Obesity Types in High-, Middle-, and Low-Income Countries. JAMA Netw Open 2021; 4:e2113775. [PMID: 34190997 PMCID: PMC8246307 DOI: 10.1001/jamanetworkopen.2021.13775] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Obesity is a growing public health threat leading to serious health consequences. Late bedtime and sleep loss are common in modern society, but their associations with specific obesity types are not well characterized. OBJECTIVE To assess whether sleep timing and napping behavior are associated with increased obesity, independent of nocturnal sleep length. DESIGN, SETTING, AND PARTICIPANTS This large, multinational, population-based cross-sectional study used data of participants from 60 study centers in 26 countries with varying income levels as part of the Prospective Urban Rural Epidemiology study. Participants were aged 35 to 70 years and were mainly recruited during 2005 and 2009. Data analysis occurred from October 2020 through March 2021. EXPOSURES Sleep timing (ie, bedtime and wake-up time), nocturnal sleep duration, daytime napping. MAIN OUTCOMES AND MEASURES The primary outcomes were prevalence of obesity, specified as general obesity, defined as body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 30 or greater, and abdominal obesity, defined as waist circumference greater than 102 cm for men or greater than 88 cm for women. Multilevel logistic regression models with random effects for study centers were performed to calculate adjusted odds ratios (AORs) and 95% CIs. RESULTS Overall, 136 652 participants (81 652 [59.8%] women; mean [SD] age, 51.0 [9.8] years) were included in analysis. A total of 27 195 participants (19.9%) had general obesity, and 37 024 participants (27.1%) had abdominal obesity. The mean (SD) nocturnal sleep duration was 7.8 (1.4) hours, and the median (interquartile range) midsleep time was 2:15 am (1:30 am-3:00 am). A total of 19 660 participants (14.4%) had late bedtime behavior (ie, midnight or later). Compared with bedtime between 8 pm and 10 pm, late bedtime was associated with general obesity (AOR, 1.20; 95% CI, 1.12-1.29) and abdominal obesity (AOR, 1.20; 95% CI, 1.12-1.28), particularly among participants who went to bed between 2 am and 6 am (general obesity: AOR, 1.35; 95% CI, 1.18-1.54; abdominal obesity: AOR, 1.38; 95% CI, 1.21-1.58). Short nocturnal sleep of less than 6 hours was associated with general obesity (eg, <5 hours: AOR, 1.27; 95% CI, 1.13-1.43), but longer napping was associated with higher abdominal obesity prevalence (eg, ≥1 hours: AOR, 1.39; 95% CI, 1.31-1.47). Neither going to bed during the day (ie, before 8pm) nor wake-up time was associated with obesity. CONCLUSIONS AND RELEVANCE This cross-sectional study found that late nocturnal bedtime and short nocturnal sleep were associated with increased risk of obesity prevalence, while longer daytime napping did not reduce the risk but was associated with higher risk of abdominal obesity. Strategic weight control programs should also encourage earlier bedtime and avoid short nocturnal sleep to mitigate obesity epidemic.
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Affiliation(s)
- Lap Ah Tse
- Jockey Club School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Chuangshi Wang
- Medical Research and Biometrics Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Zhiguang Liu
- Division of Occupational and Environmental Health, Jockey Club School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Koon Teo
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Afzalhussein Yusufali
- Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Álvaro Avezum
- Research Division, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | | | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Iolanthé M. Kruger
- Africa Unit for Transdisciplinary Health Research, North-West University, Potcehfstroom, South Africa
| | - Jephat Chifamba
- Department of Physiology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - K. Burcu Tumerdem Calik
- Department of Health Management, Faculty of Health Sciences, Marmara University, Istanbul, Turkey
| | - Karen Yeates
- Department of Medicine, Faculty of Health Sciences, Queen’s University, Kingston, Canada
| | - Katarzyna Zatońska
- Department of Social Medicine, Wroclaw Medical University, Wroclaw Poland
| | - Khalid F. AlHabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, King Saud University College of Medicine, Riyadh, Saudi Arabia
| | - Khalid Yusoff
- Universiti Teknologi MARA, Selayang, Malaysia
- UCSI University, Kuala Lumpur, Malaysia
| | - Manmeet Kaur
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Noorhassim Ismail
- Department of Community Health, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Pamela Seron
- Dpto Medicina Interna, Facultad de Medicina, Universidad de La Frontera, Temuco, Chile
| | | | - Paul Poirier
- Faculté de pharmacie, Université Laval, Québec, Canada
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Jaipur, India
| | - Rasha Khatib
- Institute of Community and Public Health, Birzeit University, Birzeit, Palestine
| | - Roya Kelishadi
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Scott A. Lear
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | | | - Viswanathan Mohan
- Madras Diabetes Research Foundation, Dr Mohan’s Diabetes Specialities Centre, Chennai, India
| | - Wei Li
- Medical Research and Biometrics Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, Canada
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15
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Mohan D, Mente A, Dehghan M, Rangarajan S, O'Donnell M, Hu W, Dagenais G, Wielgosz A, Lear S, Wei L, Diaz R, Avezum A, Lopez-Jaramillo P, Lanas F, Swaminathan S, Kaur M, Vijayakumar K, Mohan V, Gupta R, Szuba A, Iqbal R, Yusuf R, Mohammadifard N, Khatib R, Yusoff K, Gulec S, Rosengren A, Yusufali A, Wentzel-Viljoen E, Chifamba J, Dans A, Alhabib KF, Yeates K, Teo K, Gerstein HC, Yusuf S. Associations of Fish Consumption With Risk of Cardiovascular Disease and Mortality Among Individuals With or Without Vascular Disease From 58 Countries. JAMA Intern Med 2021; 181:631-649. [PMID: 33683310 PMCID: PMC7941252 DOI: 10.1001/jamainternmed.2021.0036] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Cohort studies report inconsistent associations between fish consumption, a major source of long-chain ω-3 fatty acids, and risk of cardiovascular disease (CVD) and mortality. Whether the associations vary between those with and those without vascular disease is unknown. OBJECTIVE To examine whether the associations of fish consumption with risk of CVD or of mortality differ between individuals with and individuals without vascular disease. DESIGN, SETTING, AND PARTICIPANTS This pooled analysis of individual participant data involved 191 558 individuals from 4 cohort studies-147 645 individuals (139 827 without CVD and 7818 with CVD) from 21 countries in the Prospective Urban Rural Epidemiology (PURE) study and 43 413 patients with vascular disease in 3 prospective studies from 40 countries. Adjusted hazard ratios (HRs) were calculated by multilevel Cox regression separately within each study and then pooled using random-effects meta-analysis. This analysis was conducted from January to June 2020. EXPOSURES Fish consumption was recorded using validated food frequency questionnaires. In 1 of the cohorts with vascular disease, a separate qualitative food frequency questionnaire was used to assess intake of individual types of fish. MAIN OUTCOMES AND MEASURES Mortality and major CVD events (including myocardial infarction, stroke, congestive heart failure, or sudden death). RESULTS Overall, 191 558 participants with a mean (SD) age of 54.1 (8.0) years (91 666 [47.9%] male) were included in the present analysis. During 9.1 years of follow-up in PURE, compared with little or no fish intake (≤50 g/mo), an intake of 350 g/wk or more was not associated with risk of major CVD (HR, 0.95; 95% CI, 0.86-1.04) or total mortality (HR, 0.96; 0.88-1.05). By contrast, in the 3 cohorts of patients with vascular disease, the HR for risk of major CVD (HR, 0.84; 95% CI, 0.73-0.96) and total mortality (HR, 0.82; 95% CI, 0.74-0.91) was lowest with intakes of at least 175 g/wk (or approximately 2 servings/wk) compared with 50 g/mo or lower, with no further apparent decrease in HR with consumption of 350 g/wk or higher. Fish with higher amounts of ω-3 fatty acids were strongly associated with a lower risk of CVD (HR, 0.94; 95% CI, 0.92-0.97 per 5-g increment of intake), whereas other fish were neutral (collected in 1 cohort of patients with vascular disease). The association between fish intake and each outcome varied by CVD status, with a lower risk found among patients with vascular disease but not in general populations (for major CVD, I2 = 82.6 [P = .02]; for death, I2 = 90.8 [P = .001]). CONCLUSIONS AND RELEVANCE Findings of this pooled analysis of 4 cohort studies indicated that a minimal fish intake of 175 g (approximately 2 servings) weekly is associated with lower risk of major CVD and mortality among patients with prior CVD but not in general populations. The consumption of fish (especially oily fish) should be evaluated in randomized trials of clinical outcomes among people with vascular disease.
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Affiliation(s)
- Deepa Mohan
- Madras Diabetes Research Foundation and Dr. Mohan's Diabetes Specialities Centre, Chennai, India
| | - Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mahshid Dehghan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
| | - Martin O'Donnell
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,HRB-Clinical Research Facility, NUI Galway, Ireland
| | - Weihong Hu
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
| | - Gilles Dagenais
- Université Laval Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada, G1V 4G5
| | - Andreas Wielgosz
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Scott Lear
- Faculty of Health Sciences, and Department of Biomedical Physiology & Kinesiology, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Li Wei
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica ECLA, Rosario, Santa Fe, Argentina
| | - Alvaro Avezum
- International Research Centre, Hospital Alemao Oswaldo Cruz, Sao Paulo, Brazil, Universidade Santo Amaro (UNISA), Sao Paulo, SP Brazil
| | | | - Fernando Lanas
- Universidad de La Frontera, Francisco Salazar, Temuco, Chile
| | | | - Manmeet Kaur
- School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - K Vijayakumar
- Health Action by People, Amrita Institute of Medical Sciences, Trivandrum, Kerala, India
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation and Dr. Mohan's Diabetes Specialities Centre, Chennai, India
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Rajasthan University of Health Sciences, Jaipur, India
| | - Andrzej Szuba
- Wroclaw Medical University, Department of Internal Medicine, 4th Military Hospital, Wroclaw, Poland
| | - Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi Pakistan
| | - Rita Yusuf
- Independent University, Bangladesh, Bashundhara, Dhaka, Bangladesh
| | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Rasha Khatib
- Institute for Community and Public Health, Birzeit University, Birzeit, Palestine.,Advocate Research Institute, Advocate Health Care, Chicago, Illinois
| | - Khalid Yusoff
- Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia, UCSI University, Cheras, Selangor, Malaysia
| | - Sadi Gulec
- Cardiology Department, Ankara University Medical School, Ankara, Turkey
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital/Östra Hospital, Gothenburg, Sweden
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Health Authority, Dubai Medical University, Dubai, United Arab Emirates
| | | | - Jephat Chifamba
- Physiology Department, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Antonio Dans
- University of the Philippines, Ermita, Manila, Philippines
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Karen Yeates
- Department of Medicine, Etherington Hall, Queen's University, Kingston, Ontario, Canada
| | - Koon Teo
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Hertzel C Gerstein
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Judge C, O’Donnell MJ, Hankey GJ, Rangarajan S, Chin SL, Rao-Melacini P, Ferguson J, Smyth A, Xavier D, Lisheng L, Zhang H, Lopez-Jaramillo P, Damasceno A, Langhorne P, Rosengren A, Dans AL, Elsayed A, Avezum A, Mondo C, Ryglewicz D, Czlonkowska A, Pogosova N, Weimar C, Diaz R, Yusoff K, Yusufali A, Oguz A, Wang X, Lanas F, Ogah OS, Ogunniyi A, Iversen HK, Malaga G, Rumboldt Z, Oveisgharan S, Al Hussain F, Yusuf S. Urinary Sodium and Potassium, and Risk of Ischemic and Hemorrhagic Stroke (INTERSTROKE): A Case-Control Study. Am J Hypertens 2021; 34:414-425. [PMID: 33197265 PMCID: PMC8057138 DOI: 10.1093/ajh/hpaa176] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 10/27/2020] [Accepted: 11/10/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Although low sodium intake (<2 g/day) and high potassium intake (>3.5 g/day) are proposed as public health interventions to reduce stroke risk, there is uncertainty about the benefit and feasibility of this combined recommendation on prevention of stroke. METHODS We obtained random urine samples from 9,275 cases of acute first stroke and 9,726 matched controls from 27 countries and estimated the 24-hour sodium and potassium excretion, a surrogate for intake, using the Tanaka formula. Using multivariable conditional logistic regression, we determined the associations of estimated 24-hour urinary sodium and potassium excretion with stroke and its subtypes. RESULTS Compared with an estimated urinary sodium excretion of 2.8-3.5 g/day (reference), higher (>4.26 g/day) (odds ratio [OR] 1.81; 95% confidence interval [CI], 1.65-2.00) and lower (<2.8 g/day) sodium excretion (OR 1.39; 95% CI, 1.26-1.53) were significantly associated with increased risk of stroke. The stroke risk associated with the highest quartile of sodium intake (sodium excretion >4.26 g/day) was significantly greater (P < 0.001) for intracerebral hemorrhage (ICH) (OR 2.38; 95% CI, 1.93-2.92) than for ischemic stroke (OR 1.67; 95% CI, 1.50-1.87). Urinary potassium was inversely and linearly associated with risk of stroke, and stronger for ischemic stroke than ICH (P = 0.026). In an analysis of combined sodium and potassium excretion, the combination of high potassium intake (>1.58 g/day) and moderate sodium intake (2.8-3.5 g/day) was associated with the lowest risk of stroke. CONCLUSIONS The association of sodium intake and stroke is J-shaped, with high sodium intake a stronger risk factor for ICH than ischemic stroke. Our data suggest that moderate sodium intake-rather than low sodium intake-combined with high potassium intake may be associated with the lowest risk of stroke and expected to be a more feasible combined dietary target.
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Affiliation(s)
- Conor Judge
- Department of Medicine, NUI Galway, Galway, Ireland
- Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
- Wellcome Trust Health Research Board Irish Clinical Academic Training (ICAT), Dublin, Ireland
| | - Martin J O’Donnell
- Department of Medicine, NUI Galway, Galway, Ireland
- Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Graeme J Hankey
- School of Medicine and Pharmacology, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Sumathy Rangarajan
- Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Siu Lim Chin
- Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Purnima Rao-Melacini
- Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | - Andrew Smyth
- Department of Medicine, NUI Galway, Galway, Ireland
| | - Denis Xavier
- Department of Medicine, St John’s Medical College and Research Institute, Bangalore, India
| | - Liu Lisheng
- Department of Medicine, National Center of Cardiovascular Disease, Beijing, China
| | - Hongye Zhang
- Department of Medicine, Beijing Hypertension League Institute, Beijing, China
| | - Patricio Lopez-Jaramillo
- Department of Medicine, Instituto de Investigaciones MASIRA, Universidad de Santander, Bucaramanga, Colombia
| | | | - Peter Langhorne
- Department of Medicine, Glasgow Royal Infirmary, University of Glasgow, Glasgow, Scotland, UK
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, University of Gothenburg and Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Antonio L Dans
- College of Medicine, University of Philippines, Manila, Philippines
| | - Ahmed Elsayed
- Department of Surgery, Al Shaab Teaching Hospital, Khartoum, Sudan
| | - Alvaro Avezum
- Department of Medicine, International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Charles Mondo
- Department of Medicine, Kiruddu National Referral Hospital, Kampala, Uganda
| | | | - Anna Czlonkowska
- Department of Medicine, Military Institute of Aviation Medicine, Warsaw, Poland
| | - Nana Pogosova
- Department of Medicine, National Medical Research Center of Cardiology, Moscow, Russia
| | | | - Rafael Diaz
- Department of Medicine, Estudios Clínicos Latino America (ECLA), Instituto Cardiovascular de Rosario (ICR), Rosario, Argentina
| | - Khalid Yusoff
- Department of Medicine, Universiti Teknologi MARA, Selayang, Selangor and UCSI University, Kuala Lumpur, Malaysia
| | - Afzalhussein Yusufali
- Department of Medicine, Hatta Hospital, Dubai Health Authority/Dubai Medical College, Dubai, UAE
| | - Aytekin Oguz
- Department of Internal Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Xingyu Wang
- Department of Medicine, Beijing Hypertension League Institute, Beijing, China
| | - Fernando Lanas
- Faculty of Medicine, Universidad de La Frontera, Temuco, Chile
| | - Okechukwu S Ogah
- Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Adesola Ogunniyi
- Department of Medicine, University College Hospital, Ibadan, Oyo State, Nigeria
| | - Helle K Iversen
- Department of Neurology, Rigshospitalet, University of Copenhagen, Denmark
| | - German Malaga
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - Shahram Oveisgharan
- Department of Medicine, Rush Alzheimer Disease Research Center in Chicago, Chicago, Illinois, USA
| | - Fawaz Al Hussain
- Department of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Salim Yusuf
- Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
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Swaminathan S, Dehghan M, Raj JM, Thomas T, Rangarajan S, Jenkins D, Mony P, Mohan V, Lear SA, Avezum A, Lopez-Jaramillo P, Rosengren A, Lanas F, AlHabib KF, Dans A, Keskinler MV, Puoane T, Soman B, Wei L, Zatonska K, Diaz R, Ismail N, Chifamba J, Kelishadi R, Yusufali A, Khatib R, Xiaoyun L, Bo H, Iqbal R, Yusuf R, Yeates K, Teo K, Yusuf S. Associations of cereal grains intake with cardiovascular disease and mortality across 21 countries in Prospective Urban and Rural Epidemiology study: prospective cohort study. BMJ 2021; 372:m4948. [PMID: 33536317 PMCID: PMC7856570 DOI: 10.1136/bmj.m4948] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To evaluate the association between intakes of refined grains, whole grains, and white rice with cardiovascular disease, total mortality, blood lipids, and blood pressure in the Prospective Urban and Rural Epidemiology (PURE) study. DESIGN Prospective cohort study. SETTING PURE study in 21 countries. PARTICIPANTS 148 858 participants with median follow-up of 9.5 years. EXPOSURES Country specific validated food frequency questionnaires were used to assess intakes of refined grains, whole grains, and white rice. MAIN OUTCOME MEASURE Composite of mortality or major cardiovascular events (defined as death from cardiovascular causes, non-fatal myocardial infarction, stroke, or heart failure). Hazard ratios were estimated for associations of grain intakes with mortality, major cardiovascular events, and their composite by using multivariable Cox frailty models with random intercepts to account for clustering by centre. RESULTS Analyses were based on 137 130 participants after exclusion of those with baseline cardiovascular disease. During follow-up, 9.2% (n=12 668) of these participants had a composite outcome event. The highest category of intake of refined grains (≥350 g/day or about 7 servings/day) was associated with higher risk of total mortality (hazard ratio 1.27, 95% confidence interval 1.11 to 1.46; P for trend=0.004), major cardiovascular disease events (1.33, 1.16 to 1.52; P for trend<0.001), and their composite (1.28, 1.15 to 1.42; P for trend<0.001) compared with the lowest category of intake (<50 g/day). Higher intakes of refined grains were associated with higher systolic blood pressure. No significant associations were found between intakes of whole grains or white rice and health outcomes. CONCLUSION High intake of refined grains was associated with higher risk of mortality and major cardiovascular disease events. Globally, lower consumption of refined grains should be considered.
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Affiliation(s)
| | - Mahshid Dehghan
- Population Health Research Institute (PHRI), McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada
| | | | | | - Sumathy Rangarajan
- Population Health Research Institute (PHRI), McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada
| | - David Jenkins
- Department of Nutritional Sciences and Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Prem Mony
- St John's Research Institute, Bangalore, India
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation and Dr Mohan's Diabetes Specialities Centre, Chennai, India
| | - Scott A Lear
- Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada
| | - Alvaro Avezum
- International Research Centre, Hospital Alemao Oswaldo Cruz, Sao Paulo, Brazil, Universidade Santo Amaro (UNISA), Sao Paulo, Brazil
| | | | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Khalid F AlHabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Antonio Dans
- University of Philippines, Section of Adult Medicine and Medical Research Unit, Manila, Philippines
| | - Mirac Vural Keskinler
- Department of Internal Medicine, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Thandi Puoane
- University of the Western Cape, Bellville, South Africa
| | - Biju Soman
- Health Action by People, Thiruvananthapuram, Kerala, India
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Li Wei
- National Centre for Cardiovascular Diseases, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Katarzyna Zatonska
- Wroclaw Medical University, Department of Social Medicine, Wroclaw, Poland
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica ECLA, Rosario, Santa Fe, Argentina
| | - Noorhassim Ismail
- Department of Community Health, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Jephat Chifamba
- Physiology Department, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Roya Kelishadi
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Afzalhussein Yusufali
- Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Rasha Khatib
- Institute for Community and Public Health, Birzeit University, Birzeit, Palestine
- Advocate Research Institute, Advocate Health Care, Illinois, USA
| | - Liu Xiaoyun
- National Centre for Cardiovascular Diseases, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Hu Bo
- National Centre for Cardiovascular Diseases, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Romaina Iqbal
- Departments of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Rita Yusuf
- School of Life Sciences, Independent University, Bangladesh, Dhaka, Bangladesh
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, ON, Canada
- New York University, College of Global Public Health, NY, USA
| | - Koon Teo
- Population Health Research Institute (PHRI), McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute (PHRI), McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada
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O' Donnell M, Hankey GJ, Rangarajan S, Chin SL, Rao-Melacini P, Ferguson J, Xavier D, Lisheng L, Zhang H, Pais P, Lopez-Jaramillo P, Damasceno A, Langhorne P, Rosengren A, Dans AL, Elsayed A, Avezum A, Mondo C, Smyth A, Judge C, Diener HC, Ryglewicz D, Czlonkowska A, Pogosova N, Weimar C, Iqbal R, Diaz R, Yusoff K, Yusufali A, Oguz A, Wang X, Penaherrera E, Lanas F, Ogah OS, Ogunniyi A, Iversen HK, Malaga G, Rumboldt Z, Oveisgharan S, AlHussain F, Daliwonga M, Nilanont Y, Yusuf S. Variations in knowledge, awareness and treatment of hypertension and stroke risk by country income level. Heart 2020; 107:heartjnl-2019-316515. [PMID: 33318082 DOI: 10.1136/heartjnl-2019-316515] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/27/2020] [Accepted: 09/10/2020] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Hypertension is the most important modifiable risk factor for stroke globally. We hypothesised that country-income level variations in knowledge, detection and treatment of hypertension may contribute to variations in the association of blood pressure with stroke. METHODS We undertook a standardised case-control study in 32 countries (INTERSTROKE). Cases were patients with acute first stroke (n=13 462) who were matched by age, sex and site to controls (n=13 483). We evaluated the associations of knowledge, awareness and treatment of hypertension with risk of stroke and its subtypes and whether this varied by gross national income (GNI) of country. We estimated OR and population attributable risk (PAR) associated with treated and untreated hypertension. RESULTS Hypertension was associated with a graded increase in OR by reducing GNI, ranging from OR 1.92 (99% CI 1.48 to 2.49) to OR 3.27 (2.72 to 3.93) for highest to lowest country-level GNI (p-heterogeneity<0.0001). Untreated hypertension was associated with a higher OR for stroke (OR 5.25; 4.53 to 6.10) than treated hypertension (OR 2.60; 2.32 to 2.91) and younger age of first stroke (61.4 vs 65.4 years; p<0.01). Untreated hypertension was associated with a greater risk of intracerebral haemorrhage (OR 6.95; 5.61 to 8.60) than ischaemic stroke (OR 4.76; 3.99 to 5.68). The PAR associated with untreated hypertension was higher in lower-income regions, PAR 36.3%, 26.3%, 19.8% to 10.4% by increasing GNI of countries. Lifetime non-measurement of blood pressure was associated with stroke (OR 1.80; 1.32 to 2.46). CONCLUSIONS Deficits in knowledge, detection and treatment of hypertension contribute to higher risk of stroke, younger age of onset and larger proportion of intracerebral haemorrhage in lower-income countries.
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Affiliation(s)
- Martin O' Donnell
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland
| | - Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Sumathy Rangarajan
- Dept of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Siu Lim Chin
- Dept of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Purnima Rao-Melacini
- Dept of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - John Ferguson
- National University of Ireland Galway, Galway, Ireland
| | - Denis Xavier
- St John's Research Insitiute, Bangalore, Karnataka, India
| | - Liu Lisheng
- National Center for Cardiovascular Diseases China, Xicheng District, Beijing, China
- Beijing Hypertension League Institute, Beijing, China
| | - Hongye Zhang
- Beijing Hypertension League Institute, Beijing, China
| | - Prem Pais
- St John's National Academy of Health Sciences, Bangalore, Karnataka, India
| | | | | | - Peter Langhorne
- Academic Section of Geriatric Medicine, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, University of Gothenburg and Region Västra Götaland, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Antonio L Dans
- University of the Philippines Manila College of Medicine, Manila, Metro Manila, Philippines
| | | | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | | | - Andrew Smyth
- National University of Ireland Galway, Galway, Ireland
| | - Conor Judge
- Medicine, National University of Ireland Galway, Galway, Galway, Ireland
| | - Hans-Christoph Diener
- Department of Neurology, University Hospital Essen, Essen, Nordrhein-Westfalen, Germany
| | | | | | - Nana Pogosova
- National Medical Research Center of Cardiology, Moscow, Russia, Moskva, Russian Federation
| | - Christian Weimar
- Neurology, Institute for Medical Informatics, Biometry and Epidemiology, University of Duisburg-Essen, Essen, Germany
- BDH-clinic Elzach, Elzach, Germany
| | - Romana Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Rafael Diaz
- Estudios Clínicos Latino America (ECLA), Instituto Cardiovascular de Rosario (ICR), Rosario, Argentina
| | - Khalid Yusoff
- Universiti Teknologi MARA, Selayang, Selangor and UCSI University, Kuala Lumpur, Malaysia
| | | | - Aytekin Oguz
- Department of Internal Medicine, Istanbul Medeniyet University, Istanbul, Istanbul, Turkey
| | - Xingyu Wang
- Laboratory of Human Genetics, Beijing Hypertension League Institute, Beijing, China
| | - Ernesto Penaherrera
- Department of Cardiology, Luis Vernaza General Hospital, Guayaquil, Guayas, Ecuador
| | - Fernando Lanas
- Internal Medicine, Universidad de La Frontera, Temuco, Chile
| | | | - Adensola Ogunniyi
- Neurology Unit, Department of Medicine, University College Hospital Ibadan, Ibadan, Oyo, Nigeria
| | - Helle K Iversen
- Department of Neurology, University of Copenhagen, Rigshospitalet, Denmark
| | - German Malaga
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Zvonko Rumboldt
- Department of Medicine, University of Split, Split, Splitsko-dalmatinska, Croatia
| | | | | | - Magazi Daliwonga
- Department of Medicine, University of Limpopo, Sovenga, Limpopo, South Africa
| | - Yongchai Nilanont
- Division of Neurology, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Salim Yusuf
- Dept of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
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19
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Hamadeh RR, Lee J, Abu-Rmeileh NME, Darawad M, Mostafa A, Kheirallah KA, Yusufali A, Thomas J, Salama M, Nakkash R, Salloum RG. Gender differences in waterpipe tobacco smoking among university students in four Eastern Mediterranean countries. Tob Induc Dis 2020; 18:100. [PMID: 33299390 PMCID: PMC7720794 DOI: 10.18332/tid/129266] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Males have a higher prevalence of waterpipe tobacco smoking (WTS) than females in most Eastern Mediterranean Region (EMR) countries, with a smaller gender gap than that of cigarette smoking. The objective of this study was to determine gender differences among university students with respect to WTS initiation, smoking behavior, tobacco flavors, and expenditure on WTS, in four EMR countries. METHODS A cross-sectional online survey was conducted based on convenient samples of ever waterpipe smokers among university students in four EMR countries (Egypt, Jordan, Occupied Palestinian Territories, and the United Arab Emirates) in 2016. The total samples included 2470 participants. Study participants were invited through flyers, university portals, emails and Facebook, followed by emails with links to the internet survey. RESULTS Females (80.4%) were more likely than males (66.4%, p<0.001) to be in the younger age group (18–22 years) and they were less likely to be current waterpipe smokers (females, 60.0%; males 69.5%, p<0.001). Two-thirds of students across both genders smoked their first waterpipe at the age of 15–19 years, with more females starting with family members. Over one-third of males and 14.9% of the females usually smoked ≥10 heads (p<0.001). About half (46.6%) of females smoked for less than half an hour compared to 30.5% of males (p<0.001). Only 1% of females smoked non-flavored tobacco compared to 11% of males (p<0.001). There was a significant (p=0.05) positive correlation (r=0.808) with respect to tobacco flavor usually smoked between males and females with apple/double apple being the most popular. CONCLUSIONS There were gender differences in WTS in several aspects. The study has implications for educational establishments, tobacco control and women civil society groups, as well as policymakers.
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Affiliation(s)
- Randah R Hamadeh
- College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Juhan Lee
- Department of Health Education and Behavior, College of Health and Human Performance, University of Florida, Gainesville, United States
| | - Niveen M E Abu-Rmeileh
- Institute of Community and Public Health, Birzeit University, Birzeit, Occupied Palestinian Territories
| | | | - Aya Mostafa
- Department of Community, Environmental and Occupational Medicine, Ain Shams University, Cairo, Egypt
| | - Khalid A Kheirallah
- Department of Public Health, Jordan University of Science and Technology, Irbid, Jordan
| | | | - Justin Thomas
- Department of Psychology, Zayed University, Abu Dhabi, United Arab Emirates
| | - Mohamed Salama
- Institute of Global Health and Human Ecology, The American University in Cairo, New Cairo, Egypt
| | - Rima Nakkash
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Ramzi G Salloum
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, United States
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20
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Anjana RM, Mohan V, Rangarajan S, Gerstein HC, Venkatesan U, Sheridan P, Dagenais GR, Lear SA, Teo K, Karsidag K, Alhabib KF, Yusoff K, Ismail N, Mony PK, Lopez-Jaramillo P, Chifamba J, Palileo-Villanueva LM, Iqbal R, Yusufali A, Kruger IM, Rosengren A, Bahonar A, Zatonska K, Yeates K, Gupta R, Li W, Hu L, Rahman MO, Lakshmi PVM, Iype T, Avezum A, Diaz R, Lanas F, Yusuf S. Contrasting Associations Between Diabetes and Cardiovascular Mortality Rates in Low-, Middle-, and High-Income Countries: Cohort Study Data From 143,567 Individuals in 21 Countries in the PURE Study. Diabetes Care 2020; 43:3094-3101. [PMID: 33060076 PMCID: PMC7770267 DOI: 10.2337/dc20-0886] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 09/18/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We aimed to compare cardiovascular (CV) events, all-cause mortality, and CV mortality rates among adults with and without diabetes in countries with differing levels of income. RESEARCH DESIGN AND METHODS The Prospective Urban Rural Epidemiology (PURE) study enrolled 143,567 adults aged 35-70 years from 4 high-income countries (HIC), 12 middle-income countries (MIC), and 5 low-income countries (LIC). The mean follow-up was 9.0 ± 3.0 years. RESULTS Among those with diabetes, CVD rates (LIC 10.3, MIC 9.2, HIC 8.3 per 1,000 person-years, P < 0.001), all-cause mortality (LIC 13.8, MIC 7.2, HIC 4.2 per 1,000 person-years, P < 0.001), and CV mortality (LIC 5.7, MIC 2.2, HIC 1.0 per 1,000 person-years, P < 0.001) were considerably higher in LIC compared with MIC and HIC. Within LIC, mortality was higher in those in the lowest tertile of wealth index (low 14.7%, middle 10.8%, and high 6.5%). In contrast to HIC and MIC, the increased CV mortality in those with diabetes in LIC remained unchanged even after adjustment for behavioral risk factors and treatments (hazard ratio [95% CI] 1.89 [1.58-2.27] to 1.78 [1.36-2.34]). CONCLUSIONS CVD rates, all-cause mortality, and CV mortality were markedly higher among those with diabetes in LIC compared with MIC and HIC with mortality risk remaining unchanged even after adjustment for risk factors and treatments. There is an urgent need to improve access to care to those with diabetes in LIC to reduce the excess mortality rates, particularly among those in the poorer strata of society.
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Affiliation(s)
- Ranjit Mohan Anjana
- Madras Diabetes Research Foundation and Dr. Mohan's Diabetes Specialities Centre, Chennai, India
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation and Dr. Mohan's Diabetes Specialities Centre, Chennai, India
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Hertzel C Gerstein
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Ulagamadesan Venkatesan
- Madras Diabetes Research Foundation and Dr. Mohan's Diabetes Specialities Centre, Chennai, India
| | - Patrick Sheridan
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Gilles R Dagenais
- Institut universitaire de Cardiologie et Pneumologie de Québec-Université Laval, Québec, Québec, Canada
| | - Scott A Lear
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada.,Division of Cardiology, Providence Health Care, Vancouver, British Columbia, Canada
| | - Koon Teo
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Kubilay Karsidag
- Department of Internal Medicine, Division of Endocrinology, Istanbul, Turkey
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Khalid Yusoff
- Department of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia.,Department of Medicine, UCSI University, Cheras, Selangor, Malaysia
| | - Noorhassim Ismail
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - Prem K Mony
- Division of Epidemiology and Population Health, St. John's Medical College and Research Institute, Bangalore, India
| | | | - Jephat Chifamba
- College of Health Sciences, Physiology Department, University of Zimbabwe, Harare, Zimbabwe
| | | | - Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Afzalhussein Yusufali
- Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Iolanthe M Kruger
- Africa Unit for Transdisciplinary Health Research, Department of Medicine, Faculty of Health Sciences, North-West University, Mmabatho, South Africa
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ahmad Bahonar
- Hypertension Research Center, Cardiovascular Research Institute, Department of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Katarzyna Zatonska
- Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Jaipur, India
| | - Wei Li
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Beijing, China
| | - Lihua Hu
- Nanchang County Center for Disease Prevention and Control, Nanchang, Jiangxi Province, China
| | | | - P V M Lakshmi
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Thomas Iype
- Health Action by People and Government Medical College, Thiruvanthapuram, Kerala, India
| | - Alvaro Avezum
- Hospital Alemão Oswaldo Cruz and UNISA, São Paulo, Brazil
| | - Rafael Diaz
- Estudios Clínicos Latino America, Instituto Cardiovascular de Rosario, Rosario, Santa Fe, Argentina
| | | | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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21
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Elsayed M, Al Otaibi L, Quraishy N, Yusufali A. A Novel Hope for Alopecia Totalis Patients: Case Report. Dubai Med J 2020. [DOI: 10.1159/000511690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Alopecia areata (AA) is a common autoimmune disorder causing nonscarring patchy hair loss. Alopecia totalis (AT) is a severe variant of AA. Although there are several available treatment modalities for AA, efficacy of most of them is not satisfactory in case of AT. Recently, several case reports and series and small open-label studies have shown efficacy of oral Janus kinase (JAK) inhibitors as treatment for AT. Tofacitinib is one of the JAK inhibitors, which is an approved drug for treatment of rheumatoid and psoriatic arthritis. In this case report, we have treated a 24-year-old girl who had juvenile chronic arthritis and developed AT. She was treated for 3 years with different modalities without satisfactorily results. We treated her with tofacitinib 5 mg orally twice a day and assessed its efficacy and adverse effects if any. We monitored scalp hair regrowth of the patient using the score of severity of alopecia tool. The patient tolerated the treatment well; hair regrowth started from the 4th week and full regrowth attained by the 9th month of the treatment. No serious adverse effects were noticed. Tofacitinib can potentially be considered as an effective and well-tolerated treatment for AT; however, larger studies are needed to address its long-term efficacy.
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22
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Bhavadharini B, Mohan V, Dehghan M, Rangarajan S, Swaminathan S, Rosengren A, Wielgosz A, Avezum A, Lopez-Jaramillo P, Lanas F, Dans AL, Yeates K, Poirier P, Chifamba J, Alhabib KF, Mohammadifard N, Zatońska K, Khatib R, Vural Keskinler M, Wei L, Wang C, Liu X, Iqbal R, Yusuf R, Wentzel-Viljoen E, Yusufali A, Diaz R, Keat NK, Lakshmi PVM, Ismail N, Gupta R, Palileo-Villanueva LM, Sheridan P, Mente A, Yusuf S. White Rice Intake and Incident Diabetes: A Study of 132,373 Participants in 21 Countries. Diabetes Care 2020; 43:2643-2650. [PMID: 32873587 PMCID: PMC7576435 DOI: 10.2337/dc19-2335] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 07/08/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Previous prospective studies on the association of white rice intake with incident diabetes have shown contradictory results but were conducted in single countries and predominantly in Asia. We report on the association of white rice with risk of diabetes in the multinational Prospective Urban Rural Epidemiology (PURE) study. RESEARCH DESIGN AND METHODS Data on 132,373 individuals aged 35-70 years from 21 countries were analyzed. White rice consumption (cooked) was categorized as <150, ≥150 to <300, ≥300 to <450, and ≥450 g/day, based on one cup of cooked rice = 150 g. The primary outcome was incident diabetes. Hazard ratios (HRs) were calculated using a multivariable Cox frailty model. RESULTS During a mean follow-up period of 9.5 years, 6,129 individuals without baseline diabetes developed incident diabetes. In the overall cohort, higher intake of white rice (≥450 g/day compared with <150 g/day) was associated with increased risk of diabetes (HR 1.20; 95% CI 1.02-1.40; P for trend = 0.003). However, the highest risk was seen in South Asia (HR 1.61; 95% CI 1.13-2.30; P for trend = 0.02), followed by other regions of the world (which included South East Asia, Middle East, South America, North America, Europe, and Africa) (HR 1.41; 95% CI 1.08-1.86; P for trend = 0.01), while in China there was no significant association (HR 1.04; 95% CI 0.77-1.40; P for trend = 0.38). CONCLUSIONS Higher consumption of white rice is associated with an increased risk of incident diabetes with the strongest association being observed in South Asia, while in other regions, a modest, nonsignificant association was seen.
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Affiliation(s)
- Balaji Bhavadharini
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation and Dr. Mohan's Diabetes Specialities Centre, Chennai, India
| | - Mahshid Dehghan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
| | | | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | | | - Patricio Lopez-Jaramillo
- Instituto Masira, Medical School, Universidad de Santander, and Fundación Oftalmológica de Santander-Clínica Carlos Ardila Lulle, Bucaramanga, Colombia
| | | | - Antonio L Dans
- University of the Philippines College of Medicine, Manila, Philippines
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, Canada
| | - Paul Poirier
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada
| | - Jephat Chifamba
- Department of Physiology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Katarzyna Zatońska
- Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Rasha Khatib
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Mirac Vural Keskinler
- Department of Internal Medicine, Goztepe Training and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey
| | - Li Wei
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Chuangshi Wang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoyun Liu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Rita Yusuf
- Independent University, Dhaka, Bangladesh
| | | | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Medical University, Dubai Health Authority, Dubai, United Arab Emirates
| | - Rafael Diaz
- Estudios Clínicos Latinoamerica, Rosario, Santa Fe, Argentina
| | - Ng Kien Keat
- Universiti Teknologi MARA, Sungai Buloh, Malaysia.,University College Sedaya International University, Cheras, Malaysia
| | - P V M Lakshmi
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Noorhassim Ismail
- Department of Community Health, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Jaipur, India
| | - Lia M Palileo-Villanueva
- University of the Philippines College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Patrick Sheridan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
| | - Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
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23
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Yusufali A, Bazargani N, Bin Belaila BA, Suhail AM, Shuri HH, Agrawal A, Muhammed K, Gabroun A, Albawab A, Vazir Z, Ravi Kumar R, Ghannam D, Beaney T, Ster AC, Poulter NR. May Measurement Month 2018: an analysis of blood pressure screening results from United Arab Emirates. Eur Heart J Suppl 2020; 22:H128-H131. [PMID: 32884492 PMCID: PMC7455288 DOI: 10.1093/eurheartj/suaa046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Hypertension is one of the most important modifiable risk factors for cardiovascular disease and death even in high-income countries. According to the PURE Study, globally only half of hypertensives are aware and less than a fifth controlled. May Measurement Month (MMM) is a global campaign to raise awareness and screen for high blood pressure (BP) in lieu of formal screening. United Arab Emirates (UAE) has taken part in MMM since its inception and here data from MMM18 are reported. Trained volunteers from 54 sites screened 31 316 individuals from all the Emirates of UAE using convenience sampling. Blood pressure measurement, the definition of hypertension, and statistical analysis followed the standard MMM protocol. The mean age was 36.8 ± 11.4 years and 18 411(59%) were male. Participants of Arab descent were 11 829 (38%) and 11 569 (37%) were South Asian. Mean body mass index was 26.8 ± 5.29 kg/m2. Of those screened, 7 917 (25%) had never had a BP recorded, while 16 892 (54%) had recorded BP in the previous year. After imputation, 6 243 (20%) had hypertension. Of those participants, only 2 540 (41%) were aware and 2 331 (37%) were on antihypertensive medication, of which 61% were controlled. Of all hypertensives, only 23% were controlled. May Measurement Month in UAE expanded significantly compared to 2017. A quarter had never had BP measured and awareness of hypertension low (41%). This opportunistic screening method found a substantial number of adults with untreated or inadequately treated hypertension.
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Affiliation(s)
- Afzalhussein Yusufali
- Dubai Health Authority, Hatta Hospital, Dubai, UAE.,Dubai Medical University, Dubai, UAE
| | | | | | | | | | - Amrish Agrawal
- Ministry of Health and Prevention, Fujairah Hospital, Fujairah, UAE
| | | | | | - Amer Albawab
- Dubai Health Authority, Hatta Hospital, Dubai, UAE
| | - Zainab Vazir
- Rashid Hospital, Dubai Health Authority, Dubai, UAE
| | | | | | - Thomas Beaney
- Imperial Clinical Trials Unit, Imperial College London, Stadium House, 68 Wood Lane, London, W12 7RH, UK.,Department of Primary Care and Public Health, Imperial College London, London, W6 8RP, St, Dunstan's Road UK
| | - Anca Chis Ster
- Imperial Clinical Trials Unit, Imperial College London, Stadium House, 68 Wood Lane, London, W12 7RH, UK
| | - Neil R Poulter
- Imperial Clinical Trials Unit, Imperial College London, Stadium House, 68 Wood Lane, London, W12 7RH, UK
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24
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Joseph PG, Healey JS, Raina P, Connolly SJ, Ibrahim Q, Gupta R, Avezum A, Dans AL, Lopez-Jaramillo P, Yeates K, Teo K, Douma R, Bahonar A, Chifamba J, Lanas F, Dagenais GR, Lear SA, Kumar R, Kengne AP, Keskinler M, Mohan V, Mony P, Alhabib KF, Huisman H, Iype T, Zatonska K, Ismail R, Kazmi K, Rosengren A, Rahman O, Yusufali A, Wei L, Orlandini A, Islam S, Rangarajan S, Yusuf S. Global variations in the prevalence, treatment, and impact of atrial fibrillation in a multi-national cohort of 153 152 middle-aged individuals. Cardiovasc Res 2020; 117:1523-1531. [PMID: 32777820 DOI: 10.1093/cvr/cvaa241] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/17/2020] [Accepted: 08/04/2020] [Indexed: 11/13/2022] Open
Abstract
AIMS To compare the prevalence of electrocardiogram (ECG)-documented atrial fibrillation (or flutter) (AF) across eight regions of the world, and to examine antithrombotic use and clinical outcomes. METHODS AND RESULTS Baseline ECGs were collected in 153 152 middle-aged participants (ages 35-70 years) to document AF in two community-based studies, spanning 20 countries. Medication use and clinical outcome data (mean follow-up of 7.4 years) were available in one cohort. Cross-sectional analyses were performed to document the prevalence of AF and medication use, and associations between AF and clinical events were examined prospectively. Mean age of participants was 52.1 years, and 57.7% were female. Age and sex-standardized prevalence of AF varied 12-fold between regions; with the highest in North America, Europe, China, and Southeast Asia (270-360 cases per 100 000 persons); and lowest in the Middle East, Africa, and South Asia (30-60 cases per 100 000 persons) (P < 0.001). Compared with low-income countries (LICs), AF prevalence was 7-fold higher in middle-income countries (MICs) and 11-fold higher in high-income countries (HICs) (P < 0.001). Differences in AF prevalence remained significant after adjusting for traditional AF risk factors. In LICs/MICs, 24% of participants with AF and a CHADS2 score ≥1 received antithrombotic therapy, compared with 85% in HICs. AF was associated with an increased risk of stroke [hazard ratio (HR) 2.29; 95% confidence interval (CI) 1.49-3.52] and death (HR 2.97; 95% CI 2.25-3.93); with similar rates in different countries grouped by income level. CONCLUSIONS Large variations in AF prevalence occur in different regions and countries grouped by income level, but this is only partially explained by traditional AF risk factors. Antithrombotic therapy is infrequently used in poorer countries despite the high risk of stroke associated with AF.
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Affiliation(s)
- Philip G Joseph
- Population Health Research Institute, McMaster University, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
| | - Jeffrey S Healey
- Population Health Research Institute, McMaster University, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
| | - Parminder Raina
- Canadian Longitudinal Study of Aging, McMaster University, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
| | - Quazi Ibrahim
- Population Health Research Institute, McMaster University, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, India
| | - Alvaro Avezum
- Hospital Alemão Oswaldo Cruz and UNISA, São Paulo, Brazil
| | | | | | | | - Koon Teo
- Population Health Research Institute, McMaster University, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
| | - Reuben Douma
- Population Health Research Institute, McMaster University, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
| | - Ahmad Bahonar
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Jephat Chifamba
- University of Zimbabwe, Department Of Physiology, Harare, Zimbabwe
| | | | | | | | - Rajesh Kumar
- Post Graduate Institute of Medical Education and Research (PGIMER) School of Public Health, Chandigarh, India
| | - Andre P Kengne
- South African Medical Research Council, Pietermaritzburg, South Africa
| | - Mirac Keskinler
- Istanbul Goztepe Training and Research Hospital, Istanbul, Turkey
| | | | - Prem Mony
- St John's Medical College & Research Institute, Bengaluru, India
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Hugo Huisman
- Hypertension in Africa Research Team (HART), North-West University, Potchefstroom, South Africa.,South African Medical Research Council: Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa
| | | | - Katarzyna Zatonska
- Department of Social Medicine, Medical University of Wroclaw, Wroclaw, Poland
| | | | | | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | | | - Li Wei
- Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | | | - Shofiqul Islam
- Population Health Research Institute, McMaster University, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
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25
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Walli-Attaei M, Joseph P, Rosengren A, Chow CK, Rangarajan S, Lear SA, AlHabib KF, Davletov K, Dans A, Lanas F, Yeates K, Poirier P, Teo KK, Bahonar A, Camilo F, Chifamba J, Diaz R, Didkowska JA, Irazola V, Ismail R, Kaur M, Khatib R, Liu X, Mańczuk M, Miranda JJ, Oguz A, Perez-Mayorga M, Szuba A, Tsolekile LP, Prasad Varma R, Yusufali A, Yusuf R, Wei L, Anand SS, Yusuf S. Variations between women and men in risk factors, treatments, cardiovascular disease incidence, and death in 27 high-income, middle-income, and low-income countries (PURE): a prospective cohort study. Lancet 2020; 396:97-109. [PMID: 32445693 DOI: 10.1016/s0140-6736(20)30543-2] [Citation(s) in RCA: 156] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 02/18/2020] [Accepted: 02/25/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Some studies, mainly from high-income countries (HICs), report that women receive less care (investigations and treatments) for cardiovascular disease than do men and might have a higher risk of death. However, very few studies systematically report risk factors, use of primary or secondary prevention medications, incidence of cardiovascular disease, or death in populations drawn from the community. Given that most cardiovascular disease occurs in low-income and middle-income countries (LMICs), there is a need for comprehensive information comparing treatments and outcomes between women and men in HICs, middle-income countries, and low-income countries from community-based population studies. METHODS In the Prospective Urban Rural Epidemiological study (PURE), individuals aged 35-70 years from urban and rural communities in 27 countries were considered for inclusion. We recorded information on participants' sociodemographic characteristics, risk factors, medication use, cardiac investigations, and interventions. 168 490 participants who enrolled in the first two of the three phases of PURE were followed up prospectively for incident cardiovascular disease and death. FINDINGS From Jan 6, 2005 to May 6, 2019, 202 072 individuals were recruited to the study. The mean age of women included in the study was 50·8 (SD 9·9) years compared with 51·7 (10) years for men. Participants were followed up for a median of 9·5 (IQR 8·5-10·9) years. Women had a lower cardiovascular disease risk factor burden using two different risk scores (INTERHEART and Framingham). Primary prevention strategies, such as adoption of several healthy lifestyle behaviours and use of proven medicines, were more frequent in women than men. Incidence of cardiovascular disease (4·1 [95% CI 4·0-4·2] for women vs 6·4 [6·2-6·6] for men per 1000 person-years; adjusted hazard ratio [aHR] 0·75 [95% CI 0·72-0·79]) and all-cause death (4·5 [95% CI 4·4-4·7] for women vs 7·4 [7·2-7·7] for men per 1000 person-years; aHR 0·62 [95% CI 0·60-0·65]) were also lower in women. By contrast, secondary prevention treatments, cardiac investigations, and coronary revascularisation were less frequent in women than men with coronary artery disease in all groups of countries. Despite this, women had lower risk of recurrent cardiovascular disease events (20·0 [95% CI 18·2-21·7] versus 27·7 [95% CI 25·6-29·8] per 1000 person-years in men, adjusted hazard ratio 0·73 [95% CI 0·64-0·83]) and women had lower 30-day mortality after a new cardiovascular disease event compared with men (22% in women versus 28% in men; p<0·0001). Differences between women and men in treatments and outcomes were more marked in LMICs with little differences in HICs in those with or without previous cardiovascular disease. INTERPRETATION Treatments for cardiovascular disease are more common in women than men in primary prevention, but the reverse is seen in secondary prevention. However, consistently better outcomes are observed in women than in men, both in those with and without previous cardiovascular disease. Improving cardiovascular disease prevention and treatment, especially in LMICs, should be vigorously pursued in both women and men. FUNDING Full funding sources are listed at the end of the paper (see Acknowledgments).
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Affiliation(s)
- Marjan Walli-Attaei
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
| | - Philip Joseph
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Clara K Chow
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Scott A Lear
- Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada
| | - Khalid F AlHabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Kairat Davletov
- The Faculty of Medicine, Health Research Institute, Kazakh National University, Almaty, Kazakhstan
| | - Antonio Dans
- Department of Medicine, University of Philippines, Manila, Philippines
| | - Fernando Lanas
- Department of Medicine, Universidad de La Frontera, Temuco, Chile
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Paul Poirier
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec City, QC, Canada
| | - Koon K Teo
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Ahmad Bahonar
- Hypertension Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Felix Camilo
- Facultad de Ciencias Medicas Eugenio Espejo, Universidad Universidad Tecnológica Equinoccial, Quito, Ecuador
| | - Jephat Chifamba
- Physiology Department, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica, Rosario, Argentina
| | - Joanna A Didkowska
- Department of Epidemiology and Cancer Prevention, The Maria Sklodowska-Curie Memorial Cancer Center and Institute, Warsaw, Poland
| | - Vilma Irazola
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina; South American Center of Excellence for Cardiovascular Health, Buenos Aires, Argentina
| | - Rosnah Ismail
- Department of Community Health, Faculty of Medicine, University Kebangsaan Malaysia, Medical Center, Kuala Lumpur, Malaysia
| | - Manmeet Kaur
- School of Public Health, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Rasha Khatib
- Institute for Community and Public Health, Birzeit University, Birzeit, Palestine
| | - Xiaoyun Liu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Marta Mańczuk
- Department of Epidemiology and Cancer Prevention, The Maria Sklodowska-Curie Memorial Cancer Center and Institute, Warsaw, Poland
| | - J Jaime Miranda
- Department of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Aytekin Oguz
- Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Maritza Perez-Mayorga
- Facultad de Medicina, Universidad Nueva Granada and Clinica de Marly, Bogota, Colombia
| | - Andrzej Szuba
- Wroclaw Medical University, Department of Angiology, Diabetology and Hypertension, Wroclaw, Poland
| | - Lungiswa P Tsolekile
- University of the Western Cape, School of Public Health, Cape Town, South Africa
| | - Ravi Prasad Varma
- Health Action by People, Thiruvananthapuram, India; Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Afzalhussein Yusufali
- Department of Medicine, Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Rita Yusuf
- School of Life Sciences, Independent University, Dhaka, Bangladesh
| | - Li Wei
- National Centre for Cardiovascular Diseases, Cardiovascular Institute & Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Sonia S Anand
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
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26
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Bhavadharini B, Dehghan M, Mente A, Rangarajan S, Sheridan P, Mohan V, Iqbal R, Gupta R, Lear S, Wentzel-Viljoen E, Avezum A, Lopez-Jaramillo P, Mony P, Varma RP, Kumar R, Chifamba J, Alhabib KF, Mohammadifard N, Oguz A, Lanas F, Rozanska D, Bengtsson Bostrom K, Yusoff K, Tsolkile LP, Dans A, Yusufali A, Orlandini A, Poirier P, Khatib R, Hu B, Wei L, Yin L, Deeraili A, Yeates K, Yusuf R, Ismail N, Mozaffarian D, Teo K, Anand SS, Yusuf S. Association of dairy consumption with metabolic syndrome, hypertension and diabetes in 147 812 individuals from 21 countries. BMJ Open Diabetes Res Care 2020; 8:8/1/e000826. [PMID: 32423962 PMCID: PMC7326257 DOI: 10.1136/bmjdrc-2019-000826] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 01/07/2020] [Accepted: 01/22/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE Our aims were to assess the association of dairy intake with prevalence of metabolic syndrome (MetS) (cross-sectionally) and with incident hypertension and incident diabetes (prospectively) in a large multinational cohort study. METHODS The Prospective Urban Rural Epidemiology (PURE) study is a prospective epidemiological study of individuals aged 35 and 70 years from 21 countries on five continents, with a median follow-up of 9.1 years. In the cross-sectional analyses, we assessed the association of dairy intake with prevalent MetS and its components among individuals with information on the five MetS components (n=112 922). For the prospective analyses, we examined the association of dairy with incident hypertension (in 57 547 individuals free of hypertension) and diabetes (in 131 481 individuals free of diabetes). RESULTS In cross-sectional analysis, higher intake of total dairy (at least two servings/day compared with zero intake; OR 0.76, 95% CI 0.71 to 0.80, p-trend<0.0001) was associated with a lower prevalence of MetS after multivariable adjustment. Higher intakes of whole fat dairy consumed alone (OR 0.72, 95% CI 0.66 to 0.78, p-trend<0.0001), or consumed jointly with low fat dairy (OR 0.89, 95% CI 0.80 to 0.98, p-trend=0.0005), were associated with a lower MetS prevalence. Low fat dairy consumed alone was not associated with MetS (OR 1.03, 95% CI 0.77 to 1.38, p-trend=0.13). In prospective analysis, 13 640 people with incident hypertension and 5351 people with incident diabetes were recorded. Higher intake of total dairy (at least two servings/day vs zero serving/day) was associated with a lower incidence of hypertension (HR 0.89, 95% CI 0.82 to 0.97, p-trend=0.02) and diabetes (HR 0.88, 95% CI 0.76 to 1.02, p-trend=0.01). Directionally similar associations were found for whole fat dairy versus each outcome. CONCLUSIONS Higher intake of whole fat (but not low fat) dairy was associated with a lower prevalence of MetS and most of its component factors, and with a lower incidence of hypertension and diabetes. Our findings should be evaluated in large randomized trials of the effects of whole fat dairy on the risks of MetS, hypertension, and diabetes.
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Affiliation(s)
- Balaji Bhavadharini
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Mahshid Dehghan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Patrick Sheridan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Viswanathan Mohan
- Epidemiology, Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India
- Diabetology, Dr Mohan's Diabetes Specialities Centre Gopalapuram, Chennai, Tamil Nadu, India
| | | | - Rajeev Gupta
- Preventive Cardiology, Eternal Heart Care Centre & Research Institute, Jaipur, Rajasthan, India
| | - Scott Lear
- Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
| | | | - Alvaro Avezum
- Research Division, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | | | - Prem Mony
- St John's Medical College & Research Institute, Bengaluru, Karnataka, India
| | - Ravi Prasad Varma
- Achutha Menon Centre for Health Science Studies, Thiruvananthapuram, Kerala, India
| | - Rajesh Kumar
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | | | - Aytekin Oguz
- Internal Medicine, Goztepe Training and Research Hospital, Istanbul, Marmara, Turkey
| | | | | | | | - Khalid Yusoff
- Universiti Teknologi MARA, Shah Alam, Selangor, Malaysia
| | | | - Antonio Dans
- University of the Philippines System, Quezon City, Metro Manila, Philippines
| | | | | | - Paul Poirier
- Cardiology, Institut universitaire de cardiologie et de pneumologie de Quebec, Quebec City, Quebec, Canada
| | - Rasha Khatib
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Bo Hu
- Peking Union Medical College School of Basic Medicine, Beijing, China
| | - Li Wei
- Medical Research & Biometrics Center, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, Xicheng District, Beijing, China
| | - Lu Yin
- Peking Union Medical College School of Basic Medicine, Beijing, China
| | - Ai Deeraili
- Xinjiang Uighur Autonomous Region Center for Disease Control and Prevention, Wulumuqi, Xinjiang, China
| | | | - Rita Yusuf
- Independent University, Dhaka, Bangladesh
| | | | - Dariush Mozaffarian
- Tufts Friedman School of Nutrition Science & Policy, Boston, Massachusetts, USA
| | - Koon Teo
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sonia S Anand
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Yusuf S, Joseph P, Rangarajan S, Islam S, Mente A, Hystad P, Brauer M, Kutty VR, Gupta R, Wielgosz A, AlHabib KF, Dans A, Lopez-Jaramillo P, Avezum A, Lanas F, Oguz A, Kruger IM, Diaz R, Yusoff K, Mony P, Chifamba J, Yeates K, Kelishadi R, Yusufali A, Khatib R, Rahman O, Zatonska K, Iqbal R, Wei L, Bo H, Rosengren A, Kaur M, Mohan V, Lear SA, Teo KK, Leong D, O'Donnell M, McKee M, Dagenais G. Modifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from 21 high-income, middle-income, and low-income countries (PURE): a prospective cohort study. Lancet 2020; 395:795-808. [PMID: 31492503 PMCID: PMC8006904 DOI: 10.1016/s0140-6736(19)32008-2] [Citation(s) in RCA: 799] [Impact Index Per Article: 199.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/12/2019] [Accepted: 08/14/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Global estimates of the effect of common modifiable risk factors on cardiovascular disease and mortality are largely based on data from separate studies, using different methodologies. The Prospective Urban Rural Epidemiology (PURE) study overcomes these limitations by using similar methods to prospectively measure the effect of modifiable risk factors on cardiovascular disease and mortality across 21 countries (spanning five continents) grouped by different economic levels. METHODS In this multinational, prospective cohort study, we examined associations for 14 potentially modifiable risk factors with mortality and cardiovascular disease in 155 722 participants without a prior history of cardiovascular disease from 21 high-income, middle-income, or low-income countries (HICs, MICs, or LICs). The primary outcomes for this paper were composites of cardiovascular disease events (defined as cardiovascular death, myocardial infarction, stroke, and heart failure) and mortality. We describe the prevalence, hazard ratios (HRs), and population-attributable fractions (PAFs) for cardiovascular disease and mortality associated with a cluster of behavioural factors (ie, tobacco use, alcohol, diet, physical activity, and sodium intake), metabolic factors (ie, lipids, blood pressure, diabetes, obesity), socioeconomic and psychosocial factors (ie, education, symptoms of depression), grip strength, and household and ambient pollution. Associations between risk factors and the outcomes were established using multivariable Cox frailty models and using PAFs for the entire cohort, and also by countries grouped by income level. Associations are presented as HRs and PAFs with 95% CIs. FINDINGS Between Jan 6, 2005, and Dec 4, 2016, 155 722 participants were enrolled and followed up for measurement of risk factors. 17 249 (11·1%) participants were from HICs, 102 680 (65·9%) were from MICs, and 35 793 (23·0%) from LICs. Approximately 70% of cardiovascular disease cases and deaths in the overall study population were attributed to modifiable risk factors. Metabolic factors were the predominant risk factors for cardiovascular disease (41·2% of the PAF), with hypertension being the largest (22·3% of the PAF). As a cluster, behavioural risk factors contributed most to deaths (26·3% of the PAF), although the single largest risk factor was a low education level (12·5% of the PAF). Ambient air pollution was associated with 13·9% of the PAF for cardiovascular disease, although different statistical methods were used for this analysis. In MICs and LICs, household air pollution, poor diet, low education, and low grip strength had stronger effects on cardiovascular disease or mortality than in HICs. INTERPRETATION Most cardiovascular disease cases and deaths can be attributed to a small number of common, modifiable risk factors. While some factors have extensive global effects (eg, hypertension and education), others (eg, household air pollution and poor diet) vary by a country's economic level. Health policies should focus on risk factors that have the greatest effects on averting cardiovascular disease and death globally, with additional emphasis on risk factors of greatest importance in specific groups of countries. FUNDING Full funding sources are listed at the end of the paper (see Acknowledgments).
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Affiliation(s)
- Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
| | - Philip Joseph
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Shofiqul Islam
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Andrew Mente
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Perry Hystad
- School of Biological and Population Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA
| | - Michael Brauer
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | | | - Rajeev Gupta
- Eternal Heart Care Centre & Research Institute, Jaipur, India
| | - Andreas Wielgosz
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Khalid F AlHabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Antonio Dans
- Department of Cardiac Sciences, University of Philippines, Manila, Philippines
| | - Patricio Lopez-Jaramillo
- Fundación Oftalmológica de Santander Clínica Carlos Ardila Lulle (FOSCAL), Bucaramanga, Colombia; Escuela de Medicina, Universidad de Santander, Bucaramanga, Colombia
| | - Alvaro Avezum
- Department of Medicine, Universidade de Santo Amaro, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Fernando Lanas
- Department of Medicine, Universidad de La Frontera, Temuco, Chile
| | - Aytekin Oguz
- Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Iolanthe M Kruger
- Africa Unit for Transdisciplinary Health Research (AUTHeR), North-West University, Potchefstroom, South Africa
| | - Rafael Diaz
- Estudios Clínicos Latinoamérica (ECLA), Rosario, Santa Fe, Argentina
| | - Khalid Yusoff
- Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia; UCSI University, Cheras, Kuala Lumpur, Malaysia
| | - Prem Mony
- St John's Research Institute, St John's Medical College, Bangalore, India
| | - Jephat Chifamba
- Physiology Department, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Roya Kelishadi
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Afzalhussein Yusufali
- Department of Medicine, Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Rasha Khatib
- Institute for Community and Public Health, Birzeit University, Birzeit, Palestine; Advocate Health Care, Chicago, IL, USA
| | | | - Katarzyna Zatonska
- Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Li Wei
- National Centre for Cardiovascular Diseases, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Hu Bo
- National Centre for Cardiovascular Diseases, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Manmeet Kaur
- School of Public Health, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation, Chennai, India; Dr Mohan's Diabetes Specialities Centre, Chennai, India
| | - Scott A Lear
- Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada
| | - Koon K Teo
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Darryl Leong
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Martin O'Donnell
- Department of Medicine, National University of Ireland Galway, London, UK
| | - Martin McKee
- Department of Public Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Gilles Dagenais
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec, QC, Canada
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Salloum RG, Nakkash R, Abu-Rmeileh NME, Hamadeh RR, Darawad MW, Kheirallah KA, Al-Farsi Y, Yusufali A, Thomas J, Mostafa A, Salama M, El Kadi L, Alzyoud S, Al-Sheyab N, Thrasher JF. Individual-level determinants of waterpipe smoking demand in four Eastern-Mediterranean countries. Health Promot Int 2019; 34:1157-1166. [PMID: 30412234 DOI: 10.1093/heapro/day084] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The prevalence of waterpipe tobacco smoking in the Eastern Mediterranean Region is at alarmingly high levels, especially among young people. The objective of this research was to evaluate the preferences of young adult waterpipe smokers with respect to potential individual-level determinants of waterpipe smoking using discrete choice experiment methodology. Participants were young adult university students (18-29 years) who were ever waterpipe smokers, recruited from universities across four Eastern Mediterranean countries: Jordan, Oman, Palestine and the United Arab Emirates. The Internet-based discrete choice experiment, with 6 × 3 × 2 block design, evaluated preferences for choices of waterpipe smoking sessions, presented on hypothetical waterpipe café menus. Participants evaluated nine choice sets, each with five fruit-flavored options, a tobacco flavored option (non-flavored), and an opt-out option. Choices also varied based on nicotine content (0.0% vs. 0.05% vs. 0.5%) and price (low vs. high). Participants were randomized to receive menus with either a pictorial + text health-warning message or no message (between-subjects attribute). Multinomial logit regression models evaluated the influence of these attributes on waterpipe smoking choices. Across all four samples (n = 1859), participants preferred fruit-flavored varieties to tobacco flavor, lower nicotine content and lower prices. Exposure to the health warning did not significantly predict likelihood to opt-out. Flavor accounted for 81.4% of waterpipe smoking decisions. Limiting the use of fruit flavors in waterpipe tobacco, in addition to accurate nicotine content labeling and higher pricing may be effective at curbing the demand for waterpipe smoking among young adults.
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Affiliation(s)
- Ramzi G Salloum
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, 2004 Mowry Road, Gainesville, FL, USA
| | - Rima Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, PO Box 11-0236, Riad El-Solh, 1107 2020 Beirut, Lebanon
| | - Niveen M E Abu-Rmeileh
- Institute of Community and Public Health, Birzeit University, PO Box 14, Birzeit, Palestine
| | - Randah R Hamadeh
- College of Medicine and Medical Sciences, Arabian Gulf University, Road 2904, 293 Manama, Bahrain
| | - Muhammad W Darawad
- School of Nursing, The University of Jordan, Queen Rania Street, 11942 Amman, Jordan
| | - Khalid A Kheirallah
- Department of Public Health, Community Medicine, Jordan University of Science and Technology, PO Box 3030, 22110 Irbid, Jordan
| | - Yahya Al-Farsi
- Department of Family Medicine and Public Health, College of Medicine and Health Sciences, Sultan Qaboos University, PO Box 35, 123, Al Khod, Muscat, Oman
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Health Authority and Dubai Medical College, 35th Street, PO Box 2017, Dubai, United Arab Emirates
| | - Justin Thomas
- Department of Psychology, College of Natural and Health Sciences, Zayed University, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Aya Mostafa
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Abbassiya, 11566 Cairo, Egypt
| | - Mohamed Salama
- Medical Experimental Research Center, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Lama El Kadi
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, PO Box 11-0236, Riad El-Solh, 1107 2020 Beirut, Lebanon
| | - Sukaina Alzyoud
- Department of Community and Mental Health Nursing, Faculty of Nursing, Hashemite University, PO Box 330127, 13133 Zarqa, Jordan
| | - Nihaya Al-Sheyab
- Department of Maternal and Child Nursing, Jordan University of Science and Technology, PO Box 3030, 22110 Irbid, Jordan
| | - James F Thrasher
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, 915 Greene Street, 29208 Columbia, SC, USA
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Yusufali A, Bazargani N, Agrawal A, Muhammed K, Obaid H, Gabroun A, Albadwawi M, Albawab A, Musa A, Alraeesi F, Vazir Z, Varghese R, Ravi Kumar R, Kobeissi E, Beaney T, Poulter NR. May Measurement Month 2017: an analysis of blood pressure screening results from the United Arab Emirates-Northern Africa and Middle East. Eur Heart J Suppl 2019; 21:D118-D120. [PMID: 31043897 PMCID: PMC6479438 DOI: 10.1093/eurheartj/suz074] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2019] [Indexed: 11/27/2022]
Abstract
Elevated blood pressure (BP) is a growing burden worldwide, leading to over 10 million deaths each year. May Measurement Month (MMM) is a global initiative aimed at raising awareness of high BP and to act as a temporary solution to the lack of screening programmes worldwide. United Arab Emirates has a young population, but cardiovascular disease (CVD) is the commonest cause of death (40%). Myocardial infarction and stroke occurs at least a decade earlier than in western countries. Previous screening in our young population showed that 85% of the population had at least one CVD risk factor and about 62% of them were unaware of it. An opportunistic cross-sectional survey of volunteers aged ≥18 was carried out in May 2017. Blood pressure measurement, the definition of hypertension and statistical analysis followed the standard MMM protocol. Screening was held in 23 sites such as mosques, sports, and men’s/ladies’ clubs, airports, parks, shopping malls, work places as well as their residences, and in the public areas of hospitals or outpatient clinics. A total of 6193 individuals were screened during MMM17. The mean age was 39.2 ± 13.1 years. After multiple imputation, 1867 (30.2%) had hypertension. Of individuals not receiving anti-hypertensive medication, 813 (15.8%) were hypertensive. Of 1054 individuals receiving anti-hypertensive medication, 427 (40.6%) had uncontrolled BP. MMM17 was a useful screening model as it makes BP measurement easily accessible. Eight hundred and thirteen (16%) possibly new hypertensives were uncovered and 427(40.6%) of those on treatment for hypertension were found to be uncontrolled. These results suggest that opportunistic screening can identify significant numbers with raised BP.
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Affiliation(s)
- Afzalhussein Yusufali
- Hatta Hospital, Dubai Health Authority/Dubai Medical University, Dubai, UAE.,Dubai Medical University, Dubai, UAE
| | | | - Amrish Agrawal
- Fujairah Hospital, Ministry of Health and Prevention, Fujairah, UAE
| | | | - Hanan Obaid
- Primary Health Care, Dubai Health Authority, Dubai, UAE
| | | | - Mouza Albadwawi
- Hatta Hospital, Dubai Health Authority/Dubai Medical University, Dubai, UAE
| | - Amer Albawab
- Hatta Hospital, Dubai Health Authority/Dubai Medical University, Dubai, UAE
| | - Anas Musa
- Rashid Hospital, Dubai Health Authority, Dubai, UAE
| | | | - Zainab Vazir
- Rashid Hospital, Dubai Health Authority, Dubai, UAE
| | - Rekha Varghese
- Hatta Hospital, Dubai Health Authority/Dubai Medical University, Dubai, UAE
| | | | - Elsa Kobeissi
- Imperial Clinical Trials Unit, Imperial College London, Stadium House, 68 Wood Lane, London W12 7RH, UK
| | - Thomas Beaney
- Imperial Clinical Trials Unit, Imperial College London, Stadium House, 68 Wood Lane, London W12 7RH, UK
| | - Neil R Poulter
- Imperial Clinical Trials Unit, Imperial College London, Stadium House, 68 Wood Lane, London W12 7RH, UK
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30
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Chow CK, Ramasundarahettige C, Hu W, AlHabib KF, Avezum A, Cheng X, Chifamba J, Dagenais G, Dans A, Egbujie BA, Gupta R, Iqbal R, Ismail N, Keskinler MV, Khatib R, Kruger L, Kumar R, Lanas F, Lear S, Lopez-Jaramillo P, McKee M, Mohammadifard N, Mohan V, Mony P, Orlandini A, Rosengren A, Vijayakumar K, Wei L, Yeates K, Yusoff K, Yusuf R, Yusufali A, Zatonska K, Zhou Y, Islam S, Corsi D, Rangarajan S, Teo K, Gerstein HC, Yusuf S. Availability and affordability of essential medicines for diabetes across high-income, middle-income, and low-income countries: a prospective epidemiological study. Lancet Diabetes Endocrinol 2018; 6:798-808. [PMID: 30170949 DOI: 10.1016/s2213-8587(18)30233-x] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/22/2018] [Accepted: 07/23/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Data are scarce on the availability and affordability of essential medicines for diabetes. Our aim was to examine the availability and affordability of metformin, sulfonylureas, and insulin across multiple regions of the world and explore the effect of these on medicine use. METHODS In the Prospective Urban Rural Epidemiology (PURE) study, participants aged 35-70 years (n=156 625) were recruited from 110 803 households, in 604 communities and 22 countries; availability (presence of any dose of medication in the pharmacy on the day of audit) and medicine cost data were collected from pharmacies with the Environmental Profile of a Community's Health audit tool. Our primary analysis was to describe the availability and affordability of metformin and insulin and also commonly used and prescribed combinations of two medicines for diabetes management (two oral drugs, metformin plus a sulphonylurea [either glibenclamide (also known as glyburide) or gliclazide] and one oral drug plus insulin [metformin plus insulin]). Medicines were defined as affordable if the cost of medicines was less than 20% of capacity-to-pay (the household income minus food expenditure). Our analyses included data collected in pharmacies and data from representative samples of households. Data on availability were ascertained during the pharmacy audit, as were data on cost of medications. These cost data were used to estimate the cost of a month's supply of essential medicines for diabetes. We estimated affordability of medicines using income data from household surveys. FINDINGS Metformin was available in 113 (100%) of 113 pharmacies from high-income countries, 112 (88·2%) of 127 pharmacies in upper-middle-income countries, 179 (86·1%) of 208 pharmacies in lower-middle-income countries, 44 (64·7%) of 68 pharmacies in low-income countries (excluding India), and 88 (100%) of 88 pharmacies in India. Insulin was available in 106 (93·8%) pharmacies in high-income countries, 51 (40·2%) pharmacies in upper-middle-income countries, 61 (29·3%) pharmacies in lower-middle-income countries, seven (10·3%) pharmacies in lower-income countries, and 67 (76·1%) of 88 pharmacies in India. We estimated 0·7% of households in high-income countries and 26·9% of households in low-income countries could not afford metformin and 2·8% of households in high-income countries and 63·0% of households in low-income countries could not afford insulin. Among the 13 569 (8·6% of PURE participants) that reported a diagnosis of diabetes, 1222 (74·0%) participants reported diabetes medicine use in high-income countries compared with 143 (29·6%) participants in low-income countries. In multilevel models, availability and affordability were significantly associated with use of diabetes medicines. INTERPRETATION Availability and affordability of essential diabetes medicines are poor in low-income and middle-income countries. Awareness of these global differences might importantly drive change in access for patients with diabetes. FUNDING Full funding sources listed at the end of the paper (see Acknowledgments).
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Affiliation(s)
- Clara K Chow
- Faculty of Medicine and Health, University of Sydney, The George Institute for Global Health and Westmead Hospital, Sydney, NSW, Australia; Population Health Research Institute, Hamilton, ON, Canada.
| | | | - Weihong Hu
- Population Health Research Institute, Hamilton, ON, Canada
| | - Khalid F AlHabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Alvaro Avezum
- Research Division, Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
| | - Xiaoru Cheng
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jephat Chifamba
- College of Health Sciences, Physiology Department, University of Zimbabwe, Harare, Zimbabwe
| | - Gilles Dagenais
- Institut Universitaire de Cardiologie et Pneumologie de Québec, Université Laval, QC, Canada
| | - Antonio Dans
- Department of Medicine, University of the Philippines-Manila, Ermita, Manila, Philippines
| | - Bonaventure A Egbujie
- School of PublicHealth, University of the Western Cape, Bellville, Cape Town, Western Cape Province, South Africa
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Jawahar Circle, Jaipur, India
| | - Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Noorhassim Ismail
- Department of Community Health, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Mirac V Keskinler
- Department of Internal Medicine, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Rasha Khatib
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lanthé Kruger
- Faculty of Health Science, North-West University, Potchefstroom Campus, Potchefstroom, South Africa
| | - Rajesh Kumar
- Post Graduate Institute of Medical Education and Research, School of Public Health, Chandigarh, India
| | - Fernando Lanas
- Department of Medicine, Universidad de La Frontera, Francisco Salazar, Temuco, Chile
| | - Scott Lear
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | | | - Martin McKee
- London School of Hygiene & Tropical Medicine, London, UK
| | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Prem Mony
- Division of Epidemiology and Population Health, St John's Medical College and Research Institute, Bangalore India
| | | | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Östra Hospital, Gothenburg, Sweden
| | | | - Li Wei
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Khalid Yusoff
- Department of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia; University College Sedaya International (UCSI) University, Cheras, Selangor, Malaysia
| | - Rita Yusuf
- School of Life Sciences, Independent University, Bangladesh, Bashundhara, Dhaka, Bangladesh
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Health Authority, Dubai Medical University, Dubai, United Arab Emirates
| | - Katarzyna Zatonska
- Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Yihong Zhou
- Wujin DistrictCenter for Disease Control and Prevention, Changzhou, Jiangsu Province, China
| | - Shariful Islam
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Daniel Corsi
- Population Health Research Institute, Hamilton, ON, Canada
| | | | - Koon Teo
- Population Health Research Institute, Hamilton, ON, Canada
| | | | - Salim Yusuf
- Population Health Research Institute, Hamilton, ON, Canada
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Mente A, O'Donnell M, Rangarajan S, McQueen M, Dagenais G, Wielgosz A, Lear S, Ah STL, Wei L, Diaz R, Avezum A, Lopez-Jaramillo P, Lanas F, Mony P, Szuba A, Iqbal R, Yusuf R, Mohammadifard N, Khatib R, Yusoff K, Ismail N, Gulec S, Rosengren A, Yusufali A, Kruger L, Tsolekile LP, Chifamba J, Dans A, Alhabib KF, Yeates K, Teo K, Yusuf S. Urinary sodium excretion, blood pressure, cardiovascular disease, and mortality: a community-level prospective epidemiological cohort study. Lancet 2018; 392:496-506. [PMID: 30129465 DOI: 10.1016/s0140-6736(18)31376-x] [Citation(s) in RCA: 204] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 06/04/2018] [Accepted: 06/12/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND WHO recommends that populations consume less than 2 g/day sodium as a preventive measure against cardiovascular disease, but this target has not been achieved in any country. This recommendation is primarily based on individual-level data from short-term trials of blood pressure (BP) without data relating low sodium intake to reduced cardiovascular events from randomised trials or observational studies. We investigated the associations between community-level mean sodium and potassium intake, cardiovascular disease, and mortality. METHODS The Prospective Urban Rural Epidemiology study is ongoing in 21 countries. Here we report an analysis done in 18 countries with data on clinical outcomes. Eligible participants were adults aged 35-70 years without cardiovascular disease, sampled from the general population. We used morning fasting urine to estimate 24 h sodium and potassium excretion as a surrogate for intake. We assessed community-level associations between sodium and potassium intake and BP in 369 communities (all >50 participants) and cardiovascular disease and mortality in 255 communities (all >100 participants), and used individual-level data to adjust for known confounders. FINDINGS 95 767 participants in 369 communities were assessed for BP and 82 544 in 255 communities for cardiovascular outcomes with follow-up for a median of 8·1 years. 82 (80%) of 103 communities in China had a mean sodium intake greater than 5 g/day, whereas in other countries 224 (84%) of 266 communities had a mean intake of 3-5 g/day. Overall, mean systolic BP increased by 2·86 mm Hg per 1 g increase in mean sodium intake, but positive associations were only seen among the communities in the highest tertile of sodium intake (p<0·0001 for heterogeneity). The association between mean sodium intake and major cardiovascular events showed significant deviations from linearity (p=0·043) due to a significant inverse association in the lowest tertile of sodium intake (lowest tertile <4·43 g/day, mean intake 4·04 g/day, range 3·42-4·43; change -1·00 events per 1000 years, 95% CI -2·00 to -0·01, p=0·0497), no association in the middle tertile (middle tertile 4·43-5·08 g/day, mean intake 4·70 g/day, 4·44-5.05; change 0·24 events per 1000 years, -2·12 to 2·61, p=0·8391), and a positive but non-significant association in the highest tertile (highest tertile >5·08 g/day, mean intake 5·75 g/day, >5·08-7·49; change 0·37 events per 1000 years, -0·03 to 0·78, p=0·0712). A strong association was seen with stroke in China (mean sodium intake 5·58 g/day, 0·42 events per 1000 years, 95% CI 0·16 to 0·67, p=0·0020) compared with in other countries (4·49 g/day, -0·26 events, -0·46 to -0·06, p=0·0124; p<0·0001 for heterogeneity). All major cardiovascular outcomes decreased with increasing potassium intake in all countries. INTERPRETATION Sodium intake was associated with cardiovascular disease and strokes only in communities where mean intake was greater than 5 g/day. A strategy of sodium reduction in these communities and countries but not in others might be appropriate. FUNDING Population Health Research Institute, Canadian Institutes of Health Research, Canadian Institutes of Health Canada Strategy for Patient-Oriented Research, Ontario Ministry of Health and Long-Term Care, Heart and Stroke Foundation of Ontario, and European Research Council.
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Affiliation(s)
- Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, McMaster University, Hamilton, ON, Canada.
| | - Martin O'Donnell
- Department of Medicine, McMaster University, Hamilton, ON, Canada; HRB-Clinical Research Facility, NUI Galway, Ireland
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Matthew McQueen
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada; Department of Laboratory Medicine, McMaster University, Hamilton, ON, Canada
| | - Gilles Dagenais
- Department of Cardiology, Université Laval Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada
| | - Andreas Wielgosz
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Scott Lear
- Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada; Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Vancouver, BC, Canada
| | - Shelly Tse Lap Ah
- Jockey Club School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Li Wei
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica ECLA, Rosario, Santa Fe, Argentina
| | - Alvaro Avezum
- Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
| | | | - Fernando Lanas
- Universidad de La Frontera, Francisco Salazar, Temuco, Chile
| | - Prem Mony
- Division of Epidemiology and Population Health, St John's Medical College and Research Institute, Bangalore, India
| | - Andrzej Szuba
- Department of Internal Medicine, 4th Military Hospital, Wroclaw Medical University, Wroclaw, Poland
| | - Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Rita Yusuf
- Independent University, Bangladesh, Bashundhara, Dhaka, Bangladesh
| | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Rasha Khatib
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Khalid Yusoff
- Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia; UCSI University, Cheras, Selangor, Malaysia
| | - Noorhassim Ismail
- Department of Community Health, University Kebangsaan Malaysia Medical Centre, Selangor, Malaysia
| | - Sadi Gulec
- Ankara University School of Medicine, Department of Cardiology, Ankara, Turkey
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital/Östra Hospital, Gothenburg, Sweden
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Health Authority, Dubai Medical University, Dubai, United Arab Emirates
| | - Lanthe Kruger
- Faculty of Health Science, North-West University, Potchefstroom Campus, Potchefstroom, South Africa
| | | | - Jephat Chifamba
- Physiology Department, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
| | - Antonio Dans
- University of the Philippines, Ermita, Manila, Philippines
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Koon Teo
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
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Abu-Rmeileh NM, Alkhuffash O, Kheirallah K, Mostafa A, Darawad M, Al-Farsi Y, Yusufali A, Thomas J, Salama M, Hamadeh RR, Nakkash R, Salloum RG. Harm perceptions of waterpipe tobacco smoking among university students in five Eastern Mediterranean Region countries: A cross-sectional study. Tob Induc Dis 2018; 16:20. [PMID: 31516420 PMCID: PMC6659482 DOI: 10.18332/tid/89966] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 04/10/2018] [Accepted: 04/16/2018] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Waterpipe tobacco smoking (WTS) continues to be very common in the Eastern Mediterranean Region (EMR), partially because of cultural acceptance but also because of misconceptions of its harm. This paper aimed to describe the beliefs towards waterpipe harm of university students who smoked waterpipe in five EMR countries. METHODS This study was conducted in 2016 across five EMR countries: Egypt, Jordan, Occupied Palestinian Territories, Oman and United Arab Emirates (UAE). Participants were recruited from among university students in each country. Students' characteristics, smoking behavior, flavor preference and knowledge of WTS harm were collected using an internet-based survey. Participants were included if they were ever waterpipe tobacco smokers and between 18 and 29 years of age. Bivariate analyses assessed variations in student-perceived WTS harm across the countries. Linear regression analysis was used to assess WTS perceived harm differences between students in the different countries. RESULTS A total of 2 544 university students participated from the five countries. Among ever smoking students, 66% reported WTS in the past 30 days, with the highest proportions (40%) from Occupied Palestinian Territories (OPT) and (41%) Jordan. Dual smoking of waterpipe and cigarettes was highest among students from Egypt. Most participants from the five countries had high level of perceived harm related to WTS during pregnancy. Less than 50% of the students believed that WTS could lead to the death of the smoker, can be harmful for non-smokers and have an addictive effect. Female students, those older than 22 years, and those who didn't smoke waterpipe in the last 30 days significantly had a higher level of WTS perceived harm. Participating students believed that cigarettes are more addictive and contain more nicotine compared to waterpipe. CONCLUSIONS Misperceptions of waterpipe harm are common among university students in the five EMR countries. Immediate public health action is needed, including enforcement of waterpipe tobacco control regulations along with awareness campaigns.
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Affiliation(s)
- Niveen M.E. Abu-Rmeileh
- Institute of Community and Public Health, Birzeit University, Occupied Palestinian Territories
| | - Ola Alkhuffash
- Statistic Department, Hacettepe University, Ankara, Turkey
| | - Khalid Kheirallah
- Department of Public Health, Medical School, Jordan University of Science and Technology, Irbid, Jordan
| | - Aya Mostafa
- Department of Community Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | | | | | | | | | - Randah R. Hamadeh
- College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Rima Nakkash
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Ramzi G. Salloum
- Department of Health Outcomes and Policy, College of Medicine, University of Florida, Gainesville, Florida, United States
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Salloum R, Abu-Rmeileh N, Al-Farsi Y, Hamadeh R, Kheirallah K, Mostafa A, Yusufali A, Nakkash R. Using discrete choice experiments to characterize demand for waterpipe tobacco smoking among university students in the Eastern Mediterranean region. Tob Induc Dis 2018. [DOI: 10.18332/tid/84026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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34
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Abu-Rmeileh N, Khufash O, Kheirallah K, Mostafa A, Alfarsi Y, Yusufali A, Nakkash R, Salloum R. Knowledge and perception of waterpipe harm among university students in five Eastern Mediterranean countries: a cross sectional study. Tob Induc Dis 2018. [DOI: 10.18332/tid/84718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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35
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Nakkash R, Abu-Rmeileh N, Al-Farsi Y, Hamadeh R, Kheirallah K, Mostafa A, Yusufali A, Salloum R. Evaluation of health warnings for waterpipe tobacco smoking among university students in the Eastern Mediterranean region. Tob Induc Dis 2018. [DOI: 10.18332/tid/84636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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36
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Palafox B, Goryakin Y, Stuckler D, Suhrcke M, Balabanova D, Alhabib KF, Avezum A, Bahonar A, Bai X, Chifamba J, Dans AL, Diaz R, Gupta R, Iqbal R, Ismail N, Kaur M, Keskinler MV, Khatib R, Kruger A, Kruger IM, Lanas F, Lear SA, Li W, Liu J, Lopez-Jaramillo P, Peer N, Poirier P, Rahman O, Pillai RK, Rangarajan S, Rosengren A, Swaminathan S, Szuba A, Teo K, Wang Y, Wielgosz A, Yeates KE, Yusufali A, Yusuf S, McKee M. Does greater individual social capital improve the management of hypertension? Cross-national analysis of 61 229 individuals in 21 countries. BMJ Glob Health 2018; 2:e000443. [PMID: 29333284 PMCID: PMC5759715 DOI: 10.1136/bmjgh-2017-000443] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 10/06/2017] [Accepted: 10/25/2017] [Indexed: 11/18/2022] Open
Abstract
Introduction Social capital, characterised by trust, reciprocity and cooperation, is positively associated with a number of health outcomes. We test the hypothesis that among hypertensive individuals, those with greater social capital are more likely to have their hypertension detected, treated and controlled. Methods Cross-sectional data from 21 countries in the Prospective Urban and Rural Epidemiology study were collected covering 61 229 hypertensive individuals aged 35–70 years, their households and the 656 communities in which they live. Outcomes include whether hypertensive participants have their condition detected, treated and/or controlled. Multivariate statistical models adjusting for community fixed effects were used to assess the associations of three social capital measures: (1) membership of any social organisation, (2) trust in other people and (3) trust in organisations, stratified into high-income and low-income country samples. Results In low-income countries, membership of any social organisation was associated with a 3% greater likelihood of having one’s hypertension detected and controlled, while greater trust in organisations significantly increased the likelihood of detection by 4%. These associations were not observed among participants in high-income countries. Conclusion Although the observed associations are modest, some aspects of social capital are associated with better management of hypertension in low-income countries where health systems are often weak. Given that hypertension affects millions in these countries, even modest gains at all points along the treatment pathway could improve management for many, and translate into the prevention of thousands of cardiovascular events each year.
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Affiliation(s)
- Benjamin Palafox
- The Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK
| | - Yevgeniy Goryakin
- Organization for Economic Cooperation and Development, Paris, France
| | - David Stuckler
- Department of Policy Analysis and Public Management and Dondena Research Centre, University of Bocconi, Milan, Italy
| | - Marc Suhrcke
- Centre for Health Economics, University of York, York, UK
| | - Dina Balabanova
- The Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Alvaro Avezum
- Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | - Ahmad Bahonar
- Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, The Islamic Republic of Iran
| | - Xiulin Bai
- National Center for Cardiovascular Disease, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Jephat Chifamba
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Antonio L Dans
- UP College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Rafael Diaz
- Estudios Clinicos Latino America, Rosario, Argentina
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Jaipur, India
| | - Romaina Iqbal
- Departments of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Noorhassim Ismail
- Department of Community Health, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Manmeet Kaur
- School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mirac V Keskinler
- Department of Internal Medicine, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Rasha Khatib
- Department of Public Health Sciences, Loyola University Medical Center, Maywood, Illinois, USA
| | - Annamarie Kruger
- Africa Unit for Transdisciplinary Health Research, North-West University, Potchefstroom, South Africa
| | - Iolanthe M Kruger
- Africa Unit for Transdisciplinary Health Research, North-West University, Potchefstroom, South Africa
| | | | - Scott A Lear
- Simon Fraser University, Burnaby, British Columbia, Canada
| | - Wei Li
- National Center for Cardiovascular Disease, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Jia Liu
- National Center for Cardiovascular Disease, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | | | - Nasheeta Peer
- South African Medical Research Council, Durban, South Africa
| | - Paul Poirier
- Institut universitaire de cardiologie et de pneumologie de Quebec, Quebec, Canada
| | | | | | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, University of Gothenburg, Goteborg, Sweden
| | | | - Andrzej Szuba
- Division of Angiology, Wroclaw Medical University, Wroclaw, Poland
| | - Koon Teo
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Yang Wang
- National Center for Cardiovascular Disease, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | | | - Karen E Yeates
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Health Authority/Dubai Medical University, Dubai, United Arab Emirates
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Martin McKee
- The Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK
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Miller V, Mente A, Dehghan M, Rangarajan S, Zhang X, Swaminathan S, Dagenais G, Gupta R, Mohan V, Lear S, Bangdiwala SI, Schutte AE, Wentzel-Viljoen E, Avezum A, Altuntas Y, Yusoff K, Ismail N, Peer N, Chifamba J, Diaz R, Rahman O, Mohammadifard N, Lana F, Zatonska K, Wielgosz A, Yusufali A, Iqbal R, Lopez-Jaramillo P, Khatib R, Rosengren A, Kutty VR, Li W, Liu J, Liu X, Yin L, Teo K, Anand S, Yusuf S. Fruit, vegetable, and legume intake, and cardiovascular disease and deaths in 18 countries (PURE): a prospective cohort study. Lancet 2017; 390:2037-2049. [PMID: 28864331 DOI: 10.1016/s0140-6736(17)32253-5] [Citation(s) in RCA: 345] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/25/2017] [Accepted: 08/01/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND The association between intake of fruits, vegetables, and legumes with cardiovascular disease and deaths has been investigated extensively in Europe, the USA, Japan, and China, but little or no data are available from the Middle East, South America, Africa, or south Asia. METHODS We did a prospective cohort study (Prospective Urban Rural Epidemiology [PURE] in 135 335 individuals aged 35 to 70 years without cardiovascular disease from 613 communities in 18 low-income, middle-income, and high-income countries in seven geographical regions: North America and Europe, South America, the Middle East, south Asia, China, southeast Asia, and Africa. We documented their diet using country-specific food frequency questionnaires at baseline. Standardised questionnaires were used to collect information about demographic factors, socioeconomic status (education, income, and employment), lifestyle (smoking, physical activity, and alcohol intake), health history and medication use, and family history of cardiovascular disease. The follow-up period varied based on the date when recruitment began at each site or country. The main clinical outcomes were major cardiovascular disease (defined as death from cardiovascular causes and non-fatal myocardial infarction, stroke, and heart failure), fatal and non-fatal myocardial infarction, fatal and non-fatal strokes, cardiovascular mortality, non-cardiovascular mortality, and total mortality. Cox frailty models with random effects were used to assess associations between fruit, vegetable, and legume consumption with risk of cardiovascular disease events and mortality. FINDINGS Participants were enrolled into the study between Jan 1, 2003, and March 31, 2013. For the current analysis, we included all unrefuted outcome events in the PURE study database through March 31, 2017. Overall, combined mean fruit, vegetable and legume intake was 3·91 (SD 2·77) servings per day. During a median 7·4 years (5·5-9·3) of follow-up, 4784 major cardiovascular disease events, 1649 cardiovascular deaths, and 5796 total deaths were documented. Higher total fruit, vegetable, and legume intake was inversely associated with major cardiovascular disease, myocardial infarction, cardiovascular mortality, non-cardiovascular mortality, and total mortality in the models adjusted for age, sex, and centre (random effect). The estimates were substantially attenuated in the multivariable adjusted models for major cardiovascular disease (hazard ratio [HR] 0·90, 95% CI 0·74-1·10, ptrend=0·1301), myocardial infarction (0·99, 0·74-1·31; ptrend=0·2033), stroke (0·92, 0·67-1·25; ptrend=0·7092), cardiovascular mortality (0·73, 0·53-1·02; ptrend=0·0568), non-cardiovascular mortality (0·84, 0·68-1·04; ptrend =0·0038), and total mortality (0·81, 0·68-0·96; ptrend<0·0001). The HR for total mortality was lowest for three to four servings per day (0·78, 95% CI 0·69-0·88) compared with the reference group, with no further apparent decrease in HR with higher consumption. When examined separately, fruit intake was associated with lower risk of cardiovascular, non-cardiovascular, and total mortality, while legume intake was inversely associated with non-cardiovascular death and total mortality (in fully adjusted models). For vegetables, raw vegetable intake was strongly associated with a lower risk of total mortality, whereas cooked vegetable intake showed a modest benefit against mortality. INTERPRETATION Higher fruit, vegetable, and legume consumption was associated with a lower risk of non-cardiovascular, and total mortality. Benefits appear to be maximum for both non-cardiovascular mortality and total mortality at three to four servings per day (equivalent to 375-500 g/day). FUNDING Full funding sources listed at the end of the paper (see Acknowledgments).
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Affiliation(s)
- Victoria Miller
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
| | - Andrew Mente
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Mahshid Dehghan
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Xiaohe Zhang
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | | | - Gilles Dagenais
- Institut universitaire de cardiologie et pneumologie de Quebec, Université Laval, QC, Canada
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Jaipur, India
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation, Dr Mohan's Diabetes Specialties Centre, Chennai, India
| | - Scott Lear
- Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada
| | | | - Aletta E Schutte
- South African Medical Research Council/North-West University, Potchefstroom, South Africa
| | | | - Alvaro Avezum
- Dante Pazzanese Institute of Cardiology, University Santo Amaro, São Paulo, Brazil
| | - Yuksel Altuntas
- Istanbul Sisli Hamidiye Etfal Health Training and Research Center, Istanbul, Turkey
| | - Khalid Yusoff
- Universiti Teknologi MARA, Selayang, Selangor, Malaysia; UCSI University, Cheras, Kuala Lumpur, Malaysia
| | - Noorhassim Ismail
- Department of Community Health, Faculty of Medicine, University of Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Nasheeta Peer
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Jephat Chifamba
- Physiology Department, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica ECLA, Rosaria, Argentina
| | | | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Katarzyna Zatonska
- Department of Social Medicine, Medical University of Wroclaw, Wroclaw, Poland
| | | | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Health Authority and Dubai Medical College, Dubai, United Arab Emirates
| | | | | | - Rasha Khatib
- Public Health Sciences, Stritch School of Medicine, IL, USA
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital/Őstra, Gőteborg, Sweden
| | | | - Wei Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Jiankang Liu
- Jianshe Road Community Health Center, Chengdu, Sichuan Province, China
| | - Xiaoyun Liu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Lu Yin
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Koon Teo
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Sonia Anand
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
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Joseph P, Yusuf S, Lee SF, Ibrahim Q, Teo K, Rangarajan S, Gupta R, Rosengren A, Lear SA, Avezum A, Lopez-Jaramillo P, Gulec S, Yusufali A, Chifamba J, Lanas F, Kumar R, Mohammadifard N, Mohan V, Mony P, Kruger A, Liu X, Guo B, Zhao W, Yang Y, Pillai R, Diaz R, Krishnapillai A, Iqbal R, Yusuf R, Szuba A, Anand SS. Prognostic validation of a non-laboratory and a laboratory based cardiovascular disease risk score in multiple regions of the world. Heart 2017; 104:581-587. [PMID: 29066611 PMCID: PMC5861396 DOI: 10.1136/heartjnl-2017-311609] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 08/22/2017] [Accepted: 08/24/2017] [Indexed: 01/07/2023] Open
Abstract
Objective To evaluate the performance of the non-laboratory INTERHEART risk score (NL-IHRS) to predict incident cardiovascular disease (CVD) across seven major geographic regions of the world. The secondary objective was to evaluate the performance of the fasting cholesterol-based IHRS (FC-IHRS). Methods Using measures of discrimination and calibration, we tested the performance of the NL-IHRS (n=100 475) and FC-IHRS (n=107 863) for predicting incident CVD in a community-based, prospective study across seven geographic regions: South Asia, China, Southeast Asia, Middle East, Europe/North America, South America and Africa. CVD was defined as the composite of cardiovascular death, myocardial infarction, stroke, heart failure or coronary revascularisation. Results Mean age of the study population was 50.53 (SD 9.79) years and mean follow-up was 4.89 (SD 2.24) years. The NL-IHRS had moderate to good discrimination for incident CVD across geographic regions (concordance statistic (C-statistic) ranging from 0.64 to 0.74), although recalibration was necessary in all regions, which improved its performance in the overall cohort (increase in C-statistic from 0.69 to 0.72, p<0.001). Regional recalibration was also necessary for the FC-IHRS, which also improved its overall discrimination (increase in C-statistic from 0.71 to 0.74, p<0.001). In 85 078 participants with complete data for both scores, discrimination was only modestly better with the FC-IHRS compared with the NL-IHRS (0.74 vs 0.73, p<0.001). Conclusions External validations of the NL-IHRS and FC-IHRS suggest that regionally recalibrated versions of both can be useful for estimating CVD risk across a diverse range of community-based populations. CVD prediction using a non-laboratory score can provide similar accuracy to laboratory-based methods.
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Affiliation(s)
- Philip Joseph
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Shun Fu Lee
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Quazi Ibrahim
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Koon Teo
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Rajasthan University of Health Sciences, and Fortis Escorts Hospital, Jaipur, India
| | - Annika Rosengren
- Sahlgrenska University Hospital/Ã-stra Hospital, Goteborg, Sweden
| | - Scott A Lear
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Alvaro Avezum
- Dante Pazzanese Institute of Cardiology and UNISA, São Paulo, Brazil
| | - Patricio Lopez-Jaramillo
- Fundacion Oftalmologica de Santander (FOSCAL) and Medical School, Universidad de Santander (UDES), Bucaramanga, Colombia
| | - Sadi Gulec
- School of Medicine, Ankara University, Ankara, Turkey
| | | | - Jephat Chifamba
- Department of Physiology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Fernando Lanas
- Department of Internal Medicine, Universidad de La Frontera, Temuco, Chile
| | - Rajesh Kumar
- Department of Community Medicine & School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Prem Mony
- St John's Medical College & Research Institute, Bangalore, India
| | - Annamarie Kruger
- Faculty of Health Science, North-West University, Potchefstroom, South Africa
| | - Xu Liu
- Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, Fu Wai Hospital, Beijing, China
| | - Baoxia Guo
- Shenyang Red Cross Hospital, Shenyang, China
| | - Wenqi Zhao
- Chinese Center for Disease Control and Prevention, Xi'ning, China
| | | | - Rajamohanan Pillai
- Health Action by People, and SMCSI Medical College Karakonam, Trivandrum, India
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica ECLA, Rosario, Argentina
| | | | - Romaina Iqbal
- Departments of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Rita Yusuf
- Independent University, Bangladesh (IUB), Dhaka, Bangladesh
| | | | - Sonia S Anand
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
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Mente A, Dehghan M, Rangarajan S, McQueen M, Dagenais G, Wielgosz A, Lear S, Li W, Chen H, Yi S, Wang Y, Diaz R, Avezum A, Lopez-Jaramillo P, Seron P, Kumar R, Gupta R, Mohan V, Swaminathan S, Kutty R, Zatonska K, Iqbal R, Yusuf R, Mohammadifard N, Khatib R, Nasir NM, Ismail N, Oguz A, Rosengren A, Yusufali A, Wentzel-Viljoen E, Puoane T, Chifamba J, Teo K, Anand SS, Yusuf S. Association of dietary nutrients with blood lipids and blood pressure in 18 countries: a cross-sectional analysis from the PURE study. Lancet Diabetes Endocrinol 2017; 5:774-787. [PMID: 28864143 DOI: 10.1016/s2213-8587(17)30283-8] [Citation(s) in RCA: 169] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 08/08/2017] [Accepted: 08/08/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND The relation between dietary nutrients and cardiovascular disease risk markers in many regions worldwide is unknown. In this study, we investigated the effect of dietary nutrients on blood lipids and blood pressure, two of the most important risk factors for cardiovascular disease, in low-income, middle-income, and high-income countries. METHODS We studied 125 287 participants from 18 countries in North America, South America, Europe, Africa, and Asia in the Prospective Urban Rural Epidemiology (PURE) study. Habitual food intake was measured with validated food frequency questionnaires. We assessed the associations between nutrients (total fats, saturated fatty acids, monounsaturated fatty acids, polyunsaturated fatty acids, carbohydrates, protein, and dietary cholesterol) and cardiovascular disease risk markers using multilevel modelling. The effect of isocaloric replacement of saturated fatty acids with other fats and carbohydrates was determined overall and by levels of intakes by use of nutrient density models. We did simulation modelling in which we assumed that the effects of saturated fatty acids on cardiovascular disease events was solely related to their association through an individual risk marker, and then compared these simulated risk marker-based estimates with directly observed associations of saturated fatty acids with cardiovascular disease events. FINDINGS Participants were enrolled into the study from Jan 1, 2003, to March 31, 2013. Intake of total fat and each type of fat was associated with higher concentrations of total cholesterol and LDL cholesterol, but also with higher HDL cholesterol and apolipoprotein A1 (ApoA1), and lower triglycerides, ratio of total cholesterol to HDL cholesterol, ratio of triglycerides to HDL cholesterol, and ratio of apolipoprotein B (ApoB) to ApoA1 (all ptrend<0·0001). Higher carbohydrate intake was associated with lower total cholesterol, LDL cholesterol, and ApoB, but also with lower HDL cholesterol and ApoA1, and higher triglycerides, ratio of total cholesterol to HDL cholesterol, ratio of triglycerides to HDL cholesterol, and ApoB-to-ApoA1 ratio (all ptrend<0·0001, apart from ApoB [ptrend=0·0014]). Higher intakes of total fat, saturated fatty acids, and carbohydrates were associated with higher blood pressure, whereas higher protein intake was associated with lower blood pressure. Replacement of saturated fatty acids with carbohydrates was associated with the most adverse effects on lipids, whereas replacement of saturated fatty acids with unsaturated fats improved some risk markers (LDL cholesterol and blood pressure), but seemed to worsen others (HDL cholesterol and triglycerides). The observed associations between saturated fatty acids and cardiovascular disease events were approximated by the simulated associations mediated through the effects on the ApoB-to-ApoA1 ratio, but not with other lipid markers including LDL cholesterol. INTERPRETATION Our data are at odds with current recommendations to reduce total fat and saturated fats. Reducing saturated fatty acid intake and replacing it with carbohydrate has an adverse effect on blood lipids. Substituting saturated fatty acids with unsaturated fats might improve some risk markers, but might worsen others. Simulations suggest that ApoB-to-ApoA1 ratio probably provides the best overall indication of the effect of saturated fatty acids on cardiovascular disease risk among the markers tested. Focusing on a single lipid marker such as LDL cholesterol alone does not capture the net clinical effects of nutrients on cardiovascular risk. FUNDING Full funding sources listed at the end of the paper (see Acknowledgments).
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Affiliation(s)
- Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
| | - Mahshid Dehghan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Matthew McQueen
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada; Department of Laboratory Medicine, McMaster University, Hamilton, ON, Canada
| | - Gilles Dagenais
- Université Laval Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, QC, Canada
| | - Andreas Wielgosz
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Scott Lear
- Faculty of Health Sciences, and Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Vancouver, BC, Canada
| | - Wei Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Hui Chen
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Sun Yi
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Wang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica ECLA, Rosario, Santa Fe, Argentina
| | - Alvaro Avezum
- Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
| | | | - Pamela Seron
- Universidad de La Frontera, Temuco, Araucanía, Chile
| | - Rajesh Kumar
- Post Graduate Institute of Medical Education and Research, School of Public Health, Chandigarh, India
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Jawahar Circle, Jaipur, India
| | | | - Sumathi Swaminathan
- St John's Research Institute, St John's National Academy of Health Sciences, Koramangala, Bangalore, India
| | - Raman Kutty
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Achutha Menon Centre for Health Science Studies, Thiruvananthapuram, India
| | - Katarzyna Zatonska
- Department of Social Medicine, Medical University of Wroclaw, Wrocław, Poland
| | - Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Rita Yusuf
- School of Life Sciences, Independent University, Dhaka, Bangladesh
| | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Rasha Khatib
- Institute of Community and Public Health, Birzeit University, Birzeit, occupied Palestinian territory
| | - Nafiza Mat Nasir
- Faculty of Medicine, Health and Wellbeing, Universiti Teknologi MARA, Shah Alam, Malaysia
| | - Noorhassim Ismail
- Department of Community Health, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Aytekin Oguz
- Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Goztepe, Istanbul, Turkey
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital/Östra, Göteborg, Sweden
| | - Afzalhussein Yusufali
- Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | | | - Thandi Puoane
- School of Public Health, Faculty of Community and Health, University of the Western Cape, Cape Town, South Africa
| | - Jephat Chifamba
- Physiology Department, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Koon Teo
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sonia S Anand
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
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Salloum RG, Abu-Rmeileh N, Hamadeh R, Thomas J, Mostafa A, Yusufali A, Kheirallah KA, Macauda MM, Theis RP, El Kadi L, Johnson EJ, Darawad MW, Nakkash R. Policy-Relevant Context of Waterpipe Tobacco Smoking among University Students in Six Countries Across the Eastern Mediterranean Region: A Qualitative Study. Asian Pac J Cancer Prev 2017; 18:2533-2540. [PMID: 28952296 PMCID: PMC5720662 DOI: 10.22034/apjcp.2017.18.9.2533] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Waterpipe tobacco smoking rates in the Eastern Mediterranean region are some of the highest worldwide, especially among young people. This study aimed to improve our knowledge of the policy-relevant context of waterpipe smoking among six countries in the Eastern Mediterranean region. Methods: In-depth interviews were conducted in Bahrain, Egypt, Jordan, Lebanon, Palestine, and the United Arab Emirates. Participants were young adult university students (18-29 years) from both genders who had ever smoked the waterpipe, recruited from universities participating in this study. Directed content analysis was used to analyze the transcripts. Results: A total of 53 in-depth interviews were conducted in Arabic in 2016. Findings were organized around 5 themes: waterpipe product characteristics; patterns of waterpipe smoking; the waterpipe café setting; perceived health consequences; and health warning labels. Waterpipe smoking was commonly perceived as a safe alternative to cigarettes. Waterpipe tobacco was reported to be widely accessible and affordable to young participants. There is a lack of knowledge among waterpipe smokers about the associated health effects. Warning labels are effective at communicating health risks associated with waterpipe smoking. Conclusions: Regulatory frameworks for waterpipe tobacco smoking should be developed and enforced, including waterpipe-specific health warning labels that elucidate the harmful effects of waterpipe smoking.
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Affiliation(s)
- Ramzi G Salloum
- Department of Health Outcomes and Policy, College of Medicine, University of Florida, Gainesville, FL, USA.
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Palafox B, McKee M, Balabanova D, AlHabib KF, Avezum AJ, Bahonar A, Ismail N, Chifamba J, Chow CK, Corsi DJ, Dagenais GR, Diaz R, Gupta R, Iqbal R, Kaur M, Khatib R, Kruger A, Kruger IM, Lanas F, Lopez-Jaramillo P, Minfan F, Mohan V, Mony PK, Oguz A, Palileo-Villanueva LM, Perel P, Poirier P, Rangarajan S, Rensheng L, Rosengren A, Soman B, Stuckler D, Subramanian SV, Teo K, Tsolekile LP, Wielgosz A, Yaguang P, Yeates K, Yongzhen M, Yusoff K, Yusuf R, Yusufali A, Zatońska K, Yusuf S. Wealth and cardiovascular health: a cross-sectional study of wealth-related inequalities in the awareness, treatment and control of hypertension in high-, middle- and low-income countries. Int J Equity Health 2016; 15:199. [PMID: 27931255 PMCID: PMC5146857 DOI: 10.1186/s12939-016-0478-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 11/10/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Effective policies to control hypertension require an understanding of its distribution in the population and the barriers people face along the pathway from detection through to treatment and control. One key factor is household wealth, which may enable or limit a household's ability to access health care services and adequately control such a chronic condition. This study aims to describe the scale and patterns of wealth-related inequalities in the awareness, treatment and control of hypertension in 21 countries using baseline data from the Prospective Urban and Rural Epidemiology study. METHODS A cross-section of 163,397 adults aged 35 to 70 years were recruited from 661 urban and rural communities in selected low-, middle- and high-income countries (complete data for this analysis from 151,619 participants). Using blood pressure measurements, self-reported health and household data, concentration indices adjusted for age, sex and urban-rural location, we estimate the magnitude of wealth-related inequalities in the levels of hypertension awareness, treatment, and control in each of the 21 country samples. RESULTS Overall, the magnitude of wealth-related inequalities in hypertension awareness, treatment, and control was observed to be higher in poorer than in richer countries. In poorer countries, levels of hypertension awareness and treatment tended to be higher among wealthier households; while a similar pro-rich distribution was observed for hypertension control in countries at all levels of economic development. In some countries, hypertension awareness was greater among the poor (Sweden, Argentina, Poland), as was treatment (Sweden, Poland) and control (Sweden). CONCLUSION Inequality in hypertension management outcomes decreased as countries became richer, but the considerable variation in patterns of wealth-related inequality - even among countries at similar levels of economic development - underscores the importance of health systems in improving hypertension management for all. These findings show that some, but not all, countries, including those with limited resources, have been able to achieve more equitable management of hypertension; and strategies must be tailored to national contexts to achieve optimal impact at population level.
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Affiliation(s)
- Benjamin Palafox
- ECOHOST - The Centre for Health and Social Change, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | - Martin McKee
- ECOHOST - The Centre for Health and Social Change, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Dina Balabanova
- ECOHOST - The Centre for Health and Social Change, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Khalid F AlHabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | - Ahmad Bahonar
- Hypertension Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Noorhassim Ismail
- Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Jephat Chifamba
- Physiology Department, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Clara K Chow
- The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | | | | | - Rafael Diaz
- Estudios Clinicos Latinoamerica, Rosario, Santa Fe, Argentina
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Jaipur, Rajasthan, India
| | - Romaina Iqbal
- Departments of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Manmeet Kaur
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rasha Khatib
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Annamarie Kruger
- Africa Unit for Transdisciplinary Health Research and Medical Research Council Research Unit for Hypertension and Cardiovascular Disease, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
| | - Iolanthe Marike Kruger
- Africa Unit for Transdisciplinary Health Research, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
| | | | - Patricio Lopez-Jaramillo
- Research Institute, Fundacion Oftalmologica de Santander; and Medical School, University of Santander, Floridablanca, Bucaramanga, Colombia
| | - Fu Minfan
- Daxing Health Center, Shenyang City, Liaoning Province, China
| | | | - Prem K Mony
- St John's Medical College & Research Institute, Bangalore, India
| | - Aytekin Oguz
- Department of Internal Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | | | - Pablo Perel
- World Heart Federation, Geneva, Switzerland.,The London School of Hygiene & Tropical Medicine, London, UK
| | - Paul Poirier
- Faculté de Pharmacie, Université Laval Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Lei Rensheng
- Center for Disease Control & Prevention, Nanchang City, Jiangxi Province, China
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Sahlgrenska University Hospital/Östra Hospital, Göteborg, Sweden
| | - Biju Soman
- Health Action by People, Thiruvananthapuram, and Achutha Menon Centre for Health Science Studies, Sree Chitra Institute for Medical Sciences & Technology, Trivandrum, Kerala, India
| | - David Stuckler
- Department of Sociology, University of Oxford, Oxford, UK
| | - S V Subramanian
- Department of Social and Behavioral Sciences, Harvard University, Boston, MA, USA
| | - Koon Teo
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Peng Yaguang
- Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, FuWai Hospital, Beijing, China
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, Canada
| | - Mo Yongzhen
- Institute of Geriatrics, Nanjing City, Jiangsu Province, China
| | - Khalid Yusoff
- UCSI University, Kuala Lumpur, Malaysia.,Universiti Teknologi MARA, Selayang, Selangor, Malaysia
| | - Rita Yusuf
- Independent University, Dhaka, Bangladesh
| | | | - Katarzyna Zatońska
- Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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Leong DP, Teo KK, Rangarajan S, Kutty VR, Lanas F, Hui C, Quanyong X, Zhenzhen Q, Jinhua T, Noorhassim I, AlHabib KF, Moss SJ, Rosengren A, Akalin AA, Rahman O, Chifamba J, Orlandini A, Kumar R, Yeates K, Gupta R, Yusufali A, Dans A, Avezum Á, Lopez-Jaramillo P, Poirier P, Heidari H, Zatonska K, Iqbal R, Khatib R, Yusuf S. Reference ranges of handgrip strength from 125,462 healthy adults in 21 countries: a prospective urban rural epidemiologic (PURE) study. J Cachexia Sarcopenia Muscle 2016; 7:535-546. [PMID: 27104109 PMCID: PMC4833755 DOI: 10.1002/jcsm.12112] [Citation(s) in RCA: 148] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 01/16/2016] [Accepted: 02/14/2016] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The measurement of handgrip strength (HGS) has prognostic value with respect to all-cause mortality, cardiovascular mortality and cardiovascular disease, and is an important part of the evaluation of frailty. Published reference ranges for HGS are mostly derived from Caucasian populations in high-income countries. There is a paucity of information on normative HGS values in non-Caucasian populations from low- or middle-income countries. The objective of this study was to develop reference HGS ranges for healthy adults from a broad range of ethnicities and socioeconomically diverse geographic regions. METHODS HGS was measured using a Jamar dynamometer in 125,462 healthy adults aged 35-70 years from 21 countries in the Prospective Urban Rural Epidemiology (PURE) study. RESULTS HGS values differed among individuals from different geographic regions. HGS values were highest among those from Europe/North America, lowest among those from South Asia, South East Asia and Africa, and intermediate among those from China, South America, and the Middle East. Reference ranges stratified by geographic region, age, and sex are presented. These ranges varied from a median (25th-75th percentile) 50 kg (43-56 kg) in men <40 years from Europe/North America to 18 kg (14-20 kg) in women >60 years from South East Asia. Reference ranges by ethnicity and body-mass index are also reported. CONCLUSIONS Individual HGS measurements should be interpreted using region/ethnic-specific reference ranges.
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Affiliation(s)
- Darryl P Leong
- The Population Health Research Institute McMaster University and Hamilton Health Sciences Hamilton ON Canada
| | - Koon K Teo
- The Population Health Research Institute McMaster University and Hamilton Health Sciences Hamilton ON Canada
| | - Sumathy Rangarajan
- The Population Health Research Institute McMaster University and Hamilton Health Sciences Hamilton ON Canada
| | - V Raman Kutty
- Health Action by People, 'Chemmanam', Navarangam Lane Medical College Post Office Trivandrum India
| | | | - Chen Hui
- Medical Research & Biometrics Center National Center for Cardiovascular Diseases, FuWai Hospital Beijing China
| | - Xiang Quanyong
- Jiangsu Provincial Center for Disease Control &12 Prevention Nanjing City China
| | - Qian Zhenzhen
- Jiangxinzhou community health service center Nanjing City China
| | | | - Ismail Noorhassim
- Universiti Kebangsaan Malaysia Medical Center(UKMMC) Kuala Lumpur Malaysia
| | - Khalid F AlHabib
- Department of Cardiac Sciences, King Fahad Cardiac Center College of Medicine, King Saud University Riyadh Saudi Arabia
| | - Sarah J Moss
- North-West University Physical activity, Sport and Recreation Research Focus Area, Faculty of Health Sciences Potchefstroom South Africa
| | | | - Ayse Arzu Akalin
- Department of Family Medicine and Department of Medical Education Yeditepe University Medical Faculty Atasehir, Istanbul Turkey
| | - Omar Rahman
- Independent University Bangladesh Bangladesh
| | - Jephat Chifamba
- University of Zimbabwe College of Health Sciences Department of Physiology Harare
| | | | | | - Karen Yeates
- Department of Medicine Queen's University Kingston ON Canada
| | | | | | - Antonio Dans
- College of Medicine University of the Philippines - Manila Malate Philippines
| | - Álvaro Avezum
- Dante Pazzanese Institute of Cardiology São Paulo Brazil
| | - Patricio Lopez-Jaramillo
- Fundacion Oftalmologica de Santander (FOSCAL) Universidad de Santander (UDES) Bucaramanga Colombia
| | - Paul Poirier
- Institut universitaire de cardiologie et de pneumologie de Québec Québec Canada
| | - Hosein Heidari
- Cardiac Rehabilitation Research Center Isfahan University of Medical Sciences Isfahan Iran
| | | | - Romaina Iqbal
- Departments of Community Health Sciences and Medicine Aga Khan University Pakistan
| | - Rasha Khatib
- Institute of Community and Public Health Birzeit University Ramallah Palestine
| | - Salim Yusuf
- The Population Health Research Institute McMaster University and Hamilton Health Sciences Hamilton ON Canada
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Miller V, Yusuf S, Chow CK, Dehghan M, Corsi DJ, Lock K, Popkin B, Rangarajan S, Khatib R, Lear SA, Mony P, Kaur M, Mohan V, Vijayakumar K, Gupta R, Kruger A, Tsolekile L, Mohammadifard N, Rahman O, Rosengren A, Avezum A, Orlandini A, Ismail N, Lopez-Jaramillo P, Yusufali A, Karsidag K, Iqbal R, Chifamba J, Oakley SM, Ariffin F, Zatonska K, Poirier P, Wei L, Jian B, Hui C, Xu L, Xiulin B, Teo K, Mente A. Availability, affordability, and consumption of fruits and vegetables in 18 countries across income levels: findings from the Prospective Urban Rural Epidemiology (PURE) study. Lancet Glob Health 2016; 4:e695-703. [PMID: 27567348 DOI: 10.1016/s2214-109x(16)30186-3] [Citation(s) in RCA: 225] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 06/13/2016] [Accepted: 07/21/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Several international guidelines recommend the consumption of two servings of fruits and three servings of vegetables per day, but their intake is thought to be low worldwide. We aimed to determine the extent to which such low intake is related to availability and affordability. METHODS We assessed fruit and vegetable consumption using data from country-specific, validated semi-quantitative food frequency questionnaires in the Prospective Urban Rural Epidemiology (PURE) study, which enrolled participants from communities in 18 countries between Jan 1, 2003, and Dec 31, 2013. We documented household income data from participants in these communities; we also recorded the diversity and non-sale prices of fruits and vegetables from grocery stores and market places between Jan 1, 2009, and Dec 31, 2013. We determined the cost of fruits and vegetables relative to income per household member. Linear random effects models, adjusting for the clustering of households within communities, were used to assess mean fruit and vegetable intake by their relative cost. FINDINGS Of 143 305 participants who reported plausible energy intake in the food frequency questionnaire, mean fruit and vegetable intake was 3·76 servings (95% CI 3·66-3·86) per day. Mean daily consumption was 2·14 servings (1·93-2·36) in low-income countries (LICs), 3·17 servings (2·99-3·35) in lower-middle-income countries (LMICs), 4·31 servings (4·09-4·53) in upper-middle-income countries (UMICs), and 5·42 servings (5·13-5·71) in high-income countries (HICs). In 130 402 participants who had household income data available, the cost of two servings of fruits and three servings of vegetables per day per individual accounted for 51·97% (95% CI 46·06-57·88) of household income in LICs, 18·10% (14·53-21·68) in LMICs, 15·87% (11·51-20·23) in UMICs, and 1·85% (-3·90 to 7·59) in HICs (ptrend=0·0001). In all regions, a higher percentage of income to meet the guidelines was required in rural areas than in urban areas (p<0·0001 for each pairwise comparison). Fruit and vegetable consumption among individuals decreased as the relative cost increased (ptrend=0·00040). INTERPRETATION The consumption of fruit and vegetables is low worldwide, particularly in LICs, and this is associated with low affordability. Policies worldwide should enhance the availability and affordability of fruits and vegetables. FUNDING Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma, and national or local organisations in participating countries.
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Affiliation(s)
- Victoria Miller
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Clara K Chow
- Westmead Hospital and the George Institute for Global Health, Sydney University, Sydney, NSW, Australia
| | - Mahshid Dehghan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | | | - Karen Lock
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Barry Popkin
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Rasha Khatib
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA; Institute of Community and Public Health, Birzeit University, Ramallah, Occupied Palestinian Territory
| | - Scott A Lear
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Prem Mony
- St John's Medical College & Research Institute, Bangalore, India
| | - Manmeet Kaur
- School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | - Rajeev Gupta
- Department of Medicine, Fortis Escorts Hospital, Jaipur, India
| | - Annamarie Kruger
- Faculty of Health Science North-West University, Potchefstroom Campus, Potchefstroom, South Africa
| | | | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Omar Rahman
- Independent University, Bangladesh Bashundhara, Dhaka, Bangladesh
| | - Annika Rosengren
- Sahlgrenska Academy and Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Alvaro Avezum
- Research Division, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | | | - Noorhassim Ismail
- Department of Community Health, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur Malaysia
| | - Patricio Lopez-Jaramillo
- Grupo Investigaciones FOSCAL, Fundacion Oftalmologica de Santander and Medical School, Universidad de Santander, Bucaramanga, Colombia
| | | | - Kubilay Karsidag
- Department of Internal Medicine, Istanbul University, Istanbul, Turkey
| | - Romaina Iqbal
- Department of Community Health Sciences and Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Jephat Chifamba
- Physiology Department, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | | | - Farnaza Ariffin
- Faculty of Medicine, UiTM Sungai Buloh Campus, Selangor, Malaysia
| | - Katarzyna Zatonska
- Department of Social Medicine, Medical University in Wroclaw, Wroclaw, Poland
| | - Paul Poirier
- Laval University Heart and Lungs Institute, Quebec City, QC, Canada
| | - Li Wei
- National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Bo Jian
- National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Chen Hui
- National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Liu Xu
- National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Bai Xiulin
- National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Koon Teo
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
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O'Donnell MJ, Chin SL, Rangarajan S, Xavier D, Liu L, Zhang H, Rao-Melacini P, Zhang X, Pais P, Agapay S, Lopez-Jaramillo P, Damasceno A, Langhorne P, McQueen MJ, Rosengren A, Dehghan M, Hankey GJ, Dans AL, Elsayed A, Avezum A, Mondo C, Diener HC, Ryglewicz D, Czlonkowska A, Pogosova N, Weimar C, Iqbal R, Diaz R, Yusoff K, Yusufali A, Oguz A, Wang X, Penaherrera E, Lanas F, Ogah OS, Ogunniyi A, Iversen HK, Malaga G, Rumboldt Z, Oveisgharan S, Al Hussain F, Magazi D, Nilanont Y, Ferguson J, Pare G, Yusuf S. Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. Lancet 2016; 388:761-75. [PMID: 27431356 DOI: 10.1016/s0140-6736(16)30506-2] [Citation(s) in RCA: 1157] [Impact Index Per Article: 144.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Stroke is a leading cause of death and disability, especially in low-income and middle-income countries. We sought to quantify the importance of potentially modifiable risk factors for stroke in different regions of the world, and in key populations and primary pathological subtypes of stroke. METHODS We completed a standardised international case-control study in 32 countries in Asia, America, Europe, Australia, the Middle East, and Africa. Cases were patients with acute first stroke (within 5 days of symptom onset and 72 h of hospital admission). Controls were hospital-based or community-based individuals with no history of stroke, and were matched with cases, recruited in a 1:1 ratio, for age and sex. All participants completed a clinical assessment and were requested to provide blood and urine samples. Odds ratios (OR) and their population attributable risks (PARs) were calculated, with 99% confidence intervals. FINDINGS Between Jan 11, 2007, and Aug 8, 2015, 26 919 participants were recruited from 32 countries (13 447 cases [10 388 with ischaemic stroke and 3059 intracerebral haemorrhage] and 13 472 controls). Previous history of hypertension or blood pressure of 140/90 mm Hg or higher (OR 2·98, 99% CI 2·72-3·28; PAR 47·9%, 99% CI 45·1-50·6), regular physical activity (0·60, 0·52-0·70; 35·8%, 27·7-44·7), apolipoprotein (Apo)B/ApoA1 ratio (1·84, 1·65-2·06 for highest vs lowest tertile; 26·8%, 22·2-31·9 for top two tertiles vs lowest tertile), diet (0·60, 0·53-0·67 for highest vs lowest tertile of modified Alternative Healthy Eating Index [mAHEI]; 23·2%, 18·2-28·9 for lowest two tertiles vs highest tertile of mAHEI), waist-to-hip ratio (1·44, 1·27-1·64 for highest vs lowest tertile; 18·6%, 13·3-25·3 for top two tertiles vs lowest), psychosocial factors (2·20, 1·78-2·72; 17·4%, 13·1-22·6), current smoking (1·67, 1·49-1·87; 12·4%, 10·2-14·9), cardiac causes (3·17, 2·68-3·75; 9·1%, 8·0-10·2), alcohol consumption (2·09, 1·64-2·67 for high or heavy episodic intake vs never or former drinker; 5·8%, 3·4-9·7 for current alcohol drinker vs never or former drinker), and diabetes mellitus (1·16, 1·05-1·30; 3·9%, 1·9-7·6) were associated with all stroke. Collectively, these risk factors accounted for 90·7% of the PAR for all stroke worldwide (91·5% for ischaemic stroke, 87·1% for intracerebral haemorrhage), and were consistent across regions (ranging from 82·7% in Africa to 97·4% in southeast Asia), sex (90·6% in men and in women), and age groups (92·2% in patients aged ≤55 years, 90·0% in patients aged >55 years). We observed regional variations in the importance of individual risk factors, which were related to variations in the magnitude of ORs (rather than direction, which we observed for diet) and differences in prevalence of risk factors among regions. Hypertension was more associated with intracerebral haemorrhage than with ischaemic stroke, whereas current smoking, diabetes, apolipoproteins, and cardiac causes were more associated with ischaemic stroke (p<0·0001). INTERPRETATION Ten potentially modifiable risk factors are collectively associated with about 90% of the PAR of stroke in each major region of the world, among ethnic groups, in men and women, and in all ages. However, we found important regional variations in the relative importance of most individual risk factors for stroke, which could contribute to worldwide variations in frequency and case-mix of stroke. Our findings support developing both global and region-specific programmes to prevent stroke. FUNDING Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Health Research Board Ireland, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland (Sweden), AstraZeneca, Boehringer Ingelheim (Canada), Pfizer (Canada), MSD, Chest, Heart and Stroke Scotland, and The Stroke Association, with support from The UK Stroke Research Network.
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Affiliation(s)
- Martin J O'Donnell
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Health Research Board Clinical Research Facility, Department of Medicine, NUI Galway, Galway, Ireland.
| | - Siu Lim Chin
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Denis Xavier
- St John's Medical College and Research Institute, Bangalore, India
| | - Lisheng Liu
- National Center of Cardiovascular Disease, Beijing, China
| | - Hongye Zhang
- Beijing Hypertension League Institute, Beijing, China
| | - Purnima Rao-Melacini
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Xiaohe Zhang
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Prem Pais
- St John's Medical College and Research Institute, Bangalore, India
| | - Steven Agapay
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Patricio Lopez-Jaramillo
- Instituto de Investigaciones FOSCAL, Escuela de Medicina, Universidad de Santander, Bucaramanga, Colombia
| | | | - Peter Langhorne
- Academic Section of Geriatric Medicine, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK
| | - Matthew J McQueen
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Annika Rosengren
- Sahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mahshid Dehghan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Graeme J Hankey
- School of Medicine and Pharmacology, The University of Western Australia, Perth, WA, Australia
| | - Antonio L Dans
- College of Medicine, University of Philippines, Manila, Philippines
| | | | - Alvaro Avezum
- Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Charles Mondo
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda
| | | | | | | | - Nana Pogosova
- National Research Center for Preventive Medicine of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | | | - Romaina Iqbal
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica, Rosario, Argentina
| | - Khalid Yusoff
- Universiti Teknologi MARA, Selayang, Selangor, Malaysia; UCSI University, Cheras, Kuala Lumpur, Malaysia
| | | | - Aytekin Oguz
- Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Xingyu Wang
- Beijing Hypertension League Institute, Beijing, China
| | | | - Fernando Lanas
- Faculty of Medicine, Universidad de La Frontera, Temuco, Chile
| | - Okechukwu S Ogah
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Adesola Ogunniyi
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Helle K Iversen
- Stroke Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Denmark
| | | | | | - Shahram Oveisgharan
- Rush Alzheimer Disease Research Center, Rush University Medical Center, Chicago, IL, USA
| | | | - Daliwonga Magazi
- Department of Medicine, University of Limpopo, Pretoria, South Africa
| | - Yongchai Nilanont
- Neurology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - John Ferguson
- Health Research Board Clinical Research Facility, Department of Medicine, NUI Galway, Galway, Ireland
| | - Guillaume Pare
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
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45
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Mente A, O'Donnell M, Rangarajan S, Dagenais G, Lear S, McQueen M, Diaz R, Avezum A, Lopez-Jaramillo P, Lanas F, Li W, Lu Y, Yi S, Rensheng L, Iqbal R, Mony P, Yusuf R, Yusoff K, Szuba A, Oguz A, Rosengren A, Bahonar A, Yusufali A, Schutte AE, Chifamba J, Mann JFE, Anand SS, Teo K, Yusuf S. Associations of urinary sodium excretion with cardiovascular events in individuals with and without hypertension: a pooled analysis of data from four studies. Lancet 2016; 388:465-75. [PMID: 27216139 DOI: 10.1016/s0140-6736(16)30467-6] [Citation(s) in RCA: 319] [Impact Index Per Article: 39.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Several studies reported a U-shaped association between urinary sodium excretion and cardiovascular disease events and mortality. Whether these associations vary between those individuals with and without hypertension is uncertain. We aimed to explore whether the association between sodium intake and cardiovascular disease events and all-cause mortality is modified by hypertension status. METHODS In this pooled analysis, we studied 133,118 individuals (63,559 with hypertension and 69,559 without hypertension), median age of 55 years (IQR 45-63), from 49 countries in four large prospective studies and estimated 24-h urinary sodium excretion (as group-level measure of intake). We related this to the composite outcome of death and major cardiovascular disease events over a median of 4.2 years (IQR 3.0-5.0) and blood pressure. FINDINGS Increased sodium intake was associated with greater increases in systolic blood pressure in individuals with hypertension (2.08 mm Hg change per g sodium increase) compared with individuals without hypertension (1.22 mm Hg change per g; pinteraction<0.0001). In those individuals with hypertension (6835 events), sodium excretion of 7 g/day or more (7060 [11%] of population with hypertension: hazard ratio [HR] 1.23 [95% CI 1.11-1.37]; p<0.0001) and less than 3 g/day (7006 [11%] of population with hypertension: 1.34 [1.23-1.47]; p<0.0001) were both associated with increased risk compared with sodium excretion of 4-5 g/day (reference 25% of the population with hypertension). In those individuals without hypertension (3021 events), compared with 4-5 g/day (18,508 [27%] of the population without hypertension), higher sodium excretion was not associated with risk of the primary composite outcome (≥ 7 g/day in 6271 [9%] of the population without hypertension; HR 0.90 [95% CI 0.76-1.08]; p=0.2547), whereas an excretion of less than 3 g/day was associated with a significantly increased risk (7547 [11%] of the population without hypertension; HR 1.26 [95% CI 1.10-1.45]; p=0.0009). INTERPRETATION Compared with moderate sodium intake, high sodium intake is associated with an increased risk of cardiovascular events and death in hypertensive populations (no association in normotensive population), while the association of low sodium intake with increased risk of cardiovascular events and death is observed in those with or without hypertension. These data suggest that lowering sodium intake is best targeted at populations with hypertension who consume high sodium diets. FUNDING Full funding sources listed at end of paper (see Acknowledgments).
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Affiliation(s)
- Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada; Department of Clinical Epidemiology and Biostatistics, Hamilton, ON, Canada.
| | - Martin O'Donnell
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medicine, Hamilton, ON, Canada; HRB-Clinical Research Facility, NUI Galway, Ireland
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Gilles Dagenais
- Laval University Heart and Lungs Institute, Quebec City, QC, Canada
| | - Scott Lear
- Faculty of Health Sciences, Simon Fraser University, BC, Canada; Division of Cardiology, Providence Health Care, BC, Canada
| | - Matthew McQueen
- Department of Laboratory Medicine, McMaster University, Hamilton, ON, Canada
| | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Rosario, Argentina
| | - Alvaro Avezum
- Dante Pazzanese Institute of Cardiology, Sao Paulo, SP, Brazil
| | - Patricio Lopez-Jaramillo
- Fundacion Oftalmologica de Santander-FOSCAL, Medical School, Universidad de Santander Floridablanca-Santander, Colombia
| | | | - Wei Li
- National Centre for Cardiovascular Diseases, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yin Lu
- Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, FuWai Hospital, Beijing, China
| | - Sun Yi
- Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, FuWai Hospital, Beijing, China
| | - Lei Rensheng
- Center for Disease Control & Prevention Nanchang County, Nanchang City, Jiangxi Province, China
| | - Romaina Iqbal
- Departments of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Prem Mony
- Community Health & Epidemiology, St John's Research Institute, Bangalore, India
| | - Rita Yusuf
- The School of Life Sciences and The Centre for Health, Population, and Development, Independent University, Bangladesh
| | - Khalid Yusoff
- Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
| | - Andrzej Szuba
- Division of Angiology, Wroclaw Medical University, Wrocław, Poland; Department of Internal Medicine, 4th Military Hospital in Wroclaw, Poland
| | - Aytekin Oguz
- Istanbul Medeniyet University, Faculty of Medicine, Department of Internal Medicine, Istanbul, Turkey
| | - Annika Rosengren
- Sahlgrenska Academy University of Gothenburg, Gothenburg, Sweden
| | - Ahmad Bahonar
- Hypertension Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Aletta Elisabeth Schutte
- MRC Unit for Hypertension and CVD/Hypertension in Africa Research Team, North-West University, Potchefstroom, North West Province, South Africa
| | - Jephat Chifamba
- University of Zimbabwe, College of Health Sciences, Physiology Department, Harare, Zimbabwe
| | - Johannes F E Mann
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada; Department of Nephrology, University of Erlangen-Nurnberg and Munich General Hospitals, Munich, Germany
| | - Sonia S Anand
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada; Department of Clinical Epidemiology and Biostatistics, Hamilton, ON, Canada; Department of Medicine, Hamilton, ON, Canada
| | - Koon Teo
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada
| | - S Yusuf
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada; Department of Clinical Epidemiology and Biostatistics, Hamilton, ON, Canada; Department of Medicine, Hamilton, ON, Canada
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46
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Dagenais GR, Gerstein HC, Zhang X, McQueen M, Lear S, Lopez-Jaramillo P, Mohan V, Mony P, Gupta R, Kutty VR, Kumar R, Rahman O, Yusoff K, Zatonska K, Oguz A, Rosengren A, Kelishadi R, Yusufali A, Diaz R, Avezum A, Lanas F, Kruger A, Peer N, Chifamba J, Iqbal R, Ismail N, Xiulin B, Jiankang L, Wenqing D, Gejie Y, Rangarajan S, Teo K, Yusuf S. Variations in Diabetes Prevalence in Low-, Middle-, and High-Income Countries: Results From the Prospective Urban and Rural Epidemiological Study. Diabetes Care 2016; 39:780-7. [PMID: 26965719 DOI: 10.2337/dc15-2338] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 02/11/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The goal of this study was to assess whether diabetes prevalence varies by countries at different economic levels and whether this can be explained by known risk factors. RESEARCH DESIGN AND METHODS The prevalence of diabetes, defined as self-reported or fasting glycemia ≥7 mmol/L, was documented in 119,666 adults from three high-income (HIC), seven upper-middle-income (UMIC), four lower-middle-income (LMIC), and four low-income (LIC) countries. Relationships between diabetes and its risk factors within these country groupings were assessed using multivariable analyses. RESULTS Age- and sex-adjusted diabetes prevalences were highest in the poorer countries and lowest in the wealthiest countries (LIC 12.3%, UMIC 11.1%, LMIC 8.7%, and HIC 6.6%; P < 0.0001). In the overall population, diabetes risk was higher with a 5-year increase in age (odds ratio 1.29 [95% CI 1.28-1.31]), male sex (1.19 [1.13-1.25]), urban residency (1.24 [1.11-1.38]), low versus high education level (1.10 [1.02-1.19]), low versus high physical activity (1.28 [1.20-1.38]), family history of diabetes (3.15 [3.00-3.31]), higher waist-to-hip ratio (highest vs. lowest quartile; 3.63 [3.33-3.96]), and BMI (≥35 vs. <25 kg/m(2); 2.76 [2.52-3.03]). The relationship between diabetes prevalence and both BMI and family history of diabetes differed in higher- versus lower-income country groups (P for interaction < 0.0001). After adjustment for all risk factors and ethnicity, diabetes prevalences continued to show a gradient (LIC 14.0%, LMIC 10.1%, UMIC 10.9%, and HIC 5.6%). CONCLUSIONS Conventional risk factors do not fully account for the higher prevalence of diabetes in LIC countries. These findings suggest that other factors are responsible for the higher prevalence of diabetes in LIC countries.
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Affiliation(s)
- Gilles R Dagenais
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec, Canada
| | - Hertzel C Gerstein
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Xiaohe Zhang
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Matthew McQueen
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Scott Lear
- Faculty of Health Sciences, Simon Fraser University, and Healthy Heart Program, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | | | | | - Prem Mony
- Division of Epidemiology, Biostatistics and Population Health, St. John's Research Institute, Bangalore, India
| | - Rajeev Gupta
- Fortis Escorts Hospital, Malviya Nagar, Jaipur, India
| | - V Raman Kutty
- Health Action by People, Thiruvananthapuram, Kerala, India
| | - Rajesh Kumar
- PGIMER School of Public Health, Chandigarh, India
| | - Omar Rahman
- Independent University, Bangladesh, Bashundhara, Dhaka, Bangladesh
| | - Khalid Yusoff
- Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia UCSI University, Cheras, Selangor, Malaysia
| | - Katarzyna Zatonska
- Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Aytekin Oguz
- Faculty of Medicine, Department of Internal Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital/Östra, Göteborg, Sweden
| | - Roya Kelishadi
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Rosario, Argentina
| | - Alvaro Avezum
- Dante Pazzanese Institute of Cardiology, São Paulo, São Paulo, Brazil
| | | | - Annamarie Kruger
- Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
| | - Nasheeta Peer
- Non-communicable Diseases Research Unit, South African Medical Research Council, Durban, KwaZulu-Natal, South Africa Department of Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Jephat Chifamba
- Physiology Department, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Romaina Iqbal
- Departments of Community Health Sciences and Medicine, The Aga Khan University, Karachi, Pakistan
| | - Noorhassim Ismail
- Department of Community Health, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Bai Xiulin
- Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, FuWai Hospital, Beijing, China
| | - Liu Jiankang
- Jianshe Road Community Health Center, Chengdu City, Sichuan Province, China
| | - Deng Wenqing
- Health Center, Dayicaichang Town, Sichuan Province, China
| | - Yue Gejie
- Qiluhuayuan Hospital, Jinan City, Shandong Province, China
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Koon Teo
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
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47
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Yusufali A, Bazargani N, Muhammed K, Gabroun A, AlMazrooei A, Agrawal A, Al-Mulla A, Hajat C, Baslaib F, Philip J, Gupta P, Bakir S, Krishnan S, Almahmeed W, Alsheikh-Ali A. Opportunistic Screening for CVD Risk Factors: The Dubai Shopping for Cardiovascular Risk Study (DISCOVERY). Glob Heart 2015; 10:265-72. [PMID: 26271552 DOI: 10.1016/j.gheart.2015.04.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 03/18/2015] [Accepted: 04/23/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Comprehensive cardiovascular disease risk factor (CVDRF) screening programs are limited in the developing world. Simplifying screening can increase its utility. OBJECTIVES The present study aims to estimate the burden of CVDRF in volunteers and the yield of newly discovered CVDRF comparing different sites and nationalities using this screening method. METHODS Voluntary point-of-care CVDRF screening was conducted in 4 shopping malls, 9 health care facilities, and 3 labor camps in 5 cities in the United Arab Emirates. Follow-up for newly diagnosed diabetes mellitus, hypertension, and dyslipidemia was made 1 month after screening to inquire about physician consultation, confirmation of diagnosis, and lifestyle changes. RESULTS A total of 4,128 subjects were screened (43% at malls, 36% at health care facilities, and 22% at labor camps). Subjects were relatively young (38 ± 11 years), predominantly male (75%), and of diverse nationalities (United Arab Emirates: 7%, other Arabs: 10%, South Asians: 74%, other Asians: 5%, and other nationalities: 5%). CVDRF were frequent (diabetes mellitus: 32%, hypertension: 31%, dyslipidemia: 69%, current smokers: 21%, obesity: 20%, and central obesity: 24%). Most subjects (85%) had ≥1 CVDRF, and many (17%) had ≥3 CVDRF. A new diagnosis of diabetes mellitus, hypertension, or dyslipidemia was uncovered in 61.5%, with the highest yield (74.0%) in labor camps. At follow-up of those with new CVDRF, positive lifestyle changes were reported in 60%, but only 33% had consulted a doctor; of these, diagnosis was confirmed in 63% for diabetes mellitus, 93% for hypertension, and 87% for dyslipidemia. CONCLUSIONS In this relatively young and ethnically diverse cohort, CVDRF burden and yield of screening was high. Screening in these settings is pertinent and can be simplified.
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Affiliation(s)
- Afzalhussein Yusufali
- Dubai Heart Centre, Dubai Hospital, Dubai Health Authority, Dubai, United Arab Emirates.
| | - Nooshin Bazargani
- Dubai Heart Centre, Dubai Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Khalifa Muhammed
- Rashid Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Ahmed Gabroun
- Canadian Specialist Hospital, Dubai, United Arab Emirates
| | | | | | - Arif Al-Mulla
- Dubai Heart Centre, Dubai Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Cother Hajat
- United Arab Emirates University, Al Ain, United Arab Emirates
| | - Fahad Baslaib
- Rashid Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Jessy Philip
- Dubai Heart Centre, Dubai Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Pradeep Gupta
- Saif and IBHO Hospital & RAKMSU, Ras al-Khaimah, United Arab Emirates
| | - Sherif Bakir
- Rashid Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Suresh Krishnan
- Dubai Heart Centre, Dubai Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Wael Almahmeed
- Institute of Cardiac Sciences, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Alawi Alsheikh-Ali
- Institute of Cardiac Sciences, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
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48
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Yusufali A, Bakir S, Omar K, Gupta P, Agrawal A, Gabroun A, Bazargani N, Hajat C, AlMazrooei A, Almulla A, Baslaib F, Almahmeed W, Philip J, Krishnan S, Alsheikh-Ali AA. APSC2015-1254 Opportunistic Screening for Cardiovascular Disease Risk Factors: The Dubai Shopping For Cardiovascular Risk Study (Discovery). Glob Heart 2015. [DOI: 10.1016/j.gheart.2015.03.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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49
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Rosengren A, Teo K, Rangarajan S, Kabali C, Khumalo I, Kutty VR, Gupta R, Yusuf R, Iqbal R, Ismail N, Altuntas Y, Kelishadi R, Diaz R, Avezum A, Chifamba J, Zatonska K, Wei L, Liao X, Lopez-Jaramillo P, Yusufali A, Seron P, Lear SA, Yusuf S. Psychosocial factors and obesity in 17 high-, middle- and low-income countries: the Prospective Urban Rural Epidemiologic study. Int J Obes (Lond) 2015; 39:1217-23. [PMID: 25869608 PMCID: PMC4766924 DOI: 10.1038/ijo.2015.48] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 10/21/2014] [Accepted: 11/23/2014] [Indexed: 02/05/2023]
Abstract
Background/Objectives: Psychosocial stress has been proposed to contribute to obesity, particularly abdominal, or central obesity, through chronic activation of the neuroendocrine systems. However, these putative relationships are complex and dependent on country and cultural context. We investigated the association between psychosocial factors and general and abdominal obesity in the Prospective Urban Rural Epidemiologic study. Subjects/Methods: This observational, cross-sectional study enrolled 151 966 individuals aged 35–70 years from 628 urban and rural communities in 17 high-, middle- and low-income countries. Data were collected for 125 290 individuals regarding education, anthropometrics, hypertension/diabetes, tobacco/alcohol use, diet and psychosocial factors (self-perceived stress and depression). Results: After standardization for age, sex, country income and urban/rural location, the proportion with obesity (body mass index ⩾30 kg m−2) increased from 15.7% in 40 831 individuals with no stress to 20.5% in 7720 individuals with permanent stress, with corresponding proportions for ethnicity- and sex-specific central obesity of 48.6% and 53.5%, respectively (P<0.0001 for both). Associations between stress and hypertension/diabetes tended to be inverse. Estimating the total effect of permanent stress with age, sex, physical activity, education and region as confounders, no relationship between stress and obesity persisted (adjusted prevalence ratio (PR) for obesity 1.04 (95% confidence interval: 0.99–1.10)). There was no relationship between ethnicity- and sex-specific central obesity (adjusted PR 1.00 (0.97–1.02)). Stratification by region yielded inconsistent associations. Depression was weakly but independently linked to obesity (PR 1.08 (1.04–1.12)), and very marginally to abdominal obesity (PR 1.01 (1.00–1.03)). Conclusions: Although individuals with permanent stress tended to be slightly more obese, there was no overall independent effect and no evidence that abdominal obesity or its consequences (hypertension, diabetes) increased with higher levels of stress or depression. This study does not support a causal link between psychosocial factors and abdominal obesity.
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Affiliation(s)
- A Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - K Teo
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - S Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - C Kabali
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - I Khumalo
- North-West University, Optentia Research Programme, Faculty of Humanities, Vanderbilpark, South Africa
| | - V R Kutty
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - R Gupta
- Fortis Escorts Hospital, JLN Marg, Jaipur, Rajasthan, India
| | - R Yusuf
- Independent University Bangladesh, Dhaka, Bangladesh
| | - R Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - N Ismail
- Department of Community Health, Universiti Kebangsaan, Kuala Lumpur, Malaysia
| | - Y Altuntas
- SB Pediatric Endocrinology and Metabolism, Training and Research Hospital, Istanbul, Turkey
| | - R Kelishadi
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - R Diaz
- Estudios Clinicos Latinoamerica ECLA, Rosario, Santa Fe, Argentina
| | - A Avezum
- Dante Pazzanese Institute of cardiology, Sao Paulo, Brazil
| | - J Chifamba
- Physiology Department, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
| | - K Zatonska
- Department of Social Medicine, Medical University of Wrocław, Wrocław, Poland
| | - L Wei
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - X Liao
- Sichuan University West China Hospital, Chengdu, Sichuan Province, China
| | - P Lopez-Jaramillo
- Fundacion Oftalmologica de Santander (FOSCAL) and Medical School, Universidad de Santander (UDES), Santander, Colombia
| | | | - P Seron
- Universidad de La Frontera, Temuco, Chile
| | - S A Lear
- Faculty of Health Sciences, Simon Fraser University and Division of Cardiology, Providence Health Care, Vancouver, BC, Canada
| | - S Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
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50
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Yusuf S, Rangarajan S, Teo K, Islam S, Li W, Liu L, Bo J, Lou Q, Lu F, Liu T, Yu L, Zhang S, Mony P, Swaminathan S, Mohan V, Gupta R, Kumar R, Vijayakumar K, Lear S, Anand S, Wielgosz A, Diaz R, Avezum A, Lopez-Jaramillo P, Lanas F, Yusoff K, Ismail N, Iqbal R, Rahman O, Rosengren A, Yusufali A, Kelishadi R, Kruger A, Puoane T, Szuba A, Chifamba J, Oguz A, McQueen M, McKee M, Dagenais G. Cardiovascular risk and events in 17 low-, middle-, and high-income countries. N Engl J Med 2014; 371:818-27. [PMID: 25162888 DOI: 10.1056/nejmoa1311890] [Citation(s) in RCA: 566] [Impact Index Per Article: 56.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND More than 80% of deaths from cardiovascular disease are estimated to occur in low-income and middle-income countries, but the reasons are unknown. METHODS We enrolled 156,424 persons from 628 urban and rural communities in 17 countries (3 high-income, 10 middle-income, and 4 low-income countries) and assessed their cardiovascular risk using the INTERHEART Risk Score, a validated score for quantifying risk-factor burden without the use of laboratory testing (with higher scores indicating greater risk-factor burden). Participants were followed for incident cardiovascular disease and death for a mean of 4.1 years. RESULTS The mean INTERHEART Risk Score was highest in high-income countries, intermediate in middle-income countries, and lowest in low-income countries (P<0.001). However, the rates of major cardiovascular events (death from cardiovascular causes, myocardial infarction, stroke, or heart failure) were lower in high-income countries than in middle- and low-income countries (3.99 events per 1000 person-years vs. 5.38 and 6.43 events per 1000 person-years, respectively; P<0.001). Case fatality rates were also lowest in high-income countries (6.5%, 15.9%, and 17.3% in high-, middle-, and low-income countries, respectively; P=0.01). Urban communities had a higher risk-factor burden than rural communities but lower rates of cardiovascular events (4.83 vs. 6.25 events per 1000 person-years, P<0.001) and case fatality rates (13.52% vs. 17.25%, P<0.001). The use of preventive medications and revascularization procedures was significantly more common in high-income countries than in middle- or low-income countries (P<0.001). CONCLUSIONS Although the risk-factor burden was lowest in low-income countries, the rates of major cardiovascular disease and death were substantially higher in low-income countries than in high-income countries. The high burden of risk factors in high-income countries may have been mitigated by better control of risk factors and more frequent use of proven pharmacologic therapies and revascularization. (Funded by the Population Health Research Institute and others.).
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Affiliation(s)
- Salim Yusuf
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON (S.Y., S.R., K.T., S.I., S.A., M. McQueen), Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC (S.L.), the Department of Medicine, University of Ottawa, Ottawa, ON (A.W.), and Laval University Heart and Lungs Institute, Quebec City, QC (G.D.) - all in Canada; the National Center for Cardiovascular Diseases, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing (W.L., L.L., J.B.), Jiangsu Province Institute of Geriatrics, Jiangsu Province, Nanjing City (Q.L.), Shandong Province Academy of Medical Science, Shandong Province, Jinan City (F. Lu), Xi'an Electronic Technology University Hospital, Shanxi Province, Xi'an City (T.L.), Shenyang City 242 Hospital, Liaoning Province, Shenyang City, Huanggu District (L.Y.), Bayannaoer Center for Disease Control and Prevention, Inner Mongolia, Bayannaoer City, Linhe District, Jiefangxi (S.Z.) - all in China; the Division of Epidemiology and Population Health, St. John's Research Institute, Bangalore (P.M., S.S.), Madras Diabetes Research Foundation, Chennai (V.M.), Fortis Escorts Hospitals, JLN Marg, Jaipur (R.G.), Postgraduate Institute of Medical Education and Research School of Public Health, Chandigarh (R. Kumar), and Health Action by People, Trivandrum, Kerala (K.V.) - all in India; Estudios Clinicos Latinoamerica ECLA, Rosario, Santa Fe, Argentina (R.D.); Dante Pazzanese Institute of Cardiology, São Paulo (A.A.); Fundacion Oftalmologica de Santander (FOSCAL), Medical School, Universidad de Santander, Floridablanca-Santander, Colombia (P.L.-J.); Universidad de La Frontera, Temuco, Chile (F. Lanas); Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, and UCSI University Kuala Lumpur, Kuala Lumpur (K.Y.), and the Department of Community Health, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur (N.I.) - all in Malay
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