1
|
Narula N, Wong ECL, Pray C, Marshall JK, Rangarajan S, Islam S, Bahonar A, Alhabib KF, Kontsevaya A, Ariffin F, Co HU, Al Sharief W, Szuba A, Wielgosz A, Diaz ML, Yusuf R, Kruger L, Soman B, Li Y, Wang C, Yin L, Mirrakhimov E, Lanas F, Davletov K, Rosengren A, Lopez-Jaramillo P, Khatib R, Oguz A, Iqbal R, Yeates K, Avezum Á, Reinisch W, Moayyedi P, Yusuf S. Associations of Antibiotics, Hormonal Therapies, Oral Contraceptives, and Long-Term NSAIDS With Inflammatory Bowel Disease: Results From the Prospective Urban Rural Epidemiology (PURE) Study. Clin Gastroenterol Hepatol 2023; 21:2649-2659.e16. [PMID: 36528284 DOI: 10.1016/j.cgh.2022.11.037] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 11/20/2022] [Accepted: 11/28/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND & AIMS Several medications have been suspected to contribute to the etiology of inflammatory bowel disease (IBD). This study assessed the association between medication use and the risk of developing IBD using the Prospective Urban Rural Epidemiology cohort. METHODS This was a prospective cohort study of 133,137 individuals between the ages of 20 and 80 from 24 countries. Country-specific validated questionnaires documented baseline and follow-up medication use. Participants were followed up prospectively at least every 3 years. The main outcome was the development of IBD, including Crohn's disease (CD) and ulcerative colitis (UC). Short-term (baseline but not follow-up use) and long-term use (baseline and subsequent follow-up use) were evaluated. Results are presented as adjusted odds ratios (aORs) with 95% CIs. RESULTS During a median follow-up period of 11.0 years (interquartile range, 9.2-12.2 y), there were 571 incident IBD cases (143 CD and 428 UC). Incident IBD was associated significantly with baseline antibiotic (aOR, 2.81; 95% CI, 1.67-4.73; P = .0001) and hormonal medication use (aOR, 4.43; 95% CI, 1.78-11.01; P = .001). Among females, previous or current oral contraceptive use also was associated with IBD development (aOR, 2.17; 95% CI, 1.70-2.77; P < .001). Nonsteroidal anti-inflammatory drug users also were observed to have increased odds of IBD (aOR, 1.80; 95% CI, 1.23-2.64; P = .002), which was driven by long-term use (aOR, 5.58; 95% CI, 2.26-13.80; P < .001). All significant results were consistent in direction for CD and UC with low heterogeneity. CONCLUSIONS Antibiotics, hormonal medications, oral contraceptives, and long-term nonsteroidal anti-inflammatory drug use were associated with increased odds of incident IBD after adjustment for covariates.
Collapse
Affiliation(s)
- Neeraj Narula
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada.
| | - Emily C L Wong
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Cara Pray
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - John K Marshall
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Shofiqul Islam
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Ahmad Bahonar
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Anna Kontsevaya
- National Research Center for Therapy and Preventive Medicine, Russian Federation, Moscow, Russia
| | - Farnaza Ariffin
- Primary Care Medicine, Faculty of Medicine Universiti Teknologi MARA, Selangor, Malaysia
| | - Homer U Co
- University of the Philippines College of Medicine, Manila, Philippines
| | - Wadeia Al Sharief
- Family Medicine Department, Medical Education and Research Department, Dubai Health Authority, Dubai, United Arab Emirates
| | - Andrzej Szuba
- Department of Angiology, Hypertension and Diabetology, Wroclaw Medical University, Wroclaw, Poland
| | | | - Maria Luz Diaz
- Estudios Clínicos Latinoamérica Rosario, Santa Fe, Argentina
| | - Rita Yusuf
- Independent University, Bashundhara R/A, Dhaka, Bangladesh
| | - Lanthé Kruger
- Africa Unit for Transdisciplinary Health Research, Potchefstroom, South Africa
| | - Biju Soman
- Health Action by People, Thiruvananthapuram, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Yang Li
- Medical Research and 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
| | - Chuangshi Wang
- Medical Research and 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
| | - Lu Yin
- Medical Research and 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
| | | | | | - Kairat Davletov
- Al-Farabi Kazakh National University, Health Research Institute, Almaty, Kazakhstan
| | - Annika Rosengren
- Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Västra Götaland Region Region, Sweden
| | | | - Rasha Khatib
- Advocate Aurora Research Institute, Advocate Aurora Health, Downers Grove, Illinois; Institute of Community and Public Health, Birzeit University, Birzeit, Palestine
| | - Aytekin Oguz
- Istanbul Medeniyet University, Faculty of Medicine, Department of Internal Medicine, Istanbul, Turkey
| | - Romaina Iqbal
- Department of Community Health Sciences, Aga Khan University, Karachi City, Sindh, Pakistan
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Álvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Walter Reinisch
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Paul Moayyedi
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Pray C, Narula N, Wong EC, Marshall JK, Rangarajan S, Islam S, Bahonar A, Alhabib KF, Kontsevaya A, Ariffin F, Co HU, Al Sharief W, Szuba A, Wielgosz A, Diaz ML, Yusuf R, Kruger L, Soman B, Li Y, Wang C, Yin L, Erkin M, Lanas F, Davletov K, Rosengren A, Lopez-Jaramillo P, Khatib R, Oguz A, Iqbal R, Yeates K, Avezum Á, Reinisch W, Moayyedi P, Yusuf S. A176 ASSOCIATIONS OF ANTIBIOTICS, HORMONAL THERAPIES, ORAL CONTRACEPTIVES, AND LONG-TERM NSAIDS WITH INFLAMMATORY BOWEL DISEASE: RESULTS FROM THE PROSPECTIVE URBAN RURAL EPIDEMIOLOGY (PURE) STUDY. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991214 DOI: 10.1093/jcag/gwac036.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 03/09/2023] Open
Abstract
Background The pathogenesis of inflammatory bowel disease (IBD) which includes Crohn’s disease (CD) and ulcerative colitis (UC), is believed to involve activation of the intestinal immune system in response to the gut microbiome among genetically susceptible hosts. IBD has been historically regarded as a disease of developed nations, though in the past two decades there has been a reported shift in the epidemiological pattern of disease. High-income nations with known high prevalence of disease are seeing a stabilization of incident cases, while a rapid rise of incident IBD is being observed in developing nations. This suggests that environmental exposures may play a role in mediating the risk of developing IBD. The potential environmental determinants of IBD across various regions is vast, though medications have been increasingly recognized as one broad category of risk factors. Purpose Several medications have been considered to contribute to the etiology of IBD. This study assessed the association between medication use and risk of developing IBD using the Prospective Urban Rural Epidemiology (PURE) cohort. Method This was a prospective cohort study of 133,137 individuals between the ages of 20-80 from 24 countries. Country-specific validated questionnaires documented baseline and follow-up medication use. Participants were followed prospectively at least every 3 years. The main outcome was development of IBD, including CD and UC. Short-term (baseline but not follow-up use) and long-term use (baseline and subsequent follow-up use) was evaluated. Results are presented as adjusted odds ratios (aOR) with 95% confidence intervals (CI). Result(s) During the median follow-up of 11.0 years [interquartile range (IQR) 9.2-12.2], we recorded 571 incident cases of IBD (143 CD and 428 UC). Higher risk of incident IBD was associated with baseline antibiotic use [aOR: 2.81 (95% CI: 1.67-4.73), p=0.0001] and hormonal medication use [aOR: 4.43 (95% CI: 1.78-11.01), p=0.001]. Among females, previous or current oral contraceptive use was also associated with IBD development [aOR: 2.17 (95% CI: 1.70-2.77), p=5.02E-10]. NSAID users were also observed to have increased risk of IBD [aOR: 1.80 (95% CI: 1.23-2.64), p=0.002], which was driven by long-term users [aOR: 5.58 (95% CI: 2.26-13.80), p<0.001]. All significant results were consistent in direction for CD and UC with low heterogeneity. Conclusion(s) Antibiotics, hormonal medications, oral contraceptives, and long-term NSAID use were associated with increased odds of incident IBD after adjustment for covariates. Please acknowledge all funding agencies by checking the applicable boxes below Other Please indicate your source of funding below: Salim Yusuf is supported by the Heart & Stroke Foundation/Marion W. Burke Chair in Cardiovascular Disease. The PURE Study is an investigator-initiated study funded by the Population Health Research Institute, the Canadian Institutes of Health Research (CIHR), Heart and Stroke Foundation of Ontario, support from CIHR’s Strategy for Patient Oriented Research (SPOR) through the Ontario SPOR Support Unit, as well as the Ontario Ministry of Health and Long-Term Care and through unrestricted grants from several pharmaceutical companies, with major contributions from AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, and GlaxoSmithkline, and additional contributions from Novartis and King Pharma and from various national or local organisations in participating countries; these include: Argentina: Fundacion ECLA; Bangladesh: Independent University, Bangladesh and Mitra and Associates; Brazil: Unilever Health Institute, Brazil; Canada: Public Health Agency of Canada and Champlain Cardiovascular Disease Prevention Network; Chile: Universidad de la Frontera; China: National Center for Cardiovascular Diseases; Colombia: Colciencias, grant number 6566-04-18062; India: Indian Council of Medical Research; Malaysia: Ministry of Science, Technology and Innovation of Malaysia, grant numbers 100 -IRDC/BIOTEK 16/6/21 (13/2007) and 07-05-IFN-BPH 010, Ministry of Higher Education of Malaysia grant number 600 -RMI/LRGS/5/3 (2/2011), Universiti Teknologi MARA, Universiti Kebangsaan Malaysia (UKM-Hejim-Komuniti-15-2010); occupied Palestinian territory: the UN Relief and Works Agency for Palestine Refugees in the Near East, occupied Palestinian territory; International Development Research Centre, Canada; Philippines: Philippine Council for Health Research & Development; Poland: Polish Ministry of Science and Higher Education grant number 290/W-PURE/2008/0, Wroclaw Medical University; Saudi Arabia: the Deanship of Scientific Research at King Saud University, Riyadh, Saudi Arabia (research group number RG -1436-013); South Africa: the North-West University, SANPAD (SA and Netherlands Programme for Alternative Development), National Research Foundation, Medical Research Council of SA, The SA Sugar Association (SASA), Faculty of Community and Health Sciences (UWC); Sweden: grants from the Swedish state under the Agreement concerning research and education of doctors; the Swedish Heart and Lung Foundation; the Swedish Research Council; the Swedish Council for Health, Working Life and Welfare, King Gustaf V’s and Queen Victoria Freemasons Foundation, AFA Insurance, Swedish Council for Working Life and Social Research, Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning, grant from the Swedish State under the Läkar Utbildnings Avtalet agreement, and grant from the Västra Götaland Region; Turkey: Metabolic Syndrome Society, AstraZeneca, Turkey, Sanofi Aventis, Turkey; United Arab Emirates (UAE): Sheikh Hamdan Bin Rashid Al Maktoum Award For Medical Sciences and Dubai Health Authority, Dubai UAE. Disclosure of Interest C. Pray: None Declared, N. Narula Grant / Research support from: Neeraj Narula holds a McMaster University Department of Medicine Internal Career Award. Neeraj Narula has received honoraria from Janssen, Abbvie, Takeda, Pfizer, Merck, and Ferring, E. C. Wong: None Declared, J. K. Marshall Grant / Research support from: John K. Marshall has received honoraria from Janssen, AbbVie, Allergan, Bristol-Meyer-Squibb, Ferring, Janssen, Lilly, Lupin, Merck, Pfizer, Pharmascience, Roche, Shire, Takeda and Teva., S. Rangarajan: None Declared, S. Islam: None Declared, A. Bahonar: None Declared, K. F. Alhabib: None Declared, A. Kontsevaya: None Declared, F. Ariffin: None Declared, H. U. Co: None Declared, W. Al Sharief: None Declared, A. Szuba: None Declared, A. Wielgosz: None Declared, M. L. Diaz: None Declared, R. Yusuf: None Declared, L. Kruger: None Declared, B. Soman: None Declared, Y. Li: None Declared, C. Wang: None Declared, L. Yin: None Declared, M. Erkin: None Declared, F. Lanas: None Declared, K. Davletov: None Declared, A. Rosengren: None Declared, P. Lopez-Jaramillo: None Declared, R. Khatib: None Declared, A. Oguz: None Declared, R. Iqbal: None Declared, K. Yeates: None Declared, Á. Avezum: None Declared, W. Reinisch Consultant of: Speaker for Abbott Laboratories, Abbvie, Aesca, Aptalis, Astellas, Centocor, Celltrion, Danone Austria, Elan, Falk Pharma GmbH, Ferring, Immundiagnostik, Mitsubishi Tanabe Pharma Corporation, MSD, Otsuka, PDL, Pharmacosmos, PLS Education, Schering-Plough, Shire, Takeda, Therakos, Vifor, Yakult, Consultant for Abbott Laboratories, Abbvie, Aesca, Algernon, Amgen, AM Pharma, AMT, AOP Orphan, Arena Pharmaceuticals, Astellas, Astra Zeneca, Avaxia, Roland Berger GmBH, Bioclinica, Biogen IDEC, Boehringer-Ingelheim, Bristol-Myers Squibb, Cellerix, Chemocentryx, Celgene, Centocor, Celltrion, Covance, Danone Austria, DSM, Elan, Eli Lilly, Ernest & Young, Falk Pharma GmbH, Ferring, Galapagos, Genentech, Gilead, Grünenthal, ICON, Index Pharma, Inova, Janssen, Johnson & Johnson, Kyowa Hakko Kirin Pharma, Lipid Therapeutics, LivaNova, Mallinckrodt, Medahead, MedImmune, Millenium, Mitsubishi Tanabe Pharma Corporation, MSD, Nash Pharmaceuticals, Nestle, Nippon Kayaku, Novartis, Ocera, Omass, Otsuka, Parexel, PDL, Periconsulting, Pharmacosmos, Philip Morris Institute, Pfizer, Procter & Gamble, Prometheus, Protagonist, Provention, Robarts Clinical Trial, Sandoz, Schering-Plough, Second Genome, Seres Therapeutics, Setpointmedical, Sigmoid, Sublimity, Takeda, Therakos, Theravance, Tigenix, UCB, Vifor, Zealand, Zyngenia, and 4SC, Advisory board member for Abbott Laboratories, Abbvie, Aesca, Amgen, AM Pharma, Astellas, Astra Zeneca, Avaxia, Biogen IDEC, Boehringer-Ingelheim, Bristol-Myers Squibb, Cellerix, Chemocentryx, Celgene, Centocor, Celltrion, Danone Austria, DSM, Elan, Ferring, Galapagos, Genentech, Grünenthal, Inova, Janssen, Johnson & Johnson, Kyowa Hakko Kirin Pharma, Lipid Therapeutics, MedImmune, Millenium, Mitsubishi Tanabe Pharma Corporation, MSD, Nestle, Novartis, Ocera, Otsuka, PDL, Pharmacosmos, Pfizer, Procter & Gamble, Prometheus, Sandoz, Schering-Plough, Second Genome, Setpointmedical, Takeda, Therakos, Tigenix, UCB, Zealand, Zyngenia, and 4SC, P. Moayyedi: None Declared, S. Yusuf: None Declared
Collapse
Affiliation(s)
- C Pray
- Department of Medicine (Division of Gastroenterology) and Farncombe Family Digestive Health Research Institute, McMaster University
| | - N Narula
- Department of Medicine (Division of Gastroenterology) and Farncombe Family Digestive Health Research Institute, McMaster University,Population Health Research Institute, McMaster University and Hamilton Health Sciences
| | - E C Wong
- Department of Medicine (Division of Gastroenterology) and Farncombe Family Digestive Health Research Institute, McMaster University
| | - J K Marshall
- Department of Medicine (Division of Gastroenterology) and Farncombe Family Digestive Health Research Institute, McMaster University
| | - S Rangarajan
- McMaster University and Hamilton Health Sciences, Population Health Research Institute, Hamilton, Canada
| | - S Islam
- McMaster University and Hamilton Health Sciences, Population Health Research Institute, Hamilton, Canada
| | - A Bahonar
- Isfahan Cardiovascular Research Center, Isfahan, Iran, Islamic Republic Of
| | - K F Alhabib
- King Fahad Cardiac Center, King Saud Medical City, Saudi Arabia
| | - A Kontsevaya
- National research center for therapy and preventive medicine, Moscow, Russian Federation
| | - F Ariffin
- Faculty of Medicine UiTM, Selangor, Malaysia
| | - H U Co
- University of the Philippines College of Medicine, Ermita, Philippines
| | - W Al Sharief
- Family Medicine Department, Medical Education & Research Department in Dubai Health Authority (DHA), Oud Metha-Dubai, United Arab Emirates
| | - A Szuba
- Wroclaw Medical University, Wroclaw, Poland
| | - A Wielgosz
- University of Ottawa Heart Institute, Ottawa, Canada
| | - M L Diaz
- Estudios Clínicos Latino América, Rosario, Argentina
| | - R Yusuf
- Independent University, Bangladesh, Bashundhara , Bangladesh
| | - L Kruger
- Africa Unit for Transdisciplinary Health Research , North West University, Potchefstroom, South Africa
| | - B Soman
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Y Li
- Medical Research & Biometrics Center, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - C Wang
- Medical Research & Biometrics Center, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - L Yin
- Medical Research & Biometrics Center, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - M Erkin
- Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan
| | - F Lanas
- Universidad de La Frontera, Temuco, Chile
| | - K Davletov
- Al-Farabi Kazakh National University, Almaty, Kazakhstan
| | - A Rosengren
- Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - P Lopez-Jaramillo
- Masira Research Institute, Universidad de Santander , Bucaramanga, Colombia
| | - R Khatib
- Institute of Community and Public Health, Birzeit University,, Birzeit, Palestinian, State of
| | - A Oguz
- Internal Medicine, Istanbul Medeniyet University,, Istanbul, -
| | - R Iqbal
- Department of Community Health Sciences, Aga Khan University, Karachi City, Pakistan
| | - K Yeates
- Department of Medicine, Queen's University, Kingston, Canada
| | - Á Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - W Reinisch
- Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - P Moayyedi
- Department of Medicine (Division of Gastroenterology) and Farncombe Family Digestive Health Research Institute, McMaster University,Population Health Research Institute, McMaster University and Hamilton Health Sciences
| | - S Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences
| |
Collapse
|
4
|
Walli-Attaei M, Rosengren A, Rangarajan S, Breet Y, Abdul-Razak S, Sharief WA, Alhabib KF, Avezum A, Chifamba J, Diaz R, Gupta R, Hu B, Iqbal R, Ismail R, Kelishadi R, Khatib R, Lang X, Li S, Lopez-Jaramillo P, Mohan V, Oguz A, Palileo-Villanueva LM, Poltyn-Zaradna K, R SP, Pinnaka LVM, Serón P, Teo K, Verghese ST, Wielgosz A, Yeates K, Yusuf R, Anand SS, Yusuf S. Metabolic, behavioural, and psychosocial risk factors and cardiovascular disease in women compared with men in 21 high-income, middle-income, and low-income countries: an analysis of the PURE study. Lancet 2022; 400:811-821. [PMID: 36088949 DOI: 10.1016/s0140-6736(22)01441-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [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: 06/11/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND There is a paucity of data on the prevalence of risk factors and their associations with incident cardiovascular disease in women compared with men, especially from low-income and middle-income countries. METHODS In the Prospective Urban Rural Epidemiological (PURE) study, we enrolled participants from the general population from 21 high-income, middle-income, and low-income countries and followed them up for approximately 10 years. We recorded information on participants' metabolic, behavioural, and psychosocial risk factors. For this analysis, we included participants aged 35-70 years at baseline without a history of cardiovascular disease, with at least one follow-up visit. The primary outcome was a composite of major cardiovascular events (cardiovascular disease deaths, myocardial infarction, stroke, and heart failure). We report the prevalence of each risk factor in women and men, their hazard ratios (HRs), and population-attributable fractions (PAFs) associated with major cardiovascular disease. The PURE study is registered with ClinicalTrials.gov, NCT03225586. FINDINGS In this analysis, we included 155 724 participants enrolled and followed-up between Jan 5, 2005, and Sept 13, 2021, (90 934 [58·4%] women and 64 790 [41·6%] men), with a median follow-up of 10·1 years (IQR 8·5-12·0). At study entry, the mean age of women was 49·8 years (SD 9·7) compared with 50·8 years (9·8) in men. As of data cutoff (Sept 13, 2021), 4280 major cardiovascular disease events had occurred in women (age-standardised incidence rate of 5·0 events [95% CI 4·9-5·2] per 1000 person-years) and 4911 in men (8·2 [8·0-8·4] per 1000 person-years). Compared with men, women presented with a more favourable cardiovascular risk profile, especially at younger ages. The HRs for metabolic risk factors were similar in women and men, except for non-HDL cholesterol, for which high non-HDL cholesterol was associated with an HR for major cardiovascular disease of 1·11 (95% CI 1·01-1·21) in women and 1·28 (1·19-1·39) in men, with a consistent pattern for higher risk among men than among women with other lipid markers. Symptoms of depression had a HR of 1·09 (0·98-1·21) in women and 1·42 (1·25-1·60) in men. By contrast, consumption of a diet with a PURE score of 4 or lower (score ranges from 0 to 8), was more strongly associated with major cardiovascular disease in women (1·17 [1·08-1·26]) than in men (1·07 [0·99-1·15]). The total PAFs associated with behavioural and psychosocial risk factors were greater in men (15·7%) than in women (8·4%) predominantly due to the larger contribution of smoking to PAFs in men (ie, 1·3% [95% CI 0·5-2·1] in women vs 10·7% [8·8-12·6] in men). INTERPRETATION Lipid markers and depression are more strongly associated with the risk of cardiovascular disease in men than in women, whereas diet is more strongly associated with the risk of cardiovascular disease in women than in men. The similar associations of other risk factors with cardiovascular disease in women and men emphasise the importance of a similar strategy for the prevention of cardiovascular disease in men and women. FUNDING Funding sources are listed at the end of the Article.
Collapse
Affiliation(s)
- Marjan Walli-Attaei
- 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
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Yolandi Breet
- Hypertension in Africa Research Team (HART) and MRC Research Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa
| | - Suraya Abdul-Razak
- Faculty of Medicine, Universiti Teknologi MARA (UiTM), Cardio Vascular and Lungs Research Institute (CaVaLRI), Selangor, Malaysia
| | - Wadeia Al Sharief
- Medical Education & Research Department, Medical College, University of Sharjah, Sharjah, United Arab Emirates
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
| | - Jephat Chifamba
- Physiology Department, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica (ECLA), Rosario, Santa Fe, Argentina
| | - Rajeev Gupta
- Eternal Heart Care Centre & Research Institute, Jaipur, India
| | - Bo Hu
- Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing, China
| | - Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Rosnah Ismail
- Department of Community Health, Faculty of Medicine, University Kebangsaan Malaysia, Medical Centre, Kuala Lumpur, Malaysia
| | - Roya Kelishadi
- 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
| | - Xinyue Lang
- Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing, China
| | - Sidong Li
- Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing, China
| | - Patricio Lopez-Jaramillo
- Masira Research Institute, Medical School, Universidad de Santander (UDES), Bucaramanga, Colombia
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation and Dr Mohan's Diabetes Specialities Centre, Chennai, India
| | - Aytekin Oguz
- Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Türkiye
| | | | | | - Sreelakshmi P R
- SUT Academy of Medical Sciences, Vattapara, Trivandrum, Kerala, India
| | - Lakshmi V M Pinnaka
- Department of Community Medicine & School of Public Health, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pamela Serón
- Faculty of Medicine, Universidad de La Frontera, Temuco, Chile
| | - Koon Teo
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sejil T Verghese
- Department of Physiology, St John's Medical College and Hospital, Bangalore, India
| | - Andreas Wielgosz
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Rita Yusuf
- School of Life Sciences, Independent University, Dhaka, Bangladesh
| | - 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
| |
Collapse
|
5
|
Mathiaparanam S, Nori de Macedo A, Mente A, Poirier P, Lear SA, Wielgosz A, Teo KK, Yusuf S, Britz-Mckibbin P. The Prevalence and Risk Factors Associated with Iodine Deficiency in Canadian Adults. Nutrients 2022; 14:nu14132570. [PMID: 35807751 PMCID: PMC9268597 DOI: 10.3390/nu14132570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/16/2022] [Accepted: 06/17/2022] [Indexed: 02/04/2023] Open
Abstract
Iodine is a trace micronutrient that is critical for normal thyroid function and human health. Inadequate dietary intake is associated with cognitive impairment, infertility, growth retardation and iodine deficiency disorders in affected populations. Herein, we examined the prevalence of iodine deficiency in adults (median age of 61 years) based on the analysis of 24 h urine samples collected from 800 participants in four clinical sites across Canada in the Prospective Urban and Rural Epidemiological (PURE) study. Urinary iodide together with thiocyanate and nitrate were measured using a validated capillary electrophoresis assay. Protective/risk factors associated with iodine deficiency were identified using a binary logistic regression model, whereas daily urinary iodine concentration (24 h UIC, μg/L) and urinary iodine excretion (24 h UIE, μg/day) were compared using complementary statistical methods with covariate adjustments. Overall, our Canadian adult cohort had adequate iodine status as reflected by a median UIC of 111 μg/L with 11.9% of the population <50 μg/L categorized as having moderate to severe iodine deficiency. Iodine adequacy was also evident with a median 24 h UIE of 226 μg/day as a more robust metric of iodine status with an estimated average requirement (EAR) of 7.1% (< 95 μg/day) and a tolerable upper level (UL) of 1.8% (≥1100 μg/day) based on Canadian dietary reference intake values. Participants taking iodine supplements (OR = 0.18; p = 6.35 × 10−5), had greater 24 h urine volume (OR = 0.69; p = 4.07 × 10−4), excreted higher daily urinary sodium (OR = 0.71; p = 3.03 × 10−5), and/or were prescribed thyroxine (OR = 0.33; p = 1.20 × 10−2) had lower risk for iodine deficiency. Self-reported intake of dairy products was most strongly associated with iodine status (r = 0.24; p = 2.38 × 10−9) after excluding for iodine supplementation and T4 use. Participants residing in Quebec City (OR = 2.58; p = 1.74 × 10−4) and Vancouver (OR = 2.54; p = 3.57 × 10−4) were more susceptible to iodine deficiency than Hamilton or Ottawa. Also, greater exposure to abundant iodine uptake inhibitors from tobacco smoking and intake of specific goitrogenic foods corresponded to elevated urinary thiocyanate and nitrate, which were found for residents from Quebec City as compared to other clinical sites. Recent public health policies that advocate for salt restriction and lower dairy intake may inadvertently reduce iodine nutrition of Canadians, and further exacerbate regional variations in iodine deficiency risk.
Collapse
Affiliation(s)
- Stellena Mathiaparanam
- Department of Chemistry and Chemical Biology, McMaster University, Hamilton, ON L8S 4L8, Canada; (S.M.); (A.N.d.M.)
| | - Adriana Nori de Macedo
- Department of Chemistry and Chemical Biology, McMaster University, Hamilton, ON L8S 4L8, Canada; (S.M.); (A.N.d.M.)
- Departamento de Química, Universidade Federal de Minas Gerais, Belo Horizonte 31270-901, MG, Brazil
| | - Andrew Mente
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON L8L 2X2, Canada; (A.M.); (K.K.T.); (S.Y.)
| | - Paul Poirier
- Faculté de Pharmacie, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec City, QC G1V 4G5, Canada;
| | - Scott A. Lear
- Faculty of Health Sciences, Simon Fraser University, Burnaby and Division of Cardiology, Providence Health Care, Vancouver, BC V5A 1S6, Canada;
| | - Andreas Wielgosz
- University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada;
| | - Koon K. Teo
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON L8L 2X2, Canada; (A.M.); (K.K.T.); (S.Y.)
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON L8L 2X2, Canada; (A.M.); (K.K.T.); (S.Y.)
| | - Philip Britz-Mckibbin
- Department of Chemistry and Chemical Biology, McMaster University, Hamilton, ON L8S 4L8, Canada; (S.M.); (A.N.d.M.)
- Correspondence:
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Sathish T, Teo KK, Britz-McKibbin P, Gill B, Islam S, Paré G, Rangarajan S, Duong M, Lanas F, Lopez-Jaramillo P, Mony PK, Pinnaka L, Kutty VR, Orlandini A, Avezum A, Wielgosz A, Poirier P, Alhabib KF, Temizhan A, Chifamba J, Yeates K, Kruger IM, Khatib R, Yusuf R, Rosengren A, Zatonska K, Iqbal R, Lui W, Lang X, Li S, Hu B, Dans AL, Yusufali AH, Bahonar A, O’Donnell MJ, McKee M, Yusuf S. Variations in risks from smoking between high-income, middle-income, and low-income countries: an analysis of data from 179 000 participants from 63 countries. The Lancet Global Health 2022; 10:e216-e226. [DOI: 10.1016/s2214-109x(21)00509-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/09/2021] [Accepted: 10/18/2021] [Indexed: 12/11/2022] Open
|
8
|
Khetan AK, Yusuf S, Lopez-Jaramillo P, Szuba A, Orlandini A, Mat-Nasir N, Oguz A, Gupta R, Avezum Á, Rosnah I, Poirier P, Teo KK, Wielgosz A, Lear SA, Palileo-Villanueva LM, Serón P, Chifamba J, Rangarajan S, Mushtaha M, Mohan D, Yeates K, McKee M, Mony PK, Walli-Attaei M, Khansaheb H, Rosengren A, Alhabib KF, Kruger IM, Paucar MJ, Mirrakhimov E, Assembekov B, Leong DP. Variations in the financial impact of the COVID-19 pandemic across 5 continents: A cross-sectional, individual level analysis. EClinicalMedicine 2022; 44:101284. [PMID: 35106472 PMCID: PMC8794545 DOI: 10.1016/j.eclinm.2022.101284] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [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: 10/29/2021] [Revised: 01/11/2022] [Accepted: 01/14/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND COVID-19 has caused profound socio-economic changes worldwide. However, internationally comparative data regarding the financial impact on individuals is sparse. Therefore, we conducted a survey of the financial impact of the pandemic on individuals, using an international cohort that has been well-characterized prior to the pandemic. METHODS Between August 2020 and September 2021, we surveyed 24,506 community-dwelling participants from the Prospective Urban-Rural Epidemiology (PURE) study across high (HIC), upper middle (UMIC)-and lower middle (LMIC)-income countries. We collected information regarding the impact of the pandemic on their self-reported personal finances and sources of income. FINDINGS Overall, 32.4% of participants had suffered an adverse financial impact, defined as job loss, inability to meet financial obligations or essential needs, or using savings to meet financial obligations. 8.4% of participants had lost a job (temporarily or permanently); 14.6% of participants were unable to meet financial obligations or essential needs at the time of the survey and 16.3% were using their savings to meet financial obligations. Participants with a post-secondary education were least likely to be adversely impacted (19.6%), compared with 33.4% of those with secondary education and 33.5% of those with pre-secondary education. Similarly, those in the highest wealth tertile were least likely to be financially impacted (26.7%), compared with 32.5% in the middle tertile and 30.4% in the bottom tertile participants. Compared with HICs, financial impact was greater in UMIC [odds ratio of 2.09 (1.88-2.33)] and greatest in LMIC [odds ratio of 16.88 (14.69-19.39)]. HIC participants with the lowest educational attainment suffered less financial impact (15.1% of participants affected) than those with the highest education in UMIC (22.0% of participants affected). Similarly, participants with the lowest education in UMIC experienced less financial impact (28.3%) than those with the highest education in LMIC (45.9%). A similar gradient was seen across country income categories when compared by pre-pandemic wealth status. INTERPRETATION The financial impact of the pandemic differs more between HIC, UMIC, and LMIC than between socio-economic categories within a country income level. The most disadvantaged socio-economic subgroups in HIC had a lower financial impact from the pandemic than the most advantaged subgroup in UMIC, with a similar disparity seen between UMIC and LMIC. Continued high levels of infection will exacerbate financial inequity between countries and hinder progress towards the sustainable development goals, emphasising the importance of effective measures to control COVID-19 and, especially, ensuring high vaccine coverage in all countries. FUNDING Funding for this study was provided by the Canadian Institutes of Health Research and the International Development Research Centre.
Collapse
Affiliation(s)
- Aditya K Khetan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON L8L 2X2, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON L8L 2X2, Canada
| | - Patricio Lopez-Jaramillo
- Medical School, Universidad de Santander (UDES), Masira Research Institute, Bucaramanga, Colombia
| | - Andrzej Szuba
- Department of Angiology, Hypertension and Diabetology, Wroclaw Medical University, Wroclaw, Poland
| | - Andres Orlandini
- ECLA (Estudios Clínicos Latino America) Instituto Cardiovascular de Rosario, Argentina
| | - Nafiza Mat-Nasir
- Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia
| | - Aytekin Oguz
- Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Rajeev Gupta
- Eternal Heart Care Center and Research Institute, Jaipur, India
| | - Álvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Ismail Rosnah
- Faculty of Medicine of UKM, UKM Medical Center, Kuala Lumpur, Malaysia
| | - Paul Poirier
- Faculté de pharmacie, Université Laval, Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Canada
| | - Koon K Teo
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON L8L 2X2, Canada
| | | | - Scott A. Lear
- Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
| | | | - Pamela Serón
- Faculty of Medicine, Universidad de La Frontera, Claro Solar, Temuco, Chile
| | - Jephat Chifamba
- Department of Biomedical Sciences, Physiology Unit, Faculty of Medicine and Sciences, University of Zimbabwe, Zimbabwe
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON L8L 2X2, Canada
| | - Maha Mushtaha
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON L8L 2X2, Canada
| | - Deepa Mohan
- Department of Epidemiology, Madras Diabetes Research Foundation, Chennai, India
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Martin McKee
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Prem K Mony
- St John's Medical College & Research Institute, Bangalore, India
| | - Marjan Walli-Attaei
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON L8L 2X2, Canada
| | | | - Annika Rosengren
- Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, VGR region, Sweden
| | - Khalid F Alhabib
- King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Iolanthé M Kruger
- Potchefstroom Campus, Africa Unit for Transdisciplinary Health Research (AUTHeR), North-West University, South Africa
| | - María-José Paucar
- Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Quito, Ecuador
| | | | | | - Darryl P Leong
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON L8L 2X2, Canada
| |
Collapse
|
9
|
Duong M, Rangarajan S, Zaman M, Nasir NM, Seron P, Yeates K, Yusufali AM, Khatib R, Tse LA, Wang C, Wielgosz A, Teo K, Kumar R, Avezum A, Ismail R, çalık BT, Gopakumar S, Rahman O, Zatońska K, Rosengren A, Otero J, Kelishadi R, Diaz R, Puoane T, Yusuf S. Differences and agreement between two portable hand-held spirometers across diverse community-based populations in the Prospective Urban Rural Epidemiology (PURE) study. PLOS Glob Public Health 2022; 2:e0000141. [PMID: 36962310 PMCID: PMC10021326 DOI: 10.1371/journal.pgph.0000141] [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] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 12/03/2021] [Indexed: 05/19/2023]
Abstract
INTRODUCTION Portable spirometers are commonly used in longitudinal epidemiological studies to measure and track the forced expiratory volume in first second (FEV1) and forced vital capacity (FVC). During the course of the study, it may be necessary to replace spirometers with a different model. This raise questions regarding the comparability of measurements from different devices. We examined the correlation, mean differences and agreement between two different spirometers, across diverse populations and different participant characteristics. METHODS From June 2015 to Jan 2018, a total of 4,603 adults were enrolled from 628 communities in 18 countries and 7 regions of the world. Each participant performed concurrent measurements from the MicroGP and EasyOne spirometer. Measurements were compared by the intra-class correlation coefficient (ICC) and Bland-Altman method. RESULTS Approximately 65% of the participants achieved clinically acceptable quality measurements. Overall correlations between paired FEV1 (ICC 0.88 [95% CI 0.87, 0.88]) and FVC (ICC 0.84 [0.83, 0.85]) were high. Mean differences between paired FEV1 (-0.038 L [-0.053, -0.023]) and FVC (0.033 L [0.012, 0.054]) were small. The 95% limits of agreement were wide but unbiased (FEV1 984, -1060; FVC 1460, -1394). Similar findings were observed across regions. The source of variation between spirometers was mainly at the participant level. Older age, higher body mass index, tobacco smoking and known COPD/asthma did not adversely impact on the inter-device variability. Furthermore, there were small and acceptable mean differences between paired FEV1 and FVC z-scores using the Global Lung Initiative normative values, suggesting minimal impact on lung function interpretation. CONCLUSIONS In this multicenter, diverse community-based cohort study, measurements from two portable spirometers provided good correlation, small and unbiased differences between measurements. These data support their interchangeable use across diverse populations to provide accurate trends in serial lung function measurements in epidemiological studies.
Collapse
Affiliation(s)
- MyLinh Duong
- Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
- * E-mail:
| | - Sumathy Rangarajan
- Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Michele Zaman
- Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Nafiza Mat Nasir
- Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh Campus, Selangor, Malaysia
| | - Pamela Seron
- Facultad de Medicina, Universidad de La Frontera, Temuco, Chile
| | - Karen Yeates
- Pamoja Tunaweza Research Centre, Moshi, Tanzania
| | | | - Rasha Khatib
- Advocate Aurora Research Institute, Milwaukee, IL, United States of America
| | - Lap Ah Tse
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Chuangshi Wang
- Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical, Beijing, China
| | - Andreas Wielgosz
- University of Ottawa Department of Medicine, Ottawa, Ontario, Canada
| | - Koon Teo
- Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Rajesh Kumar
- State Health System Resource Center, Punjab, India
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, SP, Brazil
| | - Rosnah Ismail
- Community Health Department, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Burcu Tumerdem çalık
- Faculty of Health Sciences, Department of Health Management, Marmara University, Istanbul, Turkey
| | - Soumya Gopakumar
- Health Action by People and Government Medical College, Thiruvananthapuram, Kerala, India
| | - Omar Rahman
- University of Liberal Arts Bangladesh, Dhaka, Bangladesh
| | | | | | - Johanna Otero
- Instituto Masira, Universidad de Santander (UDES), Bucaramanga, Colombia
| | - Roya Kelishadi
- Cardiovascular Research Institute, Chamran Hospital, Isfahan, Iran
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica ECLA Rosario, Santa Fe, Argentina
| | - Thandi Puoane
- University of the Western Cape, School of Public Health, Cape Town, South Africa
| | - Salim Yusuf
- Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Iqbal R, Dehghan M, Mente A, Rangarajan S, Wielgosz A, Avezum A, Seron P, AlHabib KF, Lopez-Jaramillo P, Swaminathan S, Mohammadifard N, Zatońska K, Bo H, Varma RP, Rahman O, Yusufali A, Lu Y, Ismail N, Rosengren A, Imeryuz N, Yeates K, Chifamba J, Dans A, Kumar R, Xiaoyun L, Tsolekile L, Khatib R, Diaz R, Teo K, Yusuf S. Associations of unprocessed and processed meat intake with mortality and cardiovascular disease in 21 countries [Prospective Urban Rural Epidemiology (PURE) Study]: a prospective cohort study. Am J Clin Nutr 2021; 114:1049-1058. [PMID: 33787869 DOI: 10.1093/ajcn/nqaa448] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [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: 08/06/2020] [Accepted: 12/29/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Dietary guidelines recommend limiting red meat intake because it is a major source of medium- and long-chain SFAs and is presumed to increase the risk of cardiovascular disease (CVD). Evidence of an association between unprocessed red meat intake and CVD is inconsistent. OBJECTIVE The study aimed to assess the association of unprocessed red meat, poultry, and processed meat intake with mortality and major CVD. METHODS The Prospective Urban Rural Epidemiology (PURE) Study is a cohort of 134,297 individuals enrolled from 21 low-, middle-, and high-income countries. Food intake was recorded using country-specific validated FFQs. The primary outcomes were total mortality and major CVD. HRs were estimated using multivariable Cox frailty models with random intercepts. RESULTS In the PURE study, during 9.5 y of follow-up, we recorded 7789 deaths and 6976 CVD events. Higher unprocessed red meat intake (≥250 g/wk vs. <50 g/wk) was not significantly associated with total mortality (HR: 0.93; 95% CI: 0.85, 1.02; P-trend = 0.14) or major CVD (HR: 1.01; 95% CI: 0.92, 1.11; P-trend = 0.72). Similarly, no association was observed between poultry intake and health outcomes. Higher intake of processed meat (≥150 g/wk vs. 0 g/wk) was associated with higher risk of total mortality (HR: 1.51; 95% CI: 1.08, 2.10; P-trend = 0.009) and major CVD (HR: 1.46; 95% CI: 1.08, 1.98; P-trend = 0.004). CONCLUSIONS In a large multinational prospective study, we did not find significant associations between unprocessed red meat and poultry intake and mortality or major CVD. Conversely, a higher intake of processed meat was associated with a higher risk of mortality and major CVD.
Collapse
Affiliation(s)
- Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Mahshid Dehghan
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Andrew Mente
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Sumathy Rangarajan
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Andreas Wielgosz
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Alvaro Avezum
- International Research Centre, Hospital Alemao Oswaldo Cruz, University of Santo Amaro (UNISA), Sao Paulo, SP Brazil
| | - Pamela Seron
- Faculty of Medicine, University of La Frontera, Temuco, Chile
| | - Khalid F AlHabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | - Sumathi Swaminathan
- Division of Nutrition, St John's Research Institute, Koramangala, Bangalore, India
| | - Noushin Mohammadifard
- Isfahan University of Medical Sciences, Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan, Iran
| | | | - Hu Bo
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Ravi Prasad Varma
- Health Action by People, Thiruvananthapuram and Achutha Menon Center for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Omar Rahman
- University of Liberal Arts, Dhaka, Bangladesh
| | - AfzalHussein Yusufali
- Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Yin Lu
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Noorhassim Ismail
- Department of Community Health, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Annika Rosengren
- University of Gothenburg and Region Västra Götaland, Sahlgrenska University Hospital, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg, Sweden
| | - Neşe Imeryuz
- Department of Internal Medicine and Gastroenterology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Karen Yeates
- Queen's University, Department of Medicine, Canada and Pamoja Tunaweza Research Center, Moshi, Tanzania
| | - Jephat Chifamba
- University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Antonio Dans
- Department of Medicine, University of the Philippines, Manila, Philippines
| | - Rajesh Kumar
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Liu Xiaoyun
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Lungi Tsolekile
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Rasha Khatib
- Birzeit University, Institute for Community and Public Health, Birzeit, Palestine.,Advocate Research Institute, Advocate Health Care, Chicago, IL, USA
| | - Rafael Diaz
- Clinical Studies Latin America, Rosario, Santa Fe, Argentina
| | - Koon Teo
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Salim Yusuf
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
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.
Collapse
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
| |
Collapse
|
14
|
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.
Collapse
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
| | | |
Collapse
|
15
|
Nolan RP, Ross HJ, Farkouh ME, Huszti E, Chan S, Toma M, D'Antono B, White M, Thomas S, Barr SI, Perreault S, McDonald M, Zieroth S, Isaac D, Wielgosz A, Mielniczuk LM. Automated E-Counseling for Chronic Heart Failure: CHF-CePPORT Trial. Circ Heart Fail 2021; 14:e007073. [PMID: 33464959 DOI: 10.1161/circheartfailure.120.007073] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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] [Indexed: 12/27/2022]
Abstract
BACKGROUND International task force statements advocate telehealth programs to promote health-related quality of life for patients with chronic heart failure (CHF). To that end, we evaluated the efficacy and usability of an automated e-counseling program. METHODS This Canadian multi-site double-blind randomized trial assessed whether usual care plus either internet-based e-counseling (motivational and cognitive-behavioral tools for CHF self-care) or e-based conventional CHF self-care education (e-UC) improved 12-month Kansas City Cardiomyopathy Questionnaire Overall Summary (KCCQ-OS). Secondary outcomes included program engagement (total logon weeks, logons, and logon hours), total CHF self-care behaviors, diet (fruit and vegetable servings), 6-minute walk test, and 4-day step count. The association between program engagement and health-related quality of life was assessed using KCCQ-OS tertiles. RESULTS We enrolled 231 patients, median age =59.5 years, 22% female, and elevated median KCCQ-OS=83.0 (interquartile range, 68-93). KCCQ-OS increase ≥5 points was not more prevalent for e-counseling, n=29 (29.6%) versus e-UC, n=32 (34.0%), P=0.51. E-Counseling versus e-UC increased total logon weeks (P=0.02), logon hours (P=0.001), and logons (P<0.001). Only e-counseling showed a positive association between 12-month KCCQ-OS tertile and logon weeks (P=0.04) and logon hours (P=0.004). E-Counseling increased CHF self-care behavior and diet but not 6-minute walk test or 4-day step count. CONCLUSIONS The primary KCCQ-OS end point was negative for this trial. Only e-counseling showed a positive association between program engagement and 12-month KCCQ-OS tertile, and it improved CHF self-care behavior and diet. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01864369.
Collapse
Affiliation(s)
- Robert P Nolan
- Cardiac eHealth and Behavioural Cardiology Research Unit, Peter Munk Cardiac Center (R.P.N.), University Health Network, Toronto, ON, Canada.,Faculty of Medicine (R.P.N., H.J.R., M.E.F., M.M.), University of Toronto, ON, Canada
| | - Heather J Ross
- Division of Cardiology, Peter Munk Cardiac Center (H.J.R., M.E.F., M.M.), University Health Network, Toronto, ON, Canada.,Faculty of Medicine (R.P.N., H.J.R., M.E.F., M.M.), University of Toronto, ON, Canada
| | - Michael E Farkouh
- Division of Cardiology, Peter Munk Cardiac Center (H.J.R., M.E.F., M.M.), University Health Network, Toronto, ON, Canada.,Faculty of Medicine (R.P.N., H.J.R., M.E.F., M.M.), University of Toronto, ON, Canada
| | - Ella Huszti
- Theta Institute (E.H.), University Health Network, Toronto, ON, Canada
| | - Sammy Chan
- Faculty of Medicine (S.C., M.T.), University of British Columbia, Vancouver, Canada.,Department of Cardiology, St Paul's Hospital, Vancouver, BC, Canada (S.C., M.T.)
| | - Mustafa Toma
- Faculty of Medicine (S.C., M.T.), University of British Columbia, Vancouver, Canada.,Department of Cardiology, St Paul's Hospital, Vancouver, BC, Canada (S.C., M.T.)
| | - Bianca D'Antono
- Centre de Recherche, Institut de Cardiologie de Montréal, QC, Canada (B.D., M.W.).,Département de Psychologie (B.D.).,Université de Montréal, QC, Canada (B.D.)
| | - Michel White
- Centre de Recherche, Institut de Cardiologie de Montréal, QC, Canada (B.D., M.W.)
| | - Scott Thomas
- Faculty of Kinesiology and Physical Education (S.T.), University of Toronto, ON, Canada
| | - Susan I Barr
- Department of Food, Nutrition, and Health (S.I.B.), University of British Columbia, Vancouver, Canada
| | | | - Michael McDonald
- Division of Cardiology, Peter Munk Cardiac Center (H.J.R., M.E.F., M.M.), University Health Network, Toronto, ON, Canada.,Faculty of Medicine (R.P.N., H.J.R., M.E.F., M.M.), University of Toronto, ON, Canada
| | - Shelley Zieroth
- Faculty of Medicine, University of Manitoba, Winnipeg, Canada (S.Z.)
| | - Debra Isaac
- Cardiac Transplant Clinic, Libin Cardiovascular Institute of Alberta, Calgary, Canada (D.I.)
| | | | | |
Collapse
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
Rajan S, McKee M, Rangarajan S, Bangdiwala S, Rosengren A, Gupta R, Kutty VR, Wielgosz A, Lear S, AlHabib KF, Co HU, Lopez-Jaramillo P, Avezum A, Seron P, Oguz A, Kruger IM, Diaz R, Nafiza MN, Chifamba J, Yeates K, Kelishadi R, Sharief WM, Szuba A, Khatib R, Rahman O, Iqbal R, Bo H, Yibing Z, Wei L, Yusuf S. Association of Symptoms of Depression With Cardiovascular Disease and Mortality in Low-, Middle-, and High-Income Countries. JAMA Psychiatry 2020; 77:1052-1063. [PMID: 32520341 PMCID: PMC7287938 DOI: 10.1001/jamapsychiatry.2020.1351] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [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: 01/13/2023]
Abstract
IMPORTANCE Depression is associated with incidence of and premature death from cardiovascular disease (CVD) and cancer in high-income countries, but it is not known whether this is true in low- and middle-income countries and in urban areas, where most people with depression now live. OBJECTIVE To identify any associations between depressive symptoms and incident CVD and all-cause mortality in countries at different levels of economic development and in urban and rural areas. DESIGN, SETTING, AND PARTICIPANTS This multicenter, population-based cohort study was conducted between January 2005 and June 2019 (median follow-up, 9.3 years) and included 370 urban and 314 rural communities from 21 economically diverse countries on 5 continents. Eligible participants aged 35 to 70 years were enrolled. Analysis began February 2018 and ended September 2019. EXPOSURES Four or more self-reported depressive symptoms from the Short-Form Composite International Diagnostic Interview. MAIN OUTCOMES AND MEASURES Incident CVD, all-cause mortality, and a combined measure of either incident CVD or all-cause mortality. RESULTS Of 145 862 participants, 61 235 (58%) were male and the mean (SD) age was 50.05 (9.7) years. Of those, 15 983 (11%) reported 4 or more depressive symptoms at baseline. Depression was associated with incident CVD (hazard ratio [HR], 1.14; 95% CI, 1.05-1.24), all-cause mortality (HR, 1.17; 95% CI, 1.11-1.25), the combined CVD/mortality outcome (HR, 1.18; 95% CI, 1.11-1.24), myocardial infarction (HR, 1.23; 95% CI, 1.10-1.37), and noncardiovascular death (HR, 1.21; 95% CI, 1.13-1.31) in multivariable models. The risk of the combined outcome increased progressively with number of symptoms, being highest in those with 7 symptoms (HR, 1.24; 95% CI, 1.12-1.37) and lowest with 1 symptom (HR, 1.05; 95% CI, 0.92 -1.19; P for trend < .001). The associations between having 4 or more depressive symptoms and the combined outcome were similar in 7 different geographical regions and in countries at all economic levels but were stronger in urban (HR, 1.23; 95% CI, 1.13-1.34) compared with rural (HR, 1.10; 95% CI, 1.02-1.19) communities (P for interaction = .001) and in men (HR, 1.27; 95% CI, 1.13-1.38) compared with women (HR, 1.14; 95% CI, 1.06-1.23; P for interaction < .001). CONCLUSIONS AND RELEVANCE In this large, population-based cohort study, adults with depressive symptoms were associated with having increased risk of incident CVD and mortality in economically diverse settings, especially in urban areas. Improving understanding and awareness of these physical health risks should be prioritized as part of a comprehensive strategy to reduce the burden of noncommunicable diseases worldwide.
Collapse
Affiliation(s)
- Selina Rajan
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, Tavistock Place, London, United Kingdom,Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, Tavistock Place, London, United Kingdom
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Shrikant Bangdiwala
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Sweden
| | - Rajeev Gupta
- Eternal Heart Care Centre & Research Institute, Jaipur, India
| | | | | | - Scott Lear
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Division of Cardiology, Providence Health Care, Vancouver, British Columbia, Canada
| | - Khalid F. AlHabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Homer U. Co
- University of the Philippines College of Medicine, Manila, Philippines
| | - Patricio Lopez-Jaramillo
- Masira Research Institute, Medical School, Universidad de Santander (UDES), FOSCAL, Bucaramanga, Colombia
| | - Alvaro Avezum
- Department of Medicine, Universidade de Santo Amaro, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | | | - Aytekin Oguz
- Istanbul Medeniyet University, Faculty of Medicine, Department of Internal Medicine, Istanbul, Turkey
| | - Iolanthé M Kruger
- Africa Unit for Transdisciplinary Health Research, North-West University, Potchefstroom, South Africa
| | - Rafael Diaz
- Estudios Clínicos Latinoamérica (ECLA), Rosario, Santa Fe, Argentina
| | | | - Jephat Chifamba
- University of Zimbabwe College of Health Sciences, Department of Physiology, Harare, Zimbabwe
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Roya Kelishadi
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Wadeia Mohammed Sharief
- Department of Medicine, Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Andrzej Szuba
- Department of Angiology, Wroclaw Medical University, Poland
| | - Rasha Khatib
- Advocate Research Institute, Advocate Health Care, Downers Grove, Illinois,Institute for Community and Public Health, Birzeit University, Birzeit, Palestine
| | - Omar Rahman
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Romaina Iqbal
- Independent University, Bangladesh, Dhaka, Bangladesh
| | - Hu Bo
- National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhu Yibing
- National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Li Wei
- National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | | |
Collapse
|
18
|
Farhat N, Birkett N, Haddad N, Fortin Y, Momoli F, Wen SW, Wielgosz A, McNair DS, Mattison DR, Krewski D. Risk of Adverse Cardiovascular Events Following a Myocardial Infarction in Patients Receiving Combined Clopidogrel and Proton Pump Inhibitor Treatment: A Nested Case-Control Study. Drugs Real World Outcomes 2020; 7:191-203. [PMID: 32617885 PMCID: PMC7392938 DOI: 10.1007/s40801-020-00204-9] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background The clinical implications of potential interactions between proton pump inhibitors (PPIs) and clopidogrel have been debated for over a decade. Objective We assessed the association between combined clopidogrel–PPI treatment and the risk of recurrent myocardial infarction (MI) and three secondary outcomes. Patients and Methods A nested case–control study was conducted within Cerner Corporation’s Health Facts® database. A retrospective cohort of patients who experienced a first MI and started clopidogrel treatment was created. Within this cohort, patients experiencing a second MI (cases) were matched with up to five controls. Logistic regression was used to estimate adjusted odds ratios (aORs). Findings were compared with those obtained from models with three negative control exposure drugs: H2 receptor antagonists, prasugrel, and ticagrelor. Results In total, 2890 recurrent MI cases were identified within 12 months following entry into the cohort of clopidogrel users (N = 52,006). aOR for PPI use versus non-use among clopidogrel users was 1.08 [95% confidence interval (CI) 0.95–1.23]. Similar ORs were obtained for secondary endpoints. A positive association between combined use of clopidogrel/PPIs and increased risk of MI was seen in the group aged 80–89 years (aOR 1.26; 95% CI 1.05–1.51). No associations with MI were observed for (1) H2 receptor antagonist use versus non-use among clopidogrel users or (2) PPI use versus non-use among prasugrel users or among ticagrelor users. Conclusions Overall, our findings do not support a significant adverse clinical impact of concomitant clopidogrel/PPI use by patients with MI. Nonetheless, investigation of the possible association seen in those aged 80–89 years may be warranted. Electronic supplementary material The online version of this article (10.1007/s40801-020-00204-9) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Nawal Farhat
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada. .,McLaughlin Centre for Population Health Risk Assessment, Ottawa, ON, Canada.
| | - Nicholas Birkett
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,McLaughlin Centre for Population Health Risk Assessment, Ottawa, ON, Canada
| | - Nisrine Haddad
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,McLaughlin Centre for Population Health Risk Assessment, Ottawa, ON, Canada
| | - Yannick Fortin
- McLaughlin Centre for Population Health Risk Assessment, Ottawa, ON, Canada
| | - Franco Momoli
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Risk Sciences International, Ottawa, ON, Canada
| | - Shi Wu Wen
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,OMNI Research Group, Department of Obstetrics and Gynecology, University of Ottawa Faculty of Medicine, Ottawa, ON, Canada
| | | | | | - Donald R Mattison
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,McLaughlin Centre for Population Health Risk Assessment, Ottawa, ON, Canada.,Risk Sciences International, Ottawa, ON, Canada
| | - Daniel Krewski
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,McLaughlin Centre for Population Health Risk Assessment, Ottawa, ON, Canada.,Risk Sciences International, Ottawa, ON, Canada
| |
Collapse
|
19
|
Hystad P, Larkin A, Rangarajan S, AlHabib KF, Avezum Á, Calik KBT, Chifamba J, Dans A, Diaz R, du Plessis JL, Gupta R, Iqbal R, Khatib R, Kelishadi R, Lanas F, Liu Z, Lopez-Jaramillo P, Nair S, Poirier P, Rahman O, Rosengren A, Swidan H, Tse LA, Wei L, Wielgosz A, Yeates K, Yusoff K, Zatoński T, Burnett R, Yusuf S, Brauer M. Associations of outdoor fine particulate air pollution and cardiovascular disease in 157 436 individuals from 21 high-income, middle-income, and low-income countries (PURE): a prospective cohort study. Lancet Planet Health 2020; 4:e235-e245. [PMID: 32559440 PMCID: PMC7457447 DOI: 10.1016/s2542-5196(20)30103-0] [Citation(s) in RCA: 92] [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: 11/14/2019] [Revised: 03/19/2020] [Accepted: 04/21/2020] [Indexed: 05/05/2023]
Abstract
BACKGROUND Most studies of long-term exposure to outdoor fine particulate matter (PM2·5) and cardiovascular disease are from high-income countries with relatively low PM2·5 concentrations. It is unclear whether risks are similar in low-income and middle-income countries (LMICs) and how outdoor PM2·5 contributes to the global burden of cardiovascular disease. In our analysis of the Prospective Urban and Rural Epidemiology (PURE) study, we aimed to investigate the association between long-term exposure to PM2·5 concentrations and cardiovascular disease in a large cohort of adults from 21 high-income, middle-income, and low-income countries. METHODS In this multinational, prospective cohort study, we studied 157 436 adults aged 35-70 years who were enrolled in the PURE study in countries with ambient PM2·5 estimates, for whom follow-up data were available. Cox proportional hazard frailty models were used to estimate the associations between long-term mean community outdoor PM2·5 concentrations and cardiovascular disease events (fatal and non-fatal), cardiovascular disease mortality, and other non-accidental mortality. FINDINGS Between Jan 1, 2003, and July 14, 2018, 157 436 adults from 747 communities in 21 high-income, middle-income, and low-income countries were enrolled and followed up, of whom 140 020 participants resided in LMICs. During a median follow-up period of 9·3 years (IQR 7·8-10·8; corresponding to 1·4 million person-years), we documented 9996 non-accidental deaths, of which 3219 were attributed to cardiovascular disease. 9152 (5·8%) of 157 436 participants had cardiovascular disease events (fatal and non-fatal incident cardiovascular disease), including 4083 myocardial infarctions and 4139 strokes. Mean 3-year PM2·5 at cohort baseline was 47·5 μg/m3 (range 6-140). In models adjusted for individual, household, and geographical factors, a 10 μg/m3 increase in PM2·5 was associated with increased risk for cardiovascular disease events (hazard ratio 1·05 [95% CI 1·03-1·07]), myocardial infarction (1·03 [1·00-1·05]), stroke (1·07 [1·04-1·10]), and cardiovascular disease mortality (1·03 [1·00-1·05]). Results were similar for LMICs and communities with high PM2·5 concentrations (>35 μg/m3). The population attributable fraction for PM2·5 in the PURE cohort was 13·9% (95% CI 8·8-18·6) for cardiovascular disease events, 8·4% (0·0-15·4) for myocardial infarction, 19·6% (13·0-25·8) for stroke, and 8·3% (0·0-15·2) for cardiovascular disease mortality. We identified no consistent associations between PM2·5 and risk for non-cardiovascular disease deaths. INTERPRETATION Long-term outdoor PM2·5 concentrations were associated with increased risks of cardiovascular disease in adults aged 35-70 years. Air pollution is an important global risk factor for cardiovascular disease and a need exists to reduce air pollution concentrations, especially in LMICs, where air pollution levels are highest. FUNDING Full funding sources are listed at the end of the paper (see Acknowledgments).
Collapse
Affiliation(s)
- Perry Hystad
- College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
| | - Andrew Larkin
- College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Khalid F AlHabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Álvaro Avezum
- Department of Medicine, Universidade de Santo Amaro, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | | | - Jephat Chifamba
- Department of Physiology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Antonio Dans
- Department of Cardiac Sciences, University of Philippines, Manila, Philippines
| | - Rafael Diaz
- Estudios Clínicos Latinoamérica (ECLA), Rosario, Santa Fe, Argentina
| | - Johan L du Plessis
- Occupational Hygiene and Health Research Initiative, North-West University, Potchefstroom, South Africa
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Jaipur, India
| | - Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Rasha Khatib
- Institute for Community and Public Health, Birzeit University, Birzeit, Palestine; Advocate Health Care, Chicago, IL, USA
| | - Roya Kelishadi
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fernando Lanas
- Department of Medicine, Universidad de La Frontera, Temuco, Chile
| | - Zhiguang Liu
- Jockey Club School of Public Health and Primary Care, the Chinese University of Hong Kong, Prince of Wales Hospital, Sha Tin, Hong Kong
| | - Patricio Lopez-Jaramillo
- Fundación Oftalmológica de Santander Clínica Carlos Ardila Lulle (FOSCAL), Bucaramanga, Colombia; Escuela de Medicina, Universidad de Santander, Bucaramanga, Colombia
| | - Sanjeev Nair
- Health Action by People, Thiruvananthapuram, India
| | - Paul Poirier
- Faculty of Pharmacy, University Institute of Cardiology and Respirology of Quebec, Laval University, Québec, QC, Canada
| | | | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hany Swidan
- Dubai Health Authority, Dubai, United Arab Emirates
| | - Lap Ah Tse
- Jockey Club School of Public Health and Primary Care, the Chinese University of Hong Kong, Prince of Wales Hospital, Sha Tin, Hong Kong
| | - Li Wei
- National Centre for Cardiovascular Diseases, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Andreas Wielgosz
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Khalid Yusoff
- Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia; UCSI University, Cheras, Kuala Lumpur, Malaysia
| | - Tomasz Zatoński
- Department of Otolaryngology Head and Neck Surgery, Wrocław Medical University, Wrocław, Poland
| | - Rick Burnett
- Environmental Health Science and Research Bureau, Health Canada, Ottawa, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Michael Brauer
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
20
|
Dehghan M, Mente A, Rangarajan S, Mohan V, Lear S, Swaminathan S, Wielgosz A, Seron P, Avezum A, Lopez-Jaramillo P, Turbide G, Chifamba J, AlHabib KF, Mohammadifard N, Szuba A, Khatib R, Altuntas Y, Liu X, Iqbal R, Rosengren A, Yusuf R, Smuts M, Yusufali A, Li N, Diaz R, Yusoff K, Kaur M, Soman B, Ismail N, Gupta R, Dans A, Sheridan P, Teo K, Anand SS, Yusuf S. Association of egg intake with blood lipids, cardiovascular disease, and mortality in 177,000 people in 50 countries. Am J Clin Nutr 2020; 111:795-803. [PMID: 31965140 PMCID: PMC7138651 DOI: 10.1093/ajcn/nqz348] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [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: 08/19/2019] [Accepted: 12/26/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Eggs are a rich source of essential nutrients, but they are also a source of dietary cholesterol. Therefore, some guidelines recommend limiting egg consumption. However, there is contradictory evidence on the impact of eggs on diseases, largely based on studies conducted in high-income countries. OBJECTIVES Our aim was to assess the association of egg consumption with blood lipids, cardiovascular disease (CVD), and mortality in large global studies involving populations from low-, middle-, and high-income countries. METHODS We studied 146,011 individuals from 21 countries in the Prospective Urban Rural Epidemiology (PURE) study. Egg consumption was recorded using country-specific validated FFQs. We also studied 31,544 patients with vascular disease in 2 multinational prospective studies: ONTARGET (Ongoing Telmisartan Alone and in Combination with Ramipril Global End Point Trial) and TRANSCEND (Telmisartan Randomized Assessment Study in ACEI Intolerant Subjects with Cardiovascular Disease). We calculated HRs using multivariable Cox frailty models with random intercepts to account for clustering by study center separately within each study. RESULTS In the PURE study, we recorded 14,700 composite events (8932 deaths and 8477 CVD events). In the PURE study, after excluding those with history of CVD, higher intake of egg (≥7 egg/wk compared with <1 egg/wk intake) was not significantly associated with blood lipids, composite outcome (HR: 0.96; 95% CI: 0.89, 1.04; P-trend = 0.74), total mortality (HR: 1.04; 95% CI: 0.94, 1.15; P-trend = 0.38), or major CVD (HR: 0.92; 95% CI: 0.83, 1.01; P-trend = 0.20). Similar results were observed in ONTARGET/TRANSCEND studies for composite outcome (HR 0.97; 95% CI: 0.76, 1.25; P-trend = 0.09), total mortality (HR: 0.88; 95% CI: 0.62, 1.24; P-trend = 0.55), and major CVD (HR: 0.97; 95% CI: 0.73, 1.29; P-trend = 0.12). CONCLUSIONS In 3 large international prospective studies including ∼177,000 individuals, 12,701 deaths, and 13,658 CVD events from 50 countries in 6 continents, we did not find significant associations between egg intake and blood lipids, mortality, or major CVD events. The ONTARGET and TRANSCEND trials were registered at clinicaltrials.gov as NCT00153101. The PURE trial was registered at clinicaltrials.gov as NCT03225586.
Collapse
Affiliation(s)
- Mahshid Dehghan
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada,Address correspondence to MD (e-mail: )
| | - Andrew Mente
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Viswanathan Mohan
- Dr. Mohan's Diabetes Specialities Centre, Gopalapuram, Chennai, India
| | - Scott Lear
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Sumathi Swaminathan
- Division of Nutrition, St John's Research Institute, Koramangala, Bangalore, India
| | - Andreas Wielgosz
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Pamela Seron
- Faculty of Medicine, University of La Frontera, Temuco, Chile
| | - Alvaro Avezum
- Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
| | | | - Ginette Turbide
- Heart and Lung Institute, Laval University, Quebec City, QC, Canada
| | - Jephat Chifamba
- 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
| | - Andrzej Szuba
- Division of Angiology, Wroclaw Medical University, Wroclaw, Poland,Department of Internal Medicine, 4th Military Hospital in Wroclaw, Wroclaw, Poland
| | - Rasha Khatib
- Institute for Community and Public Health, Birzeit University, Birzeit, Palestine,Advocate Research Institute, Advocate Health Care, Chicago, IL, USA
| | - Yuksel Altuntas
- Clinic of Endocrinology and Metabolism Sisli, Istanbul Sisli Hamidiye Etfal Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Istanbul, Turkey
| | - Xiaoyun Liu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, and Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Rita Yusuf
- School of Life Sciences, Independent University, Dhaka, Bangladesh
| | - Marius Smuts
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
| | | | - Ning Li
- Qingshan Lake Community Health Service Center, Nanchang City, China
| | - Rafael Diaz
- Clinical Studies Latin America, Rosario, Santa Fe, Argentina
| | - Khalid Yusoff
- Department of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia,Department of Medicine, UCSI University, Cheras, Selangor, Malaysia
| | - Manmeet Kaur
- Post Graduate Institute of Medical Education and Research, School of Public Health, Chandigarh, India
| | - Biju Soman
- Health Action by People, Thiruvananthapuram, India,Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, India
| | - Noorhassim Ismail
- Department of Community Health, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Rajeev Gupta
- Eternal Heart Care Centre & Research Institute, Jaipur, India
| | - Antonio Dans
- Department of Medicine, University of the Philippines, Manila, Philippines
| | - Patrick Sheridan
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Koon Teo
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Sonia S Anand
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
21
|
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).
Collapse
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
| |
Collapse
|
22
|
Dagenais GR, Leong DP, Rangarajan S, Lanas F, Lopez-Jaramillo P, Gupta R, Diaz R, Avezum A, Oliveira GBF, Wielgosz A, Parambath SR, Mony P, Alhabib KF, Temizhan A, Ismail N, Chifamba J, Yeates K, Khatib R, Rahman O, Zatonska K, Kazmi K, Wei L, Zhu J, Rosengren A, Vijayakumar K, Kaur M, Mohan V, Yusufali A, Kelishadi R, Teo KK, Joseph P, Yusuf S. Variations in common diseases, hospital admissions, and deaths in middle-aged adults in 21 countries from five continents (PURE): a prospective cohort study. Lancet 2020; 395:785-794. [PMID: 31492501 DOI: 10.1016/s0140-6736(19)32007-0] [Citation(s) in RCA: 338] [Impact Index Per Article: 84.5] [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: 07/24/2019] [Revised: 08/12/2019] [Accepted: 08/14/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND To our knowledge, no previous study has prospectively documented the incidence of common diseases and related mortality in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) with standardised approaches. Such information is key to developing global and context-specific health strategies. In our analysis of the Prospective Urban Rural Epidemiology (PURE) study, we aimed to evaluate differences in the incidence of common diseases, related hospital admissions, and related mortality in a large contemporary cohort of adults from 21 HICs, MICs, and LICs across five continents by use of standardised approaches. METHODS The PURE study is a prospective, population-based cohort study of individuals aged 35-70 years who have been enrolled from 21 countries across five continents. The key outcomes were the incidence of fatal and non-fatal cardiovascular diseases, cancers, injuries, respiratory diseases, and hospital admissions, and we calculated the age-standardised and sex-standardised incidence of these events per 1000 person-years. FINDINGS This analysis assesses the incidence of events in 162 534 participants who were enrolled in the first two phases of the PURE core study, between Jan 6, 2005, and Dec 4, 2016, and who were assessed for a median of 9·5 years (IQR 8·5-10·9). During follow-up, 11 307 (7·0%) participants died, 9329 (5·7%) participants had cardiovascular disease, 5151 (3·2%) participants had a cancer, 4386 (2·7%) participants had injuries requiring hospital admission, 2911 (1·8%) participants had pneumonia, and 1830 (1·1%) participants had chronic obstructive pulmonary disease (COPD). Cardiovascular disease occurred more often in LICs (7·1 cases per 1000 person-years) and in MICs (6·8 cases per 1000 person-years) than in HICs (4·3 cases per 1000 person-years). However, incident cancers, injuries, COPD, and pneumonia were most common in HICs and least common in LICs. Overall mortality rates in LICs (13·3 deaths per 1000 person-years) were double those in MICs (6·9 deaths per 1000 person-years) and four times higher than in HICs (3·4 deaths per 1000 person-years). This pattern of the highest mortality in LICs and the lowest in HICs was observed for all causes of death except cancer, where mortality was similar across country income levels. Cardiovascular disease was the most common cause of deaths overall (40%) but accounted for only 23% of deaths in HICs (vs 41% in MICs and 43% in LICs), despite more cardiovascular disease risk factors (as judged by INTERHEART risk scores) in HICs and the fewest such risk factors in LICs. The ratio of deaths from cardiovascular disease to those from cancer was 0·4 in HICs, 1·3 in MICs, and 3·0 in LICs, and four upper-MICs (Argentina, Chile, Turkey, and Poland) showed ratios similar to the HICs. Rates of first hospital admission and cardiovascular disease medication use were lowest in LICs and highest in HICs. INTERPRETATION Among adults aged 35-70 years, cardiovascular disease is the major cause of mortality globally. However, in HICs and some upper-MICs, deaths from cancer are now more common than those from cardiovascular disease, indicating a transition in the predominant causes of deaths in middle-age. As cardiovascular disease decreases in many countries, mortality from cancer will probably become the leading cause of death. The high mortality in poorer countries is not related to risk factors, but it might be related to poorer access to health care. FUNDING Full funding sources are listed at the end of the paper (see Acknowledgments).
Collapse
Affiliation(s)
- Gilles R Dagenais
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec, QC, Canada
| | - Darryl P Leong
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Fernando Lanas
- Department of Medicine, Universidad de La Frontera, Temuco, Chile
| | - Patricio Lopez-Jaramillo
- Medical School, Fundación Oftalmológica de Santander, Universidad de Santander, Bucaramanga, Colombia
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Jaipur, India; Department of Medicine, Rajasthan University of Health Sciences, Jaipur, India
| | - Rafael Diaz
- Estudios Clinicos Latinoamérica, Rosario, Argentina
| | - Alvaro Avezum
- Department of Medicine, Hospital Alemão Oswaldo Cruz, Universidade de Santo Amaro, São Paulo, Brazil
| | | | - Andreas Wielgosz
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Shameena R Parambath
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Prem Mony
- St John's Research Institute, St John's Medical College, Bangalore, India
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Centre, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ahmet Temizhan
- Department of Cardiology, Faculty of Medicine, Saglik Bilimleri University, Ankara, Turkey
| | - Noorhassim Ismail
- Department of Community Health, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Jephat Chifamba
- Department of Physiology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Karen Yeates
- Pamoja Tunaweza Women's Centre, Moshi, Tanzania; Division of Nephrology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Rasha Khatib
- Institute for Community and Public Health, Birzeit University, Birzeit, Palestine; Advocate Research Institute, Advocate Health Care, Chicago, IL, USA
| | | | - Katarzyna Zatonska
- Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Khawar Kazmi
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Li Wei
- National Centre for Cardiovascular Diseases, Cardiovascular Institute, Beijing, China; Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jun Zhu
- 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
| | - K Vijayakumar
- Health Action by People, Trivandrum, India; Amrita Institute of Medical Sciences, Kochi, India
| | - Manmeet Kaur
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation, Chennai, India; Dr Mohan's Diabetes Specialities Centre, Chennai, India
| | - AfzalHussein Yusufali
- Department of Medicine, Hatta Hospital, Dubai Medical University, Dubai Health Authority, Dubai, United Arab Emirates
| | - Roya Kelishadi
- Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Koon K Teo
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Philip Joseph
- 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.
| |
Collapse
|
23
|
Dagenais GR, Leong DP, Rangarajan S, Lanas F, Lopez-Jaramillo P, Gupta R, Diaz R, Avezum A, Oliveira GBF, Wielgosz A, Parambath SR, Mony P, Alhabib KF, Temizhan A, Ismail N, Chifamba J, Yeates K, Khatib R, Rahman O, Zatonska K, Kazmi K, Wei L, Zhu J, Rosengren A, Vijayakumar K, Kaur M, Mohan V, Yusufali A, Kelishadi R, Teo KK, Joseph P, Yusuf S. Variations in common diseases, hospital admissions, and deaths in middle-aged adults in 21 countries from five continents (PURE): a prospective cohort study. Lancet 2020. [PMID: 31492501 DOI: 10.1016/s0140-6736(19)32007-0]] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND To our knowledge, no previous study has prospectively documented the incidence of common diseases and related mortality in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) with standardised approaches. Such information is key to developing global and context-specific health strategies. In our analysis of the Prospective Urban Rural Epidemiology (PURE) study, we aimed to evaluate differences in the incidence of common diseases, related hospital admissions, and related mortality in a large contemporary cohort of adults from 21 HICs, MICs, and LICs across five continents by use of standardised approaches. METHODS The PURE study is a prospective, population-based cohort study of individuals aged 35-70 years who have been enrolled from 21 countries across five continents. The key outcomes were the incidence of fatal and non-fatal cardiovascular diseases, cancers, injuries, respiratory diseases, and hospital admissions, and we calculated the age-standardised and sex-standardised incidence of these events per 1000 person-years. FINDINGS This analysis assesses the incidence of events in 162 534 participants who were enrolled in the first two phases of the PURE core study, between Jan 6, 2005, and Dec 4, 2016, and who were assessed for a median of 9·5 years (IQR 8·5-10·9). During follow-up, 11 307 (7·0%) participants died, 9329 (5·7%) participants had cardiovascular disease, 5151 (3·2%) participants had a cancer, 4386 (2·7%) participants had injuries requiring hospital admission, 2911 (1·8%) participants had pneumonia, and 1830 (1·1%) participants had chronic obstructive pulmonary disease (COPD). Cardiovascular disease occurred more often in LICs (7·1 cases per 1000 person-years) and in MICs (6·8 cases per 1000 person-years) than in HICs (4·3 cases per 1000 person-years). However, incident cancers, injuries, COPD, and pneumonia were most common in HICs and least common in LICs. Overall mortality rates in LICs (13·3 deaths per 1000 person-years) were double those in MICs (6·9 deaths per 1000 person-years) and four times higher than in HICs (3·4 deaths per 1000 person-years). This pattern of the highest mortality in LICs and the lowest in HICs was observed for all causes of death except cancer, where mortality was similar across country income levels. Cardiovascular disease was the most common cause of deaths overall (40%) but accounted for only 23% of deaths in HICs (vs 41% in MICs and 43% in LICs), despite more cardiovascular disease risk factors (as judged by INTERHEART risk scores) in HICs and the fewest such risk factors in LICs. The ratio of deaths from cardiovascular disease to those from cancer was 0·4 in HICs, 1·3 in MICs, and 3·0 in LICs, and four upper-MICs (Argentina, Chile, Turkey, and Poland) showed ratios similar to the HICs. Rates of first hospital admission and cardiovascular disease medication use were lowest in LICs and highest in HICs. INTERPRETATION Among adults aged 35-70 years, cardiovascular disease is the major cause of mortality globally. However, in HICs and some upper-MICs, deaths from cancer are now more common than those from cardiovascular disease, indicating a transition in the predominant causes of deaths in middle-age. As cardiovascular disease decreases in many countries, mortality from cancer will probably become the leading cause of death. The high mortality in poorer countries is not related to risk factors, but it might be related to poorer access to health care. FUNDING Full funding sources are listed at the end of the paper (see Acknowledgments).
Collapse
Affiliation(s)
- Gilles R Dagenais
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec, QC, Canada
| | - Darryl P Leong
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Fernando Lanas
- Department of Medicine, Universidad de La Frontera, Temuco, Chile
| | - Patricio Lopez-Jaramillo
- Medical School, Fundación Oftalmológica de Santander, Universidad de Santander, Bucaramanga, Colombia
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Jaipur, India; Department of Medicine, Rajasthan University of Health Sciences, Jaipur, India
| | - Rafael Diaz
- Estudios Clinicos Latinoamérica, Rosario, Argentina
| | - Alvaro Avezum
- Department of Medicine, Hospital Alemão Oswaldo Cruz, Universidade de Santo Amaro, São Paulo, Brazil
| | | | - Andreas Wielgosz
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Shameena R Parambath
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Prem Mony
- St John's Research Institute, St John's Medical College, Bangalore, India
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Centre, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ahmet Temizhan
- Department of Cardiology, Faculty of Medicine, Saglik Bilimleri University, Ankara, Turkey
| | - Noorhassim Ismail
- Department of Community Health, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Jephat Chifamba
- Department of Physiology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Karen Yeates
- Pamoja Tunaweza Women's Centre, Moshi, Tanzania; Division of Nephrology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Rasha Khatib
- Institute for Community and Public Health, Birzeit University, Birzeit, Palestine; Advocate Research Institute, Advocate Health Care, Chicago, IL, USA
| | | | - Katarzyna Zatonska
- Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Khawar Kazmi
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Li Wei
- National Centre for Cardiovascular Diseases, Cardiovascular Institute, Beijing, China; Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jun Zhu
- 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
| | - K Vijayakumar
- Health Action by People, Trivandrum, India; Amrita Institute of Medical Sciences, Kochi, India
| | - Manmeet Kaur
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation, Chennai, India; Dr Mohan's Diabetes Specialities Centre, Chennai, India
| | - AfzalHussein Yusufali
- Department of Medicine, Hatta Hospital, Dubai Medical University, Dubai Health Authority, Dubai, United Arab Emirates
| | - Roya Kelishadi
- Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Koon K Teo
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Philip Joseph
- 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.
| |
Collapse
|
24
|
Murphy A, Palafox B, Walli-Attaei M, Powell-Jackson T, Rangarajan S, Alhabib KF, Avezum AJ, Calik KBT, Chifamba J, Choudhury T, Dagenais G, Dans AL, Gupta R, Iqbal R, Kaur M, Kelishadi R, Khatib R, Kruger IM, Kutty VR, Lear SA, Li W, Lopez-Jaramillo P, Mohan V, Mony PK, Orlandini A, Rosengren A, Rosnah I, Seron P, Teo K, Tse LA, Tsolekile L, Wang Y, Wielgosz A, Yan R, Yeates KE, Yusoff K, Zatonska K, Hanson K, Yusuf S, McKee M. The household economic burden of non-communicable diseases in 18 countries. BMJ Glob Health 2020; 5:e002040. [PMID: 32133191 PMCID: PMC7042605 DOI: 10.1136/bmjgh-2019-002040] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [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: 10/01/2019] [Revised: 01/07/2020] [Accepted: 01/09/2020] [Indexed: 11/29/2022] Open
Abstract
Background Non-communicable diseases (NCDs) are the leading cause of death globally. In 2014, the United Nations committed to reducing premature mortality from NCDs, including by reducing the burden of healthcare costs. Since 2014, the Prospective Urban and Rural Epidemiology (PURE) Study has been collecting health expenditure data from households with NCDs in 18 countries. Methods Using data from the PURE Study, we estimated risk of catastrophic health spending and impoverishment among households with at least one person with NCDs (cardiovascular disease, diabetes, kidney disease, cancer and respiratory diseases; n=17 435), with hypertension only (a leading risk factor for NCDs; n=11 831) or with neither (n=22 654) by country income group: high-income countries (Canada and Sweden), upper middle income countries (UMICs: Brazil, Chile, Malaysia, Poland, South Africa and Turkey), lower middle income countries (LMICs: the Philippines, Colombia, India, Iran and the Occupied Palestinian Territory) and low-income countries (LICs: Bangladesh, Pakistan, Zimbabwe and Tanzania) and China. Results The prevalence of catastrophic spending and impoverishment is highest among households with NCDs in LMICs and China. After adjusting for covariates that might drive health expenditure, the absolute risk of catastrophic spending is higher in households with NCDs compared with no NCDs in LMICs (risk difference=1.71%; 95% CI 0.75 to 2.67), UMICs (0.82%; 95% CI 0.37 to 1.27) and China (7.52%; 95% CI 5.88 to 9.16). A similar pattern is observed in UMICs and China for impoverishment. A high proportion of those with NCDs in LICs, especially women (38.7% compared with 12.6% in men), reported not taking medication due to costs. Conclusions Our findings show that financial protection from healthcare costs for people with NCDs is inadequate, particularly in LMICs and China. While the burden of NCD care may appear greatest in LMICs and China, the burden in LICs may be masked by care foregone due to costs. The high proportion of women reporting foregone care due to cost may in part explain gender inequality in treatment of NCDs.
Collapse
Affiliation(s)
- Adrianna Murphy
- London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| | - Benjamin Palafox
- London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| | - Marjan Walli-Attaei
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Timothy Powell-Jackson
- London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences and 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
| | | | | | - Jephat Chifamba
- Department of Physiology, University of Zimbabwe, Harare, Zimbabwe
| | | | - Gilles Dagenais
- Institut universitaire de cardiologie et de pneumologie de Québec, Quebec City, Ontario, Canada
| | - Antonio L Dans
- Department of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Jaipur, India
| | - Romaina Iqbal
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Manmeet Kaur
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Roya Kelishadi
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, the Islamic Republic of Iran
| | - Rasha Khatib
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Iolanthe Marike Kruger
- Africa Unit for Transdisciplinary Health Research, North-West University, Potchefstroom, South Africa
| | | | - Scott A Lear
- Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Wei Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, University Teknologi MARA, Beijing, China
| | | | - Viswanathan Mohan
- Dr. Mohan's Diabetes Specialities Centre & Madras Diabetes Research Foundation, Chennai, India
| | - Prem K Mony
- 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, Gothenburg, Sweden
| | - Ismail Rosnah
- Community Health Department, Faculty of Medicine, UKM Medical Centre, Kuala Lumpur, Malaysia
| | - Pamela Seron
- Facultad de Medicina, Universidad de La Frontera, Temucu, Chile
| | - Koon Teo
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Lap Ah Tse
- JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Lungiswa Tsolekile
- School of Public Health, University of the Western Cape, Bellville, Western Cape, South Africa
| | - Yang Wang
- 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
| | - Andreas Wielgosz
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ruohua Yan
- 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
| | - Karen E Yeates
- Department of Medicine, Queen's University, Kingston, New Hampshire, Canada
| | - Khalid Yusoff
- UiTM, Selayang, Selangor and UCSI University, Cheras, Kuala Lumpur, Malaysia
| | - Katarzyna Zatonska
- Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Kara Hanson
- London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Martin McKee
- London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| |
Collapse
|
25
|
Abstract
BACKGROUND: For over 30 yr the global medical community has attempted to define the acceptable cardiovascular risk in pilots. This challenge is compounded by the ever-changing technological and medical landscape of air travel. We aimed to review the existing literature on estimating the risk of pilot cardiovascular incapacitation and determine if the current guidelines are founded in the best available evidence.METHODS: A detailed review of the guidelines and literature that supports them was completed. Relevant articles were identified by review of the source literature of the guidelines and the references of these source documents. All articles referenced were reviewed in full by both authors. Data that informed the existing recommendations were reviewed and compared to available modern data. The results of these findings were incorporated into a formula that allows for the calculation of acceptable pilot cardiovascular risk given any operator-determined set of variables.RESULTS: Among the evidence that informs current guidelines, there exists a need for further updating. A number of assumptions have been made in creating guidelines and these may no longer reflect the current technological or medical aviation environment. Incorporating the identified variables into a formula allows for the calculation of acceptable cardiovascular risk. This formula was tested using past data and reproduced existing results.DISCUSSION: Current guidelines for pilot cardiovascular risk assessment require review by the international aviation medical community. We propose a novel formula that may serve as a template for future guidelines and may be adapted as aviation technology and health data evolve.Mulloy A, Wielgosz A. Cardiovascular risk assessment in pilots. Aerosp Med Hum Perform. 2019; 90(8):730-734.
Collapse
|
26
|
Rosengren A, Smyth A, Rangarajan S, Ramasundarahettige C, Bangdiwala SI, AlHabib KF, Avezum A, Bengtsson Boström K, Chifamba J, Gulec S, Gupta R, Igumbor EU, Iqbal R, Ismail N, Joseph P, Kaur M, Khatib R, Kruger IM, Lamelas P, Lanas F, Lear SA, Li W, Wang C, Quiang D, Wang Y, Lopez-Jaramillo P, Mohammadifard N, Mohan V, Mony PK, Poirier P, Srilatha S, Szuba A, Teo K, Wielgosz A, Yeates KE, Yusoff K, Yusuf R, Yusufali AH, Attaei MW, McKee M, Yusuf S. Socioeconomic status and risk of cardiovascular disease in 20 low-income, middle-income, and high-income countries: the Prospective Urban Rural Epidemiologic (PURE) study. Lancet Glob Health 2019; 7:e748-e760. [PMID: 31028013 DOI: 10.1016/s2214-109x(19)30045-2] [Citation(s) in RCA: 272] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 12/28/2018] [Accepted: 01/30/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Socioeconomic status is associated with differences in risk factors for cardiovascular disease incidence and outcomes, including mortality. However, it is unclear whether the associations between cardiovascular disease and common measures of socioeconomic status-wealth and education-differ among high-income, middle-income, and low-income countries, and, if so, why these differences exist. We explored the association between education and household wealth and cardiovascular disease and mortality to assess which marker is the stronger predictor of outcomes, and examined whether any differences in cardiovascular disease by socioeconomic status parallel differences in risk factor levels or differences in management. METHODS In this large-scale prospective cohort study, we recruited adults aged between 35 years and 70 years from 367 urban and 302 rural communities in 20 countries. We collected data on families and households in two questionnaires, and data on cardiovascular risk factors in a third questionnaire, which was supplemented with physical examination. We assessed socioeconomic status using education and a household wealth index. Education was categorised as no or primary school education only, secondary school education, or higher education, defined as completion of trade school, college, or university. Household wealth, calculated at the household level and with household data, was defined by an index on the basis of ownership of assets and housing characteristics. Primary outcomes were major cardiovascular disease (a composite of cardiovascular deaths, strokes, myocardial infarction, and heart failure), cardiovascular mortality, and all-cause mortality. Information on specific events was obtained from participants or their family. FINDINGS Recruitment to the study began on Jan 12, 2001, with most participants enrolled between Jan 6, 2005, and Dec 4, 2014. 160 299 (87·9%) of 182 375 participants with baseline data had available follow-up event data and were eligible for inclusion. After exclusion of 6130 (3·8%) participants without complete baseline or follow-up data, 154 169 individuals remained for analysis, from five low-income, 11 middle-income, and four high-income countries. Participants were followed-up for a mean of 7·5 years. Major cardiovascular events were more common among those with low levels of education in all types of country studied, but much more so in low-income countries. After adjustment for wealth and other factors, the HR (low level of education vs high level of education) was 1·23 (95% CI 0·96-1·58) for high-income countries, 1·59 (1·42-1·78) in middle-income countries, and 2·23 (1·79-2·77) in low-income countries (pinteraction<0·0001). We observed similar results for all-cause mortality, with HRs of 1·50 (1·14-1·98) for high-income countries, 1·80 (1·58-2·06) in middle-income countries, and 2·76 (2·29-3·31) in low-income countries (pinteraction<0·0001). By contrast, we found no or weak associations between wealth and these two outcomes. Differences in outcomes between educational groups were not explained by differences in risk factors, which decreased as the level of education increased in high-income countries, but increased as the level of education increased in low-income countries (pinteraction<0·0001). Medical care (eg, management of hypertension, diabetes, and secondary prevention) seemed to play an important part in adverse cardiovascular disease outcomes because such care is likely to be poorer in people with the lowest levels of education compared to those with higher levels of education in low-income countries; however, we observed less marked differences in care based on level of education in middle-income countries and no or minor differences in high-income countries. INTERPRETATION Although people with a lower level of education in low-income and middle-income countries have higher incidence of and mortality from cardiovascular disease, they have better overall risk factor profiles. However, these individuals have markedly poorer health care. Policies to reduce health inequities globally must include strategies to overcome barriers to care, especially for those with lower levels of education. FUNDING Full funding sources are listed at the end of the paper (see Acknowledgments).
Collapse
Affiliation(s)
- Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Andrew Smyth
- HRB Clinical Research Facility Galway, National University of Ireland, Galway, Ireland
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton Health Sciences Centre, Hamilton, ON, Canada
| | | | - Shrikant I Bangdiwala
- Population Health Research Institute, McMaster University, Hamilton Health Sciences Centre, 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
- Dante Pazzanese Institute of Cardiology and University Santo Amaro, São Paulo, Brazil
| | | | - Jephat Chifamba
- Department of Physiology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Sadi Gulec
- Cardiology Department, Ankara University School of Medicine, Ankara, Turkey
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Jaipur, India
| | - Ehi U Igumbor
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Romaina Iqbal
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Norhassim Ismail
- Department of Community Health, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Philip Joseph
- Population Health Research Institute, McMaster University, Hamilton Health Sciences Centre, Hamilton, ON, Canada
| | - Manmeet Kaur
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rasha Khatib
- Public Health Sciences, Stritch School of Medicine, Maywood, IL, USA
| | - Iolanthé M Kruger
- Africa Unit for Transdisciplinary Health Research, North-West University, Potchefstroom, South Africa
| | - Pablo Lamelas
- Population Health Research Institute, McMaster University, Hamilton Health Sciences Centre, Hamilton, ON, Canada
| | | | - Scott A Lear
- Faculty of Health Sciences, 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 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
| | - Deren Quiang
- Wujin District Center for Disease Control and Prevention, Changzhou, China
| | - Yang 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
| | - Patricio Lopez-Jaramillo
- Research Institute, FOSCAL International Clinic, Bucaramanga, Colombia; Eugenio Espejo Medical School, Universidad UTE, Quito, Ecuador
| | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation and Dr Mohan's Diabetes Specialities Centre, Chennai, India
| | - Prem K Mony
- 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
| | | | - Andrzej Szuba
- Division of Angiology, Wroclaw Medical University, Wroclaw, Poland
| | - Koon Teo
- Population Health Research Institute, McMaster University, Hamilton Health Sciences Centre, Hamilton, ON, Canada
| | | | - Karen E Yeates
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Khalid Yusoff
- Universiti Teknologi MARA, Selayang Campus, Selangor, Malaysia; UCSI University, Kuala Lumpur, Malaysia
| | - Rita Yusuf
- School of Life Sciences, Independent University, Dhaka, Bangladesh
| | - Afzalhusein H Yusufali
- Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates
| | - Marjan W Attaei
- Population Health Research Institute, McMaster University, Hamilton Health Sciences Centre, Hamilton, ON, Canada
| | - Martin McKee
- London School of Hygiene & Tropical Medicine, London, UK
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton Health Sciences Centre, Hamilton, ON, Canada
| |
Collapse
|
27
|
O'Donnell M, Mente A, Rangarajan S, McQueen MJ, O'Leary N, Yin L, Liu X, Swaminathan S, Khatib R, Rosengren A, Ferguson J, Smyth A, Lopez-Jaramillo P, Diaz R, Avezum A, Lanas F, Ismail N, Yusoff K, Dans A, Iqbal R, Szuba A, Mohammadifard N, Oguz A, Yusufali AH, Alhabib KF, Kruger IM, Yusuf R, Chifamba J, Yeates K, Dagenais G, Wielgosz A, Lear SA, Teo K, Yusuf S. Joint association of urinary sodium and potassium excretion with cardiovascular events and mortality: prospective cohort study. BMJ 2019; 364:l772. [PMID: 30867146 PMCID: PMC6415648 DOI: 10.1136/bmj.l772] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate the joint association of sodium and potassium urinary excretion (as surrogate measures of intake) with cardiovascular events and mortality, in the context of current World Health Organization recommendations for daily intake (<2.0 g sodium, >3.5 g potassium) in adults. DESIGN International prospective cohort study. SETTING 18 high, middle, and low income countries, sampled from urban and rural communities. PARTICIPANTS 103 570 people who provided morning fasting urine samples. MAIN OUTCOME MEASURES Association of estimated 24 hour urinary sodium and potassium excretion (surrogates for intake) with all cause mortality and major cardiovascular events, using multivariable Cox regression. A six category variable for joint sodium and potassium was generated: sodium excretion (low (<3 g/day), moderate (3-5 g/day), and high (>5 g/day) sodium intakes) by potassium excretion (greater/equal or less than median 2.1 g/day). RESULTS Mean estimated sodium and potassium urinary excretion were 4.93 g/day and 2.12 g/day, respectively. After a median follow-up of 8.2 years, 7884 (6.1%) participants had died or experienced a major cardiovascular event. Increasing urinary sodium excretion was positively associated with increasing potassium excretion (unadjusted r=0.34), and only 0.002% had a concomitant urinary excretion of <2.0 g/day of sodium and >3.5 g/day of potassium. A J-shaped association was observed of sodium excretion and inverse association of potassium excretion with death and cardiovascular events. For joint sodium and potassium excretion categories, the lowest risk of death and cardiovascular events occurred in the group with moderate sodium excretion (3-5 g/day) and higher potassium excretion (21.9% of cohort). Compared with this reference group, the combinations of low potassium with low sodium excretion (hazard ratio 1.23, 1.11 to 1.37; 7.4% of cohort) and low potassium with high sodium excretion (1.21, 1.11 to 1.32; 13.8% of cohort) were associated with the highest risk, followed by low sodium excretion (1.19, 1.02 to 1.38; 3.3% of cohort) and high sodium excretion (1.10, 1.02 to 1.18; 29.6% of cohort) among those with potassium excretion greater than the median. Higher potassium excretion attenuated the increased cardiovascular risk associated with high sodium excretion (P for interaction=0.007). CONCLUSIONS These findings suggest that the simultaneous target of low sodium intake (<2 g/day) with high potassium intake (>3.5 g/day) is extremely uncommon. Combined moderate sodium intake (3-5 g/day) with high potassium intake is associated with the lowest risk of mortality and cardiovascular events.
Collapse
Affiliation(s)
- Martin O'Donnell
- Population Health Research Institute, DBCVS Research Institute, McMaster University, 237 Barton St East, Hamilton, ON L8L 2X2, Canada
- HRB-Clinical Research Facility, Galway University Hospital, NUI Galway, Galway, Ireland
| | - Andrew Mente
- Population Health Research Institute, DBCVS Research Institute, McMaster University, 237 Barton St East, Hamilton, ON L8L 2X2, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, DBCVS Research Institute, McMaster University, 237 Barton St East, Hamilton, ON L8L 2X2, Canada
| | - Matthew J McQueen
- Population Health Research Institute, DBCVS Research Institute, McMaster University, 237 Barton St East, Hamilton, ON L8L 2X2, Canada
| | - Neil O'Leary
- HRB-Clinical Research Facility, Galway University Hospital, NUI Galway, Galway, Ireland
| | - Lu Yin
- Medical Research & Biometrics Centre, National Centre for Cardiovascular Diseases Cardiovascular, Fengcunxili, Mentougou District, Beijing, China
| | - Xiaoyun Liu
- Medical Research & Biometrics Centre, National Centre for Cardiovascular Diseases Cardiovascular, Fengcunxili, Mentougou District, Beijing, China
| | - Sumathi Swaminathan
- Division of Nutrition, St John's Research Institute, Bangalore, Karnataka, India
| | - Rasha Khatib
- Departments of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Annika Rosengren
- Sahlgrenska Academy, University of Gothenburg, and Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - John Ferguson
- HRB-Clinical Research Facility, Galway University Hospital, NUI Galway, Galway, Ireland
| | - Andrew Smyth
- HRB-Clinical Research Facility, Galway University Hospital, NUI Galway, Galway, Ireland
| | - Patricio Lopez-Jaramillo
- Fundacion Oftalmologica de Santander (FOSCAL), Medical School, Universidad de Santander, Floridablanca-Santander, Colombia
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica ECLA, Instituto Cardiovascular de Rosario, Rosario, Santa Fe, Argentina
| | - Alvaro Avezum
- Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
| | | | - Noorhassim Ismail
- Department of Community Health. University Kebangsaan Malaysia Medical Centre, Malaysia
| | - Khalid Yusoff
- Faculty of Medicine and Health Sciences, UCSI University, Kuala Lumpur, Malaysia
| | - Antonio Dans
- University of the Philippines-Manila, Ermita, Manila, Philippines
| | - Romaina Iqbal
- Departments of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Andrzej Szuba
- Division of Angiology, Wroclaw Medical University, Wroclaw, Poland
| | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Centre, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Atyekin Oguz
- Istanbul Medeniyet University, Faculty of Medicine, Department of Internal Medicine, Istanbul, Turkey
| | - Afzal Hussein Yusufali
- Hatta Hospital, Dubai Medical University, Dubai Health Authority. Dubai, United Arab Emirates
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Centre, College of Medicine, King Saud University. Riyadh, Saudi Arabia
| | - Iolanthe M Kruger
- Faculty of Health Science, North-West University, Potchefstroom campus, Potchefstroom, South Africa
| | - Rita Yusuf
- School of Life Sciences and The Centre for Health, Population and Development. Independent University, Bangladesh, Dhaka, Bangladesh
| | - Jephat Chifamba
- University of Zimbabwe, College of Health Sciences, Physiology Department, Harare, Zimbabwe
| | - Karen Yeates
- Department of Medicine, Division of Nephrology, Queen's University, Kingston, Canada
| | - Gilles Dagenais
- Laval University Heart and Lungs Institute, Quebec City, QC, Canada
| | | | - Scott A Lear
- Faculty of Health Sciences, Simon Fraser University, and Division of Cardiology, Providence Health Care, BC, Canada
| | - Koon Teo
- Population Health Research Institute, DBCVS Research Institute, McMaster University, 237 Barton St East, Hamilton, ON L8L 2X2, Canada
| | - Salim Yusuf
- Population Health Research Institute, DBCVS Research Institute, McMaster University, 237 Barton St East, Hamilton, ON L8L 2X2, Canada
| |
Collapse
|
28
|
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.
Collapse
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
| |
Collapse
|
29
|
Murphy A, Palafox B, O'Donnell O, Stuckler D, Perel P, AlHabib KF, Avezum A, Bai X, Chifamba J, Chow CK, Corsi DJ, Dagenais GR, Dans AL, Diaz R, Erbakan AN, Ismail N, Iqbal R, Kelishadi R, Khatib R, Lanas F, Lear SA, Li W, Liu J, Lopez-Jaramillo P, Mohan V, Monsef N, Mony PK, Puoane T, Rangarajan S, Rosengren A, Schutte AE, Sintaha M, Teo KK, Wielgosz A, Yeates K, Yin L, Yusoff K, Zatońska K, Yusuf S, McKee M. Inequalities in the use of secondary prevention of cardiovascular disease by socioeconomic status: evidence from the PURE observational study. Lancet Glob Health 2018; 6:e292-e301. [PMID: 29433667 PMCID: PMC5905400 DOI: 10.1016/s2214-109x(18)30031-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 11/30/2017] [Accepted: 01/16/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND There is little evidence on the use of secondary prevention medicines for cardiovascular disease by socioeconomic groups in countries at different levels of economic development. METHODS We assessed use of antiplatelet, cholesterol, and blood-pressure-lowering drugs in 8492 individuals with self-reported cardiovascular disease from 21 countries enrolled in the Prospective Urban Rural Epidemiology (PURE) study. Defining one or more drugs as a minimal level of secondary prevention, wealth-related inequality was measured using the Wagstaff concentration index, scaled from -1 (pro-poor) to 1 (pro-rich), standardised by age and sex. Correlations between inequalities and national health-related indicators were estimated. FINDINGS The proportion of patients with cardiovascular disease on three medications ranged from 0% in South Africa (95% CI 0-1·7), Tanzania (0-3·6), and Zimbabwe (0-5·1), to 49·3% in Canada (44·4-54·3). Proportions receiving at least one drug varied from 2·0% (95% CI 0·5-6·9) in Tanzania to 91·4% (86·6-94·6) in Sweden. There was significant (p<0·05) pro-rich inequality in Saudi Arabia, China, Colombia, India, Pakistan, and Zimbabwe. Pro-poor distributions were observed in Sweden, Brazil, Chile, Poland, and the occupied Palestinian territory. The strongest predictors of inequality were public expenditure on health and overall use of secondary prevention medicines. INTERPRETATION Use of medication for secondary prevention of cardiovascular disease is alarmingly low. In many countries with the lowest use, pro-rich inequality is greatest. Policies associated with an equal or pro-poor distribution include free medications and community health programmes to support adherence to medications. FUNDING Full funding sources listed at the end of the paper (see Acknowledgments).
Collapse
Affiliation(s)
- Adrianna Murphy
- Centre for Global Chronic Conditions, London School of Tropical Medicine, London, UK.
| | - Benjamin Palafox
- Centre for Global Chronic Conditions, London School of Tropical Medicine, London, UK
| | - Owen O'Donnell
- Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, Netherlands; Faculty of Economics and Business, University of Lausanne, Lausanne, Switzerland
| | - David Stuckler
- Department of Policy Analysis and Public Management, Bocconi University, Milan, Italy
| | - Pablo Perel
- Centre for Global Chronic Conditions, London School of 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
- Institute of Cardiology, University of Santo Amaro, Sao Paulo, Brazil
| | - Xiulin Bai
- 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
- Department of Physiology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Clara K Chow
- The University of Sydney and The George Institute for Global Health, Camperdown, NSW, Australia
| | - Daniel J Corsi
- Ottawa Hospital Research Institute, OMNI Research Group, Clinical Epidemiology Program, Ottawa, ON, Canada
| | - Gilles R Dagenais
- Institut Universitaire de Cardiologie et Pneumologie de Québec, Québec City, QC, Canada
| | - Antonio L Dans
- University of the Philippines-Manila, Manila, Philippines
| | - Rafael Diaz
- Estudios Clínicos Latinoamérica (ECLA) International, Rosario, Santa Fe, Argentina
| | | | - Noorhassim Ismail
- Department of Community Health, UKM Medical Centre, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Romaina Iqbal
- Departments of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Roya Kelishadi
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Chamran Hospital, Isfahan, Iran
| | - Rasha Khatib
- Department of Public Health Sciences, Loyola Medical Center, Maywood, IL, USA
| | | | | | - Wei Li
- 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
| | - Jia 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
| | - Patricio Lopez-Jaramillo
- Fundación Oftalmológica de Santander-FOSCAL-FOSCAL Internacional, Floridablanca, Santander, Colombia
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation and DrMohan's Diabetes Specialities Centre, Gopalapuram, Chennai, India
| | - Nahed Monsef
- Dubai Health Authority, Dubai, United Arab Emirates
| | - Prem K Mony
- St John's Medical College and Research Insitute, Bangalore, India
| | - Thandi Puoane
- School of Public Health, University of the Western Cape, Cape Town, Western Cape Province, South Africa
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, C2-106 DBCVSRI Hamilton General Hospital, Hamilton, ON, Canada
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital/Östra, Göteborg, Sweden
| | - Aletta E Schutte
- South African Medical Research Council Unit for Hypertension and Cardiovascular Disease, Hypertension in Africa Research Team (HART), North-West University, Potchefstroom, South Africa
| | - Mariz Sintaha
- Independent University, Bangladesh, Dhaka, Bangladesh
| | - Koon K Teo
- Population Health Research Institute, McMaster University, C2-106 DBCVSRI Hamilton General Hospital, Hamilton, ON, Canada
| | | | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Lu Yin
- 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
| | - Khalid Yusoff
- Universiti Teknologi MARA, Selyang Campus, Selayang, Selangor and UCSI University, Cheras, Malaysia
| | | | - Salim Yusuf
- Population Health Research Institute, McMaster University, C2-106 DBCVSRI Hamilton General Hospital, Hamilton, ON, Canada
| | - Martin McKee
- Centre for Global Chronic Conditions, London School of Tropical Medicine, London, UK
| |
Collapse
|
30
|
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.
Collapse
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
| |
Collapse
|
31
|
Dehghan M, Mente A, Zhang X, Swaminathan S, Li W, Mohan V, Iqbal R, Kumar R, Wentzel-Viljoen E, Rosengren A, Amma LI, Avezum A, Chifamba J, Diaz R, Khatib R, Lear S, Lopez-Jaramillo P, Liu X, Gupta R, Mohammadifard N, Gao N, Oguz A, Ramli AS, Seron P, Sun Y, Szuba A, Tsolekile L, Wielgosz A, Yusuf R, Hussein Yusufali A, Teo KK, Rangarajan S, Dagenais G, Bangdiwala SI, Islam S, Anand SS, Yusuf S. Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study. Lancet 2017; 390:2050-2062. [PMID: 28864332 DOI: 10.1016/s0140-6736(17)32252-3] [Citation(s) in RCA: 670] [Impact Index Per Article: 95.7] [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: 02/07/2023]
Abstract
BACKGROUND The relationship between macronutrients and cardiovascular disease and mortality is controversial. Most available data are from European and North American populations where nutrition excess is more likely, so their applicability to other populations is unclear. METHODS The Prospective Urban Rural Epidemiology (PURE) study is a large, epidemiological cohort study of individuals aged 35-70 years (enrolled between Jan 1, 2003, and March 31, 2013) in 18 countries with a median follow-up of 7·4 years (IQR 5·3-9·3). Dietary intake of 135 335 individuals was recorded using validated food frequency questionnaires. The primary outcomes were total mortality and major cardiovascular events (fatal cardiovascular disease, non-fatal myocardial infarction, stroke, and heart failure). Secondary outcomes were all myocardial infarctions, stroke, cardiovascular disease mortality, and non-cardiovascular disease mortality. Participants were categorised into quintiles of nutrient intake (carbohydrate, fats, and protein) based on percentage of energy provided by nutrients. We assessed the associations between consumption of carbohydrate, total fat, and each type of fat with cardiovascular disease and total mortality. We calculated hazard ratios (HRs) using a multivariable Cox frailty model with random intercepts to account for centre clustering. FINDINGS During follow-up, we documented 5796 deaths and 4784 major cardiovascular disease events. Higher carbohydrate intake was associated with an increased risk of total mortality (highest [quintile 5] vs lowest quintile [quintile 1] category, HR 1·28 [95% CI 1·12-1·46], ptrend=0·0001) but not with the risk of cardiovascular disease or cardiovascular disease mortality. Intake of total fat and each type of fat was associated with lower risk of total mortality (quintile 5 vs quintile 1, total fat: HR 0·77 [95% CI 0·67-0·87], ptrend<0·0001; saturated fat, HR 0·86 [0·76-0·99], ptrend=0·0088; monounsaturated fat: HR 0·81 [0·71-0·92], ptrend<0·0001; and polyunsaturated fat: HR 0·80 [0·71-0·89], ptrend<0·0001). Higher saturated fat intake was associated with lower risk of stroke (quintile 5 vs quintile 1, HR 0·79 [95% CI 0·64-0·98], ptrend=0·0498). Total fat and saturated and unsaturated fats were not significantly associated with risk of myocardial infarction or cardiovascular disease mortality. INTERPRETATION High carbohydrate intake was associated with higher risk of total mortality, whereas total fat and individual types of fat were related to lower total mortality. Total fat and types of fat were not associated with cardiovascular disease, myocardial infarction, or cardiovascular disease mortality, whereas saturated fat had an inverse association with stroke. Global dietary guidelines should be reconsidered in light of these findings. FUNDING Full funding sources listed at the end of the paper (see Acknowledgments).
Collapse
Affiliation(s)
- Mahshid Dehghan
- 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
| | - Xiaohe Zhang
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Sumathi Swaminathan
- St John's Research Institute, St John's National Academy of Health Sciences, Sarjapur Road, Koramangala, Bangalore, Karnataka, India
| | - 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
| | | | - Romaina Iqbal
- Departments of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Rajesh Kumar
- PGIMER School of Public Health, Chandigarh, India
| | - Edelweiss Wentzel-Viljoen
- Centre of Excellence for Nutrition, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Leela Itty Amma
- Health Action by People TC 1/1706, Medical College PO, Trivandrum, India
| | - Alvaro Avezum
- Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
| | - Jephat Chifamba
- University of Zimbabwe, College of Health Sciences, Department of Physiology, Harare, Zimbabwe
| | - Rafael Diaz
- Estudios Clínicos Latinoamérica, ECLA, Rosario, Argentina
| | - Rasha Khatib
- Institute of Community and Public Health, Birzeit University, Birzeit, occupied Palestinian territory
| | - Scott Lear
- Faculty of Health Sciences, Department of Biomedical Physiology & Kinesiology, Simon Fraser University, Burnaby, BC, Canada
| | | | - 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
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Jaipur, India
| | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Centre, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nan Gao
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Aytekin Oguz
- Istanbul Medeniyet University, Faculty of Medicine, Department of Internal Medicine, Goztepe, Istanbul, Turkey
| | | | - Pamela Seron
- Universidad de La Frontera, Temuco, Araucanía, Chile
| | - Yi Sun
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Andrzej Szuba
- Division of Angiology, Wroclaw Medical University, Wroclaw, Poland
| | - Lungiswa Tsolekile
- University of the Western Cape, Bellville, Western Province, Cape Town, South Africa
| | | | - Rita Yusuf
- Independent University, Bangladesh, Dhaka, Bangladesh
| | - Afzal Hussein Yusufali
- Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Koon K Teo
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Gilles Dagenais
- Université Laval, Institut Universitaire de Cardiologie, Ville de Québec, QC, Canada
| | | | - Shofiqul Islam
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Sonia S Anand
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
32
|
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).
Collapse
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
| |
Collapse
|
33
|
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).
Collapse
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
| | | |
Collapse
|
34
|
Wielgosz A, Dai S, Walsh P, McCrea-Logie J, Celebican E. Comorbid Conditions in Canadians Hospitalized Because of Diabetes. Can J Diabetes 2017; 42:106-111. [PMID: 28579199 DOI: 10.1016/j.jcjd.2017.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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: 10/13/2016] [Revised: 02/28/2017] [Accepted: 03/07/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The number of hospital discharges involving type 1 or type 2 diabetes as the first-listed diagnosis has increased over the past few decades. Such cases are commonly associated with various comorbidities. We analyzed data collected from hospital separations in Canada to determine the number and proportion of comorbid conditions in Canadians hospitalized because of diabetes. METHODS The most responsible diagnosis (MRDx) of diabetes (ICD-10-CA: E10 [type 1 diabetes] or E11 [type 2 diabetes]) was identified from acute care hospital separations (Discharge Abstract Database) from 2013 to 2014 in all Canadian jurisdictions except Quebec. Hospital separations were calculated by 5-year age groups and sex. The most common comorbid (secondary) diagnoses were identified for hospital separations with diabetes as the MRDx, and the average lengths of stay associated with diabetes were determined. RESULTS The total number of hospital separations in 2013-2014 in Canada (excluding Quebec) with diabetes as the MRDx in all ages was 30,422, and males represented more than half (58.7%) of the separations. The median age group when diabetes is the MRDx is 60 to 64. For all patients hospitalized with an MRDx of diabetes, there were 2.2% deaths. Hypertension was the most common comorbid diagnosis in patients with diabetes as the MRDx, followed by glomerular disorders, peripheral angiopathy and acute renal failure. CONCLUSIONS Hospitalizations resulting from diabetes are associated with vascular comorbidities, and hypertension is the most common. Prevention of shared predisposing factors should reduce the burden of hospitalizations associated with diabetes.
Collapse
Affiliation(s)
- Andreas Wielgosz
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.
| | - Sulan Dai
- Centre for Chronic Disease Prevention, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Peter Walsh
- Centre for Chronic Disease Prevention, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Jennifer McCrea-Logie
- Centre for Chronic Disease Prevention, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Ece Celebican
- Ece Celebican, Faculty of Law, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
35
|
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.
Collapse
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
| |
Collapse
|
36
|
Mente A, Dagenais G, Wielgosz A, Lear SA, McQueen MJ, Zeidler J, Fu L, DeJesus J, Rangarajan S, Bourlaud AS, De Bluts AL, Corber E, de Jong V, Boomgaardt J, Shane A, Jiang Y, de Groh M, O'Donnell MJ, Yusuf S, Teo K. Assessment of Dietary Sodium and Potassium in Canadians Using 24-Hour Urinary Collection. Can J Cardiol 2016; 32:319-26. [DOI: 10.1016/j.cjca.2015.06.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 05/31/2015] [Accepted: 06/16/2015] [Indexed: 01/15/2023] Open
|
37
|
Wielgosz A, Robinson C, Mao Y, Jiang Y, Campbell NRC, Muthuri S, Morrison H. The Impact of Using Different Methods to Assess Completeness of 24-Hour Urine Collection on Estimating Dietary Sodium. J Clin Hypertens (Greenwich) 2015; 18:581-4. [DOI: 10.1111/jch.12716] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 08/19/2015] [Accepted: 08/20/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Andreas Wielgosz
- Public Health Agency of Canada; Ottawa ON Canada
- University of Ottawa; Ottawa ON Canada
| | | | - Yang Mao
- Public Health Agency of Canada; Ottawa ON Canada
| | - Ying Jiang
- Public Health Agency of Canada; Ottawa ON Canada
| | | | - Stella Muthuri
- African Population and Health Research Center; Nairobi Kenya
| | | |
Collapse
|
38
|
Smith EE, O'Donnell M, Dagenais G, Lear SA, Wielgosz A, Sharma M, Poirier P, Stotts G, Black SE, Strother S, Noseworthy MD, Benavente O, Modi J, Goyal M, Batool S, Sanchez K, Hill V, McCreary CR, Frayne R, Islam S, DeJesus J, Rangarajan S, Teo K, Yusuf S. Early cerebral small vessel disease and brain volume, cognition, and gait. Ann Neurol 2015; 77:251-61. [PMID: 25428654 PMCID: PMC4338762 DOI: 10.1002/ana.24320] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 10/25/2014] [Accepted: 11/22/2014] [Indexed: 11/20/2022]
Abstract
Objective Decline in cognitive function begins by the 40s, and may be related to future dementia risk. We used data from a community-representative study to determine whether there are age-related differences in simple cognitive and gait tests by the 40s, and whether these differences were associated with covert cerebrovascular disease on magnetic resonance imaging (MRI). Methods Between 2010 and 2012, 803 participants aged 40 to 75 years in the Prospective Urban Rural Epidemiological (PURE) study, recruited from prespecified postal code regions centered on 4 Canadian cities, underwent brain MRI and simple tests of cognition and gait as part of a substudy (PURE-MIND). Results Mean age was 58 ± 8 years. Linear decreases in performance on the Montreal Cognitive Assessment, Digit Symbol Substitution Test (DSST), and Timed Up and Go test of gait were seen with each age decade from the 40s to the 70s. Silent brain infarcts were observed in 3% of 40- to 49-year-olds, with increasing prevalence up to 18.9% in 70-year-olds. Silent brain infarcts were associated with slower timed gait and lower volume of supratentorial white matter. Higher volume of supratentorial MRI white matter hyperintensity was associated with slower timed gait and worse performance on DSST, and lower volumes of the supratentorial cortex and white matter, and cerebellum. Interpretation Covert cerebrovascular disease and its consequences on cognitive and gait performance and brain atrophy are manifest in some clinically asymptomatic persons as early as the 5th decade of life. Ann Neurol 2015;77:251–261
Collapse
Affiliation(s)
- Eric E Smith
- Hotchkiss Brain Institute; Department of Clinical Neurosciences; Department of Radiology; Seaman Family Centre, University of Calgary, Calgary, Alberta
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
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: 569] [Impact Index Per Article: 56.9] [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: 11/19/2022]
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.).
Collapse
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
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Mente A, O'Donnell MJ, Rangarajan S, McQueen MJ, Poirier P, Wielgosz A, Morrison H, Li W, Wang X, Di C, Mony P, Devanath A, Rosengren A, Oguz A, Zatonska K, Yusufali AH, Lopez-Jaramillo P, Avezum A, Ismail N, Lanas F, Puoane T, Diaz R, Kelishadi R, Iqbal R, Yusuf R, Chifamba J, Khatib R, Teo K, Yusuf S. Association of urinary sodium and potassium excretion with blood pressure. N Engl J Med 2014; 371:601-11. [PMID: 25119606 DOI: 10.1056/nejmoa1311989] [Citation(s) in RCA: 577] [Impact Index Per Article: 57.7] [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: 11/19/2022]
Abstract
BACKGROUND Higher levels of sodium intake are reported to be associated with higher blood pressure. Whether this relationship varies according to levels of sodium or potassium intake and in different populations is unknown. METHODS We studied 102,216 adults from 18 countries. Estimates of 24-hour sodium and potassium excretion were made from a single fasting morning urine specimen and were used as surrogates for intake. We assessed the relationship between electrolyte excretion and blood pressure, as measured with an automated device. RESULTS Regression analyses showed increments of 2.11 mm Hg in systolic blood pressure and 0.78 mm Hg in diastolic blood pressure for each 1-g increment in estimated sodium excretion. The slope of this association was steeper with higher sodium intake (an increment of 2.58 mm Hg in systolic blood pressure per gram for sodium excretion >5 g per day, 1.74 mm Hg per gram for 3 to 5 g per day, and 0.74 mm Hg per gram for <3 g per day; P<0.001 for interaction). The slope of association was steeper for persons with hypertension (2.49 mm Hg per gram) than for those without hypertension (1.30 mm Hg per gram, P<0.001 for interaction) and was steeper with increased age (2.97 mm Hg per gram at >55 years of age, 2.43 mm Hg per gram at 45 to 55 years of age, and 1.96 mm Hg per gram at <45 years of age; P<0.001 for interaction). Potassium excretion was inversely associated with systolic blood pressure, with a steeper slope of association for persons with hypertension than for those without it (P<0.001) and a steeper slope with increased age (P<0.001). CONCLUSIONS In this study, the association of estimated intake of sodium and potassium, as determined from measurements of excretion of these cations, with blood pressure was nonlinear and was most pronounced in persons consuming high-sodium diets, persons with hypertension, and older persons. (Funded by the Heart and Stroke Foundation of Ontario and others.).
Collapse
Affiliation(s)
- Andrew Mente
- The authors' affiliations are listed in the Appendix
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Batool S, O'Donnell M, Sharma M, Islam S, Dagenais GR, Poirier P, Lear SA, Wielgosz A, Teo K, Stotts G, McCreary CR, Frayne R, DeJesus J, Rangarajan S, Yusuf S, Smith EE. Incidental magnetic resonance diffusion-weighted imaging-positive lesions are rare in neurologically asymptomatic community-dwelling adults. Stroke 2014; 45:2115-7. [PMID: 24923720 DOI: 10.1161/strokeaha.114.005782] [Citation(s) in RCA: 17] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Incidental magnetic resonance diffusion-weighted imaging (DWI)-positive lesions, considered to represent small acute infarcts, have been detected in patients with cerebral small vessel diseases or cognitive impairment, but the prevalence in the community population is unknown. METHODS DWI sequences collected in 793 participants in the Prospective Urban Rural Epidemiological (PURE) study were reviewed for DWI lesions consistent with small acute infarcts. RESULTS No DWI-positive lesions were detected (0%, 95% confidence interval, 0-0.5). CONCLUSIONS DWI-positive lesions are rare in an asymptomatic community population. The prevalence of DWI-positive lesions in the community seems to be lower than in patients with cerebral amyloid angiopathy, intracerebral hemorrhage, or cognitive impairment.
Collapse
Affiliation(s)
- Saima Batool
- From the Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (S.B., R.F., E.E.S.); Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada (M.O., M.S., S.I., K.T., J.D., S.R., S.Y.); Quebec Heart and Lung Institute, Laval University, Quebec, Canada (G.R.D., P.P.); Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada (S.A.L.); Division of Cardiology, Providence Health Care, Vancouver, British Columbia, Canada (S.A.L.); The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada (A.W., G.S.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (C.R.M., R.F., E.E.S.); Seaman Family MR Research Centre, Alberta Health Services, Alberta, Canada (C.R.M., R.F., E.E.S.); and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (R.F., E.E.S.)
| | - Martin O'Donnell
- From the Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (S.B., R.F., E.E.S.); Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada (M.O., M.S., S.I., K.T., J.D., S.R., S.Y.); Quebec Heart and Lung Institute, Laval University, Quebec, Canada (G.R.D., P.P.); Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada (S.A.L.); Division of Cardiology, Providence Health Care, Vancouver, British Columbia, Canada (S.A.L.); The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada (A.W., G.S.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (C.R.M., R.F., E.E.S.); Seaman Family MR Research Centre, Alberta Health Services, Alberta, Canada (C.R.M., R.F., E.E.S.); and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (R.F., E.E.S.)
| | - Mukul Sharma
- From the Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (S.B., R.F., E.E.S.); Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada (M.O., M.S., S.I., K.T., J.D., S.R., S.Y.); Quebec Heart and Lung Institute, Laval University, Quebec, Canada (G.R.D., P.P.); Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada (S.A.L.); Division of Cardiology, Providence Health Care, Vancouver, British Columbia, Canada (S.A.L.); The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada (A.W., G.S.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (C.R.M., R.F., E.E.S.); Seaman Family MR Research Centre, Alberta Health Services, Alberta, Canada (C.R.M., R.F., E.E.S.); and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (R.F., E.E.S.)
| | - Shofiqul Islam
- From the Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (S.B., R.F., E.E.S.); Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada (M.O., M.S., S.I., K.T., J.D., S.R., S.Y.); Quebec Heart and Lung Institute, Laval University, Quebec, Canada (G.R.D., P.P.); Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada (S.A.L.); Division of Cardiology, Providence Health Care, Vancouver, British Columbia, Canada (S.A.L.); The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada (A.W., G.S.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (C.R.M., R.F., E.E.S.); Seaman Family MR Research Centre, Alberta Health Services, Alberta, Canada (C.R.M., R.F., E.E.S.); and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (R.F., E.E.S.)
| | - Gilles R Dagenais
- From the Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (S.B., R.F., E.E.S.); Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada (M.O., M.S., S.I., K.T., J.D., S.R., S.Y.); Quebec Heart and Lung Institute, Laval University, Quebec, Canada (G.R.D., P.P.); Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada (S.A.L.); Division of Cardiology, Providence Health Care, Vancouver, British Columbia, Canada (S.A.L.); The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada (A.W., G.S.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (C.R.M., R.F., E.E.S.); Seaman Family MR Research Centre, Alberta Health Services, Alberta, Canada (C.R.M., R.F., E.E.S.); and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (R.F., E.E.S.)
| | - Paul Poirier
- From the Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (S.B., R.F., E.E.S.); Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada (M.O., M.S., S.I., K.T., J.D., S.R., S.Y.); Quebec Heart and Lung Institute, Laval University, Quebec, Canada (G.R.D., P.P.); Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada (S.A.L.); Division of Cardiology, Providence Health Care, Vancouver, British Columbia, Canada (S.A.L.); The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada (A.W., G.S.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (C.R.M., R.F., E.E.S.); Seaman Family MR Research Centre, Alberta Health Services, Alberta, Canada (C.R.M., R.F., E.E.S.); and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (R.F., E.E.S.)
| | - Scott A Lear
- From the Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (S.B., R.F., E.E.S.); Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada (M.O., M.S., S.I., K.T., J.D., S.R., S.Y.); Quebec Heart and Lung Institute, Laval University, Quebec, Canada (G.R.D., P.P.); Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada (S.A.L.); Division of Cardiology, Providence Health Care, Vancouver, British Columbia, Canada (S.A.L.); The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada (A.W., G.S.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (C.R.M., R.F., E.E.S.); Seaman Family MR Research Centre, Alberta Health Services, Alberta, Canada (C.R.M., R.F., E.E.S.); and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (R.F., E.E.S.)
| | - Andreas Wielgosz
- From the Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (S.B., R.F., E.E.S.); Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada (M.O., M.S., S.I., K.T., J.D., S.R., S.Y.); Quebec Heart and Lung Institute, Laval University, Quebec, Canada (G.R.D., P.P.); Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada (S.A.L.); Division of Cardiology, Providence Health Care, Vancouver, British Columbia, Canada (S.A.L.); The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada (A.W., G.S.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (C.R.M., R.F., E.E.S.); Seaman Family MR Research Centre, Alberta Health Services, Alberta, Canada (C.R.M., R.F., E.E.S.); and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (R.F., E.E.S.)
| | - Koon Teo
- From the Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (S.B., R.F., E.E.S.); Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada (M.O., M.S., S.I., K.T., J.D., S.R., S.Y.); Quebec Heart and Lung Institute, Laval University, Quebec, Canada (G.R.D., P.P.); Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada (S.A.L.); Division of Cardiology, Providence Health Care, Vancouver, British Columbia, Canada (S.A.L.); The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada (A.W., G.S.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (C.R.M., R.F., E.E.S.); Seaman Family MR Research Centre, Alberta Health Services, Alberta, Canada (C.R.M., R.F., E.E.S.); and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (R.F., E.E.S.)
| | - Grant Stotts
- From the Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (S.B., R.F., E.E.S.); Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada (M.O., M.S., S.I., K.T., J.D., S.R., S.Y.); Quebec Heart and Lung Institute, Laval University, Quebec, Canada (G.R.D., P.P.); Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada (S.A.L.); Division of Cardiology, Providence Health Care, Vancouver, British Columbia, Canada (S.A.L.); The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada (A.W., G.S.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (C.R.M., R.F., E.E.S.); Seaman Family MR Research Centre, Alberta Health Services, Alberta, Canada (C.R.M., R.F., E.E.S.); and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (R.F., E.E.S.)
| | - Cheryl R McCreary
- From the Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (S.B., R.F., E.E.S.); Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada (M.O., M.S., S.I., K.T., J.D., S.R., S.Y.); Quebec Heart and Lung Institute, Laval University, Quebec, Canada (G.R.D., P.P.); Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada (S.A.L.); Division of Cardiology, Providence Health Care, Vancouver, British Columbia, Canada (S.A.L.); The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada (A.W., G.S.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (C.R.M., R.F., E.E.S.); Seaman Family MR Research Centre, Alberta Health Services, Alberta, Canada (C.R.M., R.F., E.E.S.); and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (R.F., E.E.S.)
| | - Richard Frayne
- From the Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (S.B., R.F., E.E.S.); Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada (M.O., M.S., S.I., K.T., J.D., S.R., S.Y.); Quebec Heart and Lung Institute, Laval University, Quebec, Canada (G.R.D., P.P.); Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada (S.A.L.); Division of Cardiology, Providence Health Care, Vancouver, British Columbia, Canada (S.A.L.); The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada (A.W., G.S.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (C.R.M., R.F., E.E.S.); Seaman Family MR Research Centre, Alberta Health Services, Alberta, Canada (C.R.M., R.F., E.E.S.); and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (R.F., E.E.S.)
| | - Jane DeJesus
- From the Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (S.B., R.F., E.E.S.); Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada (M.O., M.S., S.I., K.T., J.D., S.R., S.Y.); Quebec Heart and Lung Institute, Laval University, Quebec, Canada (G.R.D., P.P.); Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada (S.A.L.); Division of Cardiology, Providence Health Care, Vancouver, British Columbia, Canada (S.A.L.); The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada (A.W., G.S.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (C.R.M., R.F., E.E.S.); Seaman Family MR Research Centre, Alberta Health Services, Alberta, Canada (C.R.M., R.F., E.E.S.); and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (R.F., E.E.S.)
| | - Sumathy Rangarajan
- From the Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (S.B., R.F., E.E.S.); Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada (M.O., M.S., S.I., K.T., J.D., S.R., S.Y.); Quebec Heart and Lung Institute, Laval University, Quebec, Canada (G.R.D., P.P.); Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada (S.A.L.); Division of Cardiology, Providence Health Care, Vancouver, British Columbia, Canada (S.A.L.); The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada (A.W., G.S.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (C.R.M., R.F., E.E.S.); Seaman Family MR Research Centre, Alberta Health Services, Alberta, Canada (C.R.M., R.F., E.E.S.); and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (R.F., E.E.S.)
| | - Salim Yusuf
- From the Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (S.B., R.F., E.E.S.); Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada (M.O., M.S., S.I., K.T., J.D., S.R., S.Y.); Quebec Heart and Lung Institute, Laval University, Quebec, Canada (G.R.D., P.P.); Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada (S.A.L.); Division of Cardiology, Providence Health Care, Vancouver, British Columbia, Canada (S.A.L.); The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada (A.W., G.S.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (C.R.M., R.F., E.E.S.); Seaman Family MR Research Centre, Alberta Health Services, Alberta, Canada (C.R.M., R.F., E.E.S.); and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (R.F., E.E.S.)
| | - Eric E Smith
- From the Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (S.B., R.F., E.E.S.); Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada (M.O., M.S., S.I., K.T., J.D., S.R., S.Y.); Quebec Heart and Lung Institute, Laval University, Quebec, Canada (G.R.D., P.P.); Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada (S.A.L.); Division of Cardiology, Providence Health Care, Vancouver, British Columbia, Canada (S.A.L.); The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada (A.W., G.S.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (C.R.M., R.F., E.E.S.); Seaman Family MR Research Centre, Alberta Health Services, Alberta, Canada (C.R.M., R.F., E.E.S.); and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (R.F., E.E.S.).
| | | |
Collapse
|
42
|
|
43
|
Dai S, Bienek A, Walsh P, Wielgosz A, Morrison H. 182 The Burden of Hospitalized Stroke in Canada. Can J Cardiol 2012. [DOI: 10.1016/j.cjca.2012.07.182] [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: 10/27/2022] Open
|
44
|
Reid RD, Morrin LI, Higginson LAJ, Wielgosz A, Blanchard C, Beaton LJ, Nelson C, McDonnell L, Oldridge N, Wells GA, Pipe AL. Motivational counselling for physical activity in patients with coronary artery disease not participating in cardiac rehabilitation. Eur J Prev Cardiol 2011; 19:161-6. [PMID: 21450579 DOI: 10.1177/1741826711400519] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [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: 11/16/2022]
Abstract
BACKGROUND Many patients with coronary artery disease (CAD) fail to attend cardiac rehabilitation following acute coronary events because they lack motivation to exercise. Theory-based approaches to promote physical activity among non-participants in cardiac rehabilitation are required. DESIGN A randomized trial comparing physical activity levels at baseline, 6, and 12 months between a motivational counselling (MC) intervention group and a usual care (UC) control group. METHOD One hundred and forty-one participants hospitalized with acute coronary syndromes not planning to attend cardiac rehabilitation were recruited at a single centre and randomized to either MC (n = 69) or UC (n = 72). The MC intervention, designed from an ecological perspective, included one face-to-face contact and eight telephone contacts with a trained physiotherapist over a 52-week period. The UC group received written information about starting a walking programme and brief physical activity advice from their attending cardiologist. Physical activity was measured by: 7-day physical activity recall interview; self-report questionnaire; and pedometer at baseline, 6, and 12 months after randomization. RESULTS Latent growth curve analyses, which combined all three outcome measures into a single latent construct, showed that physical activity increased more over time in the MC versus the UC group (µ(add) = 0.69, p < 0.05). CONCLUSION Patients with CAD not participating in cardiac rehabilitation receiving a theory-based motivational counselling intervention were more physically active at follow-up than those receiving usual care. This intervention may extend the reach of cardiac rehabilitation by increasing physical activity in those disinclined to participate in structured programmes.
Collapse
Affiliation(s)
- Robert D Reid
- Minto Prevention and Rehabilitation Centre, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, Canada.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Jiang Y, Villeneuve PJ, Wielgosz A, Schaubel DE, Fenton SSA, Mao Y. The incidence of cancer in a population-based cohort of Canadian heart transplant recipients. Am J Transplant 2010; 10:637-45. [PMID: 20121725 DOI: 10.1111/j.1600-6143.2009.02973.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
To assess the long-term risk of developing cancer among heart transplant recipients compared to the Canadian general population, we carried out a retrospective cohort study of 1703 patients who received a heart transplant between 1981 and 1998, identified from the Canadian Organ Replacement Register database. Vital status and cancer incidence were determined through record linkage to the Canadian Mortality Database and Canadian Cancer Registry. Cancer incidence rates among heart transplant patients were compared to those of the general population. The observed number of incident cancers was 160 with 58.9 expected in the general population (SIR = 2.7, 95% CI = 2.3, 3.2). The highest ratios were for non-Hodgkin's lymphoma (NHL) (SIR = 22.7, 95% CI = 17.3, 29.3), oral cancer (SIR = 4.3, 95% CI = 2.1, 8.0) and lung cancer (SIR = 2.0, 95% CI = 1.2, 3.0). Compared to the general population, SIRs for NHL were particularly elevated in the first year posttransplant during more recent calendar periods, and among younger patients. Within the heart transplant cohort, overall cancer risks increased with age, and the 15-year cumulative incidence of all cancers was estimated to be 17%. There is an excess of incident cases of cancer among heart transplant recipients. The relative excesses are most marked for NHL, oral and lung cancer.
Collapse
Affiliation(s)
- Y Jiang
- Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | | | | | | | | | | |
Collapse
|
46
|
Abstract
Information plays a key role in monitoring, management, evaluation and policy development related to cardiovascular diseases. Canada currently lacks a comprehensive, integrated pan-Canadian system to address the growing burden of cardiovascular diseases, including reliable and timely data that can be used by policy-makers, health care providers, researchers and the public. Theme Working Group 1 (one of six Theme Working Groups) aimed to address different aspects of the Canadian Heart Health Strategy and Action Plan, with a focus on strengthening information systems. Members of the group, who are experts in the cardiovascular field and/or information systems, defined the scope of the issue, identified gaps and solutions, and discussed priorities. The process is described and suggestions for final recommendations are presented. These suggestions were made taking into consideration the needs of health care providers, patients and consumers, the needs for planning, innovation, evaluation and system improvement, and the needs for information on populations and environments. A sustained integrated system that meets cardiovascular information needs requires a major commitment of expertise, leadership and funding.
Collapse
Affiliation(s)
- A McFarlane
- Canadian Institute for Health Information, Ottawa, Canada.
| | | |
Collapse
|
47
|
Affiliation(s)
- S Dai
- Chronic Disease Surveillance Division, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada
| | - C Bancej
- Chronic Disease Surveillance Division, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada
| | - A Bienek
- Chronic Disease Surveillance Division, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada
| | - P Walsh
- Chronic Disease Surveillance Division, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada
| | - P Stewart
- Chronic Disease Surveillance Division, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada
| | - A Wielgosz
- Chronic Disease Surveillance Division, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada
| |
Collapse
|
48
|
Campbell NR, Brant R, Johansen H, Walker RL, Wielgosz A, Onysko J, Gao RN, Sambell C, Phillips S, McAlister FA. Increases in Antihypertensive Prescriptions and Reductions in Cardiovascular Events in Canada. Hypertension 2009; 53:128-34. [PMID: 19114646 DOI: 10.1161/hypertensionaha.108.119784] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Canadian Hypertension Education Program, an extensive professional education program to improve the management of hypertension, was started in 1999. There were very large increases in diagnosis and treatment of hypertension in the first 4 years after initiation of the program. The purpose of this study was to examine the association between the changes in antihypertensive therapy with changes in hospitalization and death from major hypertension-related cardiovascular diseases in Canada between 1992 and 2003. Using various national databases, Canadian standardized yearly mortality and hospitalization rates per 1000 for stroke, heart failure, and acute myocardial infarction were calculated for individuals aged ≥20 years and regressed against antihypertensive prescription rates. Changes in rates were examined in a time series analysis. There were significant reductions (
P
<0.0001) in the rate of death from stroke, heart failure, and myocardial infarction starting in 1999. There was also a reduction in hospitalization rate from stroke (
P
<0.0001) and heart failure (
P
<0.0001) but not myocardial infarction in 1999. The changes in death (
P
<0.001 for all 3 diseases) and hospitalization (
P
<0.0001 for stroke and heart failure;
P
=0.018 for acute myocardial infarction) were associated with the increases in antihypertensive prescriptions. This study demonstrates that the reduction in cardiovascular death and hospitalization rates is associated with an increase in antihypertensive prescriptions and that it coincides with the introduction of the Canadian Hypertension Education Program. The Canadian Hypertension Education Program educational model for improving health care could be adopted by other countries with well-developed professional and scientific societies.
Collapse
Affiliation(s)
- Norm R.C. Campbell
- From the Departments of Medicine (N.R.C.C., R.L.W.), Community Health Sciences (N.R.C.C.), and Pharmacology and Therapeutics (N.R.C.C.), and Libin Cardiovascular Institute (N.R.C.C.), University of Calgary, Calgary, Alberta, Canada; Department of Statistics (R.B.), University of British Columbia, Vancouver, British Columbia, Canada; Health Information and Research Division (H.J., C.S.), Statistics Canada, Ottawa, Ontario, Canada; Centre for Chronic Disease Prevention and Control (R.L.W., J.O., R-N.G
| | - Rollin Brant
- From the Departments of Medicine (N.R.C.C., R.L.W.), Community Health Sciences (N.R.C.C.), and Pharmacology and Therapeutics (N.R.C.C.), and Libin Cardiovascular Institute (N.R.C.C.), University of Calgary, Calgary, Alberta, Canada; Department of Statistics (R.B.), University of British Columbia, Vancouver, British Columbia, Canada; Health Information and Research Division (H.J., C.S.), Statistics Canada, Ottawa, Ontario, Canada; Centre for Chronic Disease Prevention and Control (R.L.W., J.O., R-N.G
| | - Helen Johansen
- From the Departments of Medicine (N.R.C.C., R.L.W.), Community Health Sciences (N.R.C.C.), and Pharmacology and Therapeutics (N.R.C.C.), and Libin Cardiovascular Institute (N.R.C.C.), University of Calgary, Calgary, Alberta, Canada; Department of Statistics (R.B.), University of British Columbia, Vancouver, British Columbia, Canada; Health Information and Research Division (H.J., C.S.), Statistics Canada, Ottawa, Ontario, Canada; Centre for Chronic Disease Prevention and Control (R.L.W., J.O., R-N.G
| | - Robin L. Walker
- From the Departments of Medicine (N.R.C.C., R.L.W.), Community Health Sciences (N.R.C.C.), and Pharmacology and Therapeutics (N.R.C.C.), and Libin Cardiovascular Institute (N.R.C.C.), University of Calgary, Calgary, Alberta, Canada; Department of Statistics (R.B.), University of British Columbia, Vancouver, British Columbia, Canada; Health Information and Research Division (H.J., C.S.), Statistics Canada, Ottawa, Ontario, Canada; Centre for Chronic Disease Prevention and Control (R.L.W., J.O., R-N.G
| | - Andreas Wielgosz
- From the Departments of Medicine (N.R.C.C., R.L.W.), Community Health Sciences (N.R.C.C.), and Pharmacology and Therapeutics (N.R.C.C.), and Libin Cardiovascular Institute (N.R.C.C.), University of Calgary, Calgary, Alberta, Canada; Department of Statistics (R.B.), University of British Columbia, Vancouver, British Columbia, Canada; Health Information and Research Division (H.J., C.S.), Statistics Canada, Ottawa, Ontario, Canada; Centre for Chronic Disease Prevention and Control (R.L.W., J.O., R-N.G
| | - Jay Onysko
- From the Departments of Medicine (N.R.C.C., R.L.W.), Community Health Sciences (N.R.C.C.), and Pharmacology and Therapeutics (N.R.C.C.), and Libin Cardiovascular Institute (N.R.C.C.), University of Calgary, Calgary, Alberta, Canada; Department of Statistics (R.B.), University of British Columbia, Vancouver, British Columbia, Canada; Health Information and Research Division (H.J., C.S.), Statistics Canada, Ottawa, Ontario, Canada; Centre for Chronic Disease Prevention and Control (R.L.W., J.O., R-N.G
| | - Ru-Nie Gao
- From the Departments of Medicine (N.R.C.C., R.L.W.), Community Health Sciences (N.R.C.C.), and Pharmacology and Therapeutics (N.R.C.C.), and Libin Cardiovascular Institute (N.R.C.C.), University of Calgary, Calgary, Alberta, Canada; Department of Statistics (R.B.), University of British Columbia, Vancouver, British Columbia, Canada; Health Information and Research Division (H.J., C.S.), Statistics Canada, Ottawa, Ontario, Canada; Centre for Chronic Disease Prevention and Control (R.L.W., J.O., R-N.G
| | - Christie Sambell
- From the Departments of Medicine (N.R.C.C., R.L.W.), Community Health Sciences (N.R.C.C.), and Pharmacology and Therapeutics (N.R.C.C.), and Libin Cardiovascular Institute (N.R.C.C.), University of Calgary, Calgary, Alberta, Canada; Department of Statistics (R.B.), University of British Columbia, Vancouver, British Columbia, Canada; Health Information and Research Division (H.J., C.S.), Statistics Canada, Ottawa, Ontario, Canada; Centre for Chronic Disease Prevention and Control (R.L.W., J.O., R-N.G
| | - Stephen Phillips
- From the Departments of Medicine (N.R.C.C., R.L.W.), Community Health Sciences (N.R.C.C.), and Pharmacology and Therapeutics (N.R.C.C.), and Libin Cardiovascular Institute (N.R.C.C.), University of Calgary, Calgary, Alberta, Canada; Department of Statistics (R.B.), University of British Columbia, Vancouver, British Columbia, Canada; Health Information and Research Division (H.J., C.S.), Statistics Canada, Ottawa, Ontario, Canada; Centre for Chronic Disease Prevention and Control (R.L.W., J.O., R-N.G
| | - Finlay A. McAlister
- From the Departments of Medicine (N.R.C.C., R.L.W.), Community Health Sciences (N.R.C.C.), and Pharmacology and Therapeutics (N.R.C.C.), and Libin Cardiovascular Institute (N.R.C.C.), University of Calgary, Calgary, Alberta, Canada; Department of Statistics (R.B.), University of British Columbia, Vancouver, British Columbia, Canada; Health Information and Research Division (H.J., C.S.), Statistics Canada, Ottawa, Ontario, Canada; Centre for Chronic Disease Prevention and Control (R.L.W., J.O., R-N.G
| |
Collapse
|
49
|
Gatien M, Perry JJ, Stiell IG, Wielgosz A, Lee JS. A clinical decision rule to identify which chest pain patients can safely be removed from cardiac monitoring in the emergency department. Ann Emerg Med 2007; 50:136-43. [PMID: 17498844 DOI: 10.1016/j.annemergmed.2007.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2006] [Revised: 01/10/2007] [Accepted: 02/06/2007] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE We determine the rate of serious arrhythmias in a cohort of monitored emergency department (ED) chest pain patients and derive a clinical decision rule that can identify which patients can safely be taken off continuous cardiac monitoring at initial physician assessment. METHODS A secondary analysis of a prospectively collected cohort was completed in a university-affiliated tertiary care center. Consecutive patients with a primary complaint of chest pain who underwent cardiac monitoring in the ED in January to April 2000 were included. Serious arrhythmias were defined as those requiring treatment in the ED. Multivariate recursive partitioning analysis was undertaken to derive a decision rule. RESULTS Nine hundred ninety-two consecutive chest pain patients were monitored in the ED during the study period, of whom 14% and 12% had myocardial infarction and unstable angina, respectively. There were 17 patients (1.7%) with serious arrhythmias detected in the ED. The following decision rule was derived: patients can be removed from cardiac monitoring if they are pain free at the initial physician assessment and have a normal or nonspecific ECG result. The rule had 100% sensitivity (95% confidence interval 80% to 100%) for serious arrhythmias. Applying this rule would have allowed physicians to immediately remove 29% of patients from cardiac monitoring. CONCLUSION Serious arrhythmias are uncommon in monitored ED chest pain patients. A simple clinical decision rule could be used to safely identify low-risk patients who can be removed from continuous monitoring if its performance is prospectively validated in an independent patient population.
Collapse
Affiliation(s)
- Mathieu Gatien
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | | | | | | | | |
Collapse
|
50
|
Paszat LF, Vallis KA, Benk VMA, Groome PA, Mackillop WJ, Wielgosz A. A population-based case-cohort study of the risk of myocardial infarction following radiation therapy for breast cancer. Radiother Oncol 2007; 82:294-300. [PMID: 17276533 DOI: 10.1016/j.radonc.2007.01.004] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2006] [Revised: 01/06/2007] [Accepted: 01/08/2007] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To describe the risk of acute myocardial infarction (AMI) after radiation therapy (RT) for breast cancer (BrCa) in an exposed population. METHODS We identified and validated cases of AMI (vAMI), by electrocardiographic or enzyme criteria, among all 6680 women who received post-operative RT following lumpectomy or mastectomy, within 12 months following diagnosis of BrCa between 1982 and 1988 in Ontario, Canada. We identified women without vAMI whose death certification was ascribed to AMI (dAMI). We abstracted risk factors and treatment exposures for a random sample of women from the 6680, and for all with vAMI or dAMI. The hazards of vAMI and of dAMI were estimated using multivariate Cox proportional hazards models, corrected for study design. RESULTS We validated 121 cases of vAMI and identified 92 cases of dAMI. The risk of vAMI associated with RT to the left breast HR=1.96 (1.09,3.54) among women at age >/= 60 at time of RT, adjusted for history of smoking and prior MI. The adjusted HR dAMI=1.90 (1.08,3.35) for exposure to anterior internal mammary node (IMC) RT. Among women who received anterior left breast boost RT, increasing area of the boost is associated with adjusted HR vAMI=1.02 (1.00,1.03)/cm(2), and adjusted HR dAMI=1.02 (1.01,1.03)/cm(2). CONCLUSION The risks of vAMI and dAMI following RT for BrCa are related to anatomic sites of RT (left breast, area of anterior left breast boost field, and anterior IMC field).
Collapse
Affiliation(s)
- Lawrence F Paszat
- University of Toronto and Institute for Clinical Evaluative Sciences, Toronto, Canada
| | | | | | | | | | | |
Collapse
|