Examinando por Autor "Kaur, Manmeet"
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- PublicaciónAcceso abiertoAssociation of egg intake with blood lipids, cardiovascular disease, and mortality in 177,000 people in 50 countries(American Journal of Clinical Nutrition, 2020-04-01) Dehghan, Mahshid; Mente, Andrew; Rangarajan, Sumathy; Mohan, Viswanathan; Lear, Scott; Swaminathan, Sumathi; Wielgosz, Andreas; Seron, Pamela; Avezum, Alvaro; Lopez-Jaramillo, Patricio; Turbide, Ginette; Chifamba, Jephat; AlHabib, Khalid F.; Mohammadifard, Noushin; Szuba, Andrzej; Khatib, Rasha; Altuntas, Yuksel; Liu, Xiaoyun; Iqbal, Romaina; Rosengren, Annika; Yusuf, Rita; Smuts, Marius; Yusufali, AfzalHussein; Li, Ning; Diaz, Rafael; Yusoff, Khalid; Kaur, Manmeet; Soman, Biju; Ismail, Noorhassim; Gupta, Rajeev; Dans, Antonio; Sheridan, Patrick; Teo, Koon; Anand, Sonia S; Yusuf, Salim; Behalf of the PURE investigators; EverestABSTRACT 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. Am J Clin Nutr 2020;111:795–803.
- PublicaciónAcceso abiertoAssociations of Fish Consumption with Risk of Cardiovascular Disease and Mortality among Individuals with or without Vascular Disease from 58 Countries(JAMA Network, 2021-03-08) Mohan, Deepa; Mente, Andrew; Dehghan, Mahshid; Rangarajan, Sumathy; O’Donnell, Martin; Hu, Weihong; Dagenais, Gilles; Wielgosz, Andreas; Lear, Scott; Wei, Li; Diaz, Rafael; Avezum, Alvaro; Lopez-Jaramillo, Patricio; Lanas, Fernando; Swaminathan, Sumathi; Kaur, Manmeet; Vijayakumar, K.; Mohan, Viswanathan; Gupta, Rajeev; Szuba, Andrzej; Iqbal, Romaina; Yusuf, Rita; Mohammadifard, Noushin; Khatib, Rasha; Yusoff, Khalid; Gulec, Sadi; Rosengren, Annika; Yusufali, Afzalhussein; Wentzel-Viljoen, Edelweiss; Chifamba, Jephat; Dans, Antonio; Alhabib, Khalid F.; Yeates, Karen; Teo, Koon; Gerstein, Hertzel C.; Yusuf, Salim; The PURE, ONTARGET, TRANSCEND, and ORIGIN investigators; MasiraImportance 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.
- PublicaciónAcceso abiertoAvailability and affordability of cardiovascular disease medicines and their effect on use in high-income, middle-income, and low-income countries. An analysis of the PURE study data(ScienceDirect, 2016-10-05) Miller, Victoria; Yusuf, Salim; Chow, Clara K.; Dehghan, Mahshid; Corsi, Daniel J.; Lock, Karen; Popkin, Barry; Rangarajan, Sumathy; Khatib, Rasha; Lear, Scott A.; Mony, Prem; Kaur, Manmeet; Mohan, Viswanathan; Vijayakumar, Krishnapillai; Gupta, Rajeev; Kruger, Annamarie; Tsolekile, Lungiswa; Mohammadifard, Noushin; Rahman, Omar; Rosengren, Annika; Avezum, Alvaro; Orlandini, Andrés; Ismail, Noorhassim; Lopez-Jaramillo, Patricio; Yusufali, Afzalhussein; Karsidag, Kubilay; Iqbal, Romaina; Chifamba, Jephat; Oakley, Solange Martinez; Ariffin, Farnaza; Zatonska, Katarzyna; Poirier, Paul; Wei, Li; Jian, Bo; Hui, Chen; Xu, Liu; Xiulin, Bai; Teo, Koon; Mente, Andrew; MasiraMethods We assessed fruit and vegetable consumption using data from country-specific, validated semi-quantitative food frequency questionnaires in the Prospective Urban Rural Epidemiology (PURE) study, which enrolled participants from communities in 18 countries between Jan 1, 2003, and Dec 31, 2013. We documented household income data from participants in these communities; we also recorded the diversity and non-sale prices of fruits and vegetables from grocery stores and market places between Jan 1, 2009, and Dec 31, 2013. We determined the cost of fruits and vegetables relative to income per household member. Linear random effects models, adjusting for the clustering of households within communities, were used to assess mean fruit and vegetable intake by their relative cost. Findings Of 143 305 participants who reported plausible energy intake in the food frequency questionnaire, mean fruit and vegetable intake was 3·76 servings (95% CI 3·66–3·86) per day. Mean daily consumption was 2·14 servings (1·93–2·36) in low-income countries (LICs), 3·17 servings (2·99–3·35) in lower-middle-income countries (LMICs), 4·31 servings (4·09–4·53) in upper-middle-income countries (UMICs), and 5·42 servings (5·13–5·71) in high-income countries (HICs). In 130 402 participants who had household income data available, the cost of two servings of fruits and three servings of vegetables per day per individual accounted for 51·97% (95% CI 46·06–57·88) of household income in LICs, 18·10% (14·53–21·68) in LMICs, 15·87% (11·51–20·23) in UMICs, and 1·85% (−3·90 to 7·59) in HICs (ptrend=0·0001). In all regions, a higher percentage of income to meet the guidelines was required in rural areas than in urban areas (p<0·0001 for each pairwise comparison). Fruit and vegetable consumption among individuals decreased as the relative cost increased (ptrend=0·00040). Interpretation The consumption of fruit and vegetables is low worldwide, particularly in LICs, and this is associated with low affordability. Policies worldwide should enhance the availability and affordability of fruits and vegetables.
- PublicaciónRestringidoAvailability, affordability, and consumption of fruits and vegetables in 18 countries across income levels : Findings from the Prospective Urban Rural Epidemiology (PURE) study(2016-08-23) Lopez-Jaramillo, Patricio; Mente, Andrew; Teo, Koon; Xiulin, Bai; Xu, Liu; Hui, Chen; Jian, Bo; Wei, Li; Poirier, Paul P.; Zatonska, Katarzyna; Ariffin, Farnaza; Martinez Oakley, Solange; Chifamba, Jephat; Iqbal, Romaina; Karsidag, Kubilay; Yusufali, Afzalhussein; Ismail, Noorhassim; Orlandini, Andres; Avezum, Alvaro; Rosengren, Annika; Rahman, Omar; Mohammadifard, Noushin; Tsolekile, Lungiswa P.; Kruger, Annamarie; Gupta, Rajeev; Vijayakumar, Krishnapillai; Mohan, Viswanathan; Kaur, Manmeet; Mony, Prem; Lear, Scott A.; Khatib, Rasha; Rangarajan, Sumathy; Popkin, Barry; Lock, Karen; Corsi, Daniel J.; Dehghan, Mahshid; Chow, Clara K.; Yusuf, Salim; Miller, VictoriaBackground Several international guidelines recommend the consumption of two servings of fruits and three servings of vegetables per day, but their intake is thought to be low worldwide. We aimed to determine the extent to which such low intake is related to availability and aff ordability. Methods We assessed fruit and vegetable consumption using data from country-specific, validated semi-quantitative food frequency questionnaires in the Prospective Urban Rural Epidemiology (PURE) study, which enrolled participants from communities in 18 countries between Jan 1, 2003, and Dec 31, 2013. We documented household income data from participants in these communities; we also recorded the diversity and non-sale prices of fruits and vegetables from grocery stores and market places between Jan 1, 2009, and Dec 31, 2013. We determined the cost of fruits and vegetables relative to income per household member. Linear random eff ects models, adjusting for the clustering of households within communities, were used to assess mean fruit and vegetable intake by their relative cost. Findings Of 143 305 participants who reported plausible energy intake in the food frequency questionnaire, mean fruit and vegetable intake was 3·76 servings (95% CI 3·66–3·86) per day. Mean daily consumption was 2·14 servings (1·93–2·36) in low-income countries (LICs), 3·17 servings (2·99–3·35) in lower-middle-income countries (LMICs), 4·31 servings (4·09–4·53) in upper-middle-income countries (UMICs), and 5·42 servings (5·13–5·71) in highincome countries (HICs). In 130 402 participants who had household income data available, the cost of two servings of fruits and three servings of vegetables per day per individual accounted for 51·97% (95% CI 46·06–57·88) of household income in LICs, 18·10% (14·53–21·68) in LMICs, 15·87% (11·51–20·23) in UMICs, and 1·85% (–3·90 to 7·59) in HICs (ptrend=0·0001). In all regions, a higher percentage of income to meet the guidelines was required in rural areas than in urban areas (p<0·0001 for each pairwise comparison). Fruit and vegetable consumption among individuals decreased as the relative cost increased ptrend=0·00040). Interpretation The consumption of fruit and vegetables is low worldwide, particularly in LICs, and this is associated with low aff ordability. Policies worldwide should enhance the availability and aff ordability of fruits and vegetables. Funding Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, AstraZeneca (Canada), Sanofi -Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma, and national or local organisations in participating countries.
- PublicaciónAcceso abiertoImpact of social isolation on mortality and morbidity in 20 high-income, middle-income and low-income countries in five continents(BMJ Journals, 2021-03-22) Naito, Ryo; Leong, Darryl P.; Bangdiwala, Shrikant Ishver; McKee, Martin; Subramanian, S. V.; Rangarajan, Sumathy; Islam, Shofiqul; Avezum, Alvaro; Yeates, Karen; Lear, Scott A.; Gupta, Rajeev; Yusufali, Afzalhussein; Dans, Antonio L.; Szuba, Andrzej; Alhabib, Khalid F.; Kaur, Manmeet; Rahman, Omar; Seron, Pamela; Diaz, Rafael; Puoane, Thandi; Liu, Weida; Zhu, Yibing; Sheng, Yundong; Lopez-Jaramillo, Patricio; Chifamba, Jephat; Rosnah, Ismail; Karsidag, Kubilay; Kelishadi, Roya; Rosengren, Annika; Khatib, Rasha; K. R., Leela Itty Amma; Iqbal Azam, Syed; Teo, Koon; Yusuf, Salim; MasiraObjective To examine the association between social isolation and mortality and incident diseases in middle-aged adults in urban and rural communities from high-income, middle-income and low-income countries. Design Population-based prospective observational study. Setting Urban and rural communities in 20 high income, middle income and low income. Participants 119894 community-dwelling middle-aged adults. Main outcome measures Associations of social isolation with mortality, cardiovascular death, non-cardiovascular death and incident diseases. Results Social isolation was more common in middleincome and high-income countries compared with lowincome countries, in urban areas than rural areas, in older individuals and among women, those with less education and the unemployed. It was more frequent among smokers and those with a poorer diet. Social isolation was associated with greater risk of mortality (HR of 1.26, 95% CI: 1.17 to 1.36), incident stroke (HR: 1.23, 95%CI: 1.07 to 1.40), cardiovascular disease (HR: 1.15, 95%CI: 1.05 to 1.25) and pneumonia (HR:1.22, 95%CI: 1.09 to 1.37), but not cancer. The associations between social isolation and mortality were observed in populations in high-income, middle-income and low-income countries (HR (95%CI): 1.69 (1.32 to 2.17), 1.27 (1.15 to 1.40) and 1.47 (1.25 to 1.73), respectively, interaction p=0.02). The HR associated with social isolation was greater in men than women and in younger than older individuals. Mediation analyses for the association between social isolation and mortality showed that unhealthy behaviours and comorbidities may account for about one-fifth of the association. Conclusion Social isolation is associated with increased risk of mortality in countries at different economic levels. The increasing share of older people in populations in many countries argues for targeted strategies to mitigate its adverse effects
- PublicaciónAcceso abiertoModifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from 21 high-income, middle-income, and low-income countries (PURE)(Elsevier, 2019-09-03) Yusuf, Salim; Joseph, Philip; Rangarajan, Sumathy; Islam, Shofiqul; Mente, Andrew; Hystad, Perry; Brauer, Michael; Raman Kutty, Vellappillil; Gupta, Rajeev; Wielgosz, Andreas; AlHabib, Khalid F.; Dans, Antonio; Lopez-Jaramillo, Patricio; Avezum, Alvaro; Lanas, Fernando; Oguz, Aytekin; Kruger, Iolanthe M.; Diaz, Rafael; Yusoff, Khalid; Mony, Prem; Chifamba, Jephat; Yeates, Karen; Kelishadi, Roya; Yusufali, Afzalhussein; Khatib, Rasha; Rahman, Omar; Zatonska, Katarzyna; Iqbal, Romaina; Wei, Li; Bo, Hu; Rosengren, Annika; Kaur, Manmeet; Mohan, Viswanathan; Lear, Scott A.; Teo, Koon K.; Leong, Darryl; O'Donnell, Martin; McKee, Martin; Dagenais, Gilles; EverestBackground 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).
- PublicaciónAcceso abiertoPsychosocial Risk Factors and Cardiovascular Disease and Death in a Population-Based Cohort from 21 Low-, Middle-, and High-Income Countries(JAMA Network Open, 2021-12-15) Santosa, Ailiana; Rosengren, Annika; Ramasundarahettige, Chinthanie; Rangarajan, Sumathy; Chifamba, Jephat; Lear, Scott A.; Poirier, Paul; Yeates, Karen; Yusuf, Rita; Orlandini, Andreas; Weida, Liu; Sidong, Li; Yibing, Zhu; Mohan, Viswanathan; Kaur, Manmeet; Zatonska, Katarzyna; Ismail, Noorhassim; Lopez-Jaramillo, Patricio; Iqbal, Romaina; Palileo-Villanueva, Lia M.; Yusufali, Afzalhusein H.; AlHabib, Khalid F.; Yusuf, Salim; MasiraIMPORTANCE Stress may increase the risk of cardiovascular disease (CVD). Most studies on stress and CVD have been conducted in high-income Western countries, but whether stress is associated with CVD in other settings has been less well studied. OBJECTIVE To investigate the association of a composite measure of psychosocial stress and the development of CVD events and mortality in a large prospective study involving populations from 21 high-, middle-, and low-income countries across 5 continents. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study used data from the Prospective Urban Rural Epidemiology study, collected between January 2003 and March 2021. Participants included individuals aged 35 to 70 years living in 21 low-, middle-, and high-income countries. Data were analyzed from April 8 to June 15, 2021. EXPOSURES All participants were assessed on a composite measure of psychosocial stress assessed at study entry using brief questionnaires concerning stress at work and home, major life events, and financial stress. MAIN OUTCOMES AND MEASURES The outcomes of interest were stroke, major coronary heart disease (CHD), CVD, and all-cause mortality. RESULTS A total of 118 706 participants (mean [SD] age 50.4 [9.6] years; 69 842 [58.8%] women and 48 864 [41.2%] men) without prior CVD and with complete baseline and follow-up data were included. Of these, 8699 participants (7.3%) reported high stress, 21 797 participants (18.4%) reported moderate stress, 34 958 participants (29.4%) reported low stress, and 53 252 participants (44.8%) reported no stress. High stress, compared with no stress, was more likely with younger age (mean [SD] age, 48.9 [8.9] years vs 51.1 [9.8] years), abdominal obesity (2981 participants [34.3%] vs 10 599 participants [19.9%]), current smoking (2319 participants [26.7%] vs 10 477 participants [19.7%]) and former smoking (1571 participants [18.1%] vs 3978 participants [7.5%]), alcohol use (4222 participants [48.5%] vs 13 222 participants [24.8%]), and family history of CVD (5435 participants [62.5%] vs 20 255 participants [38.0%]). During a median (IQR) follow-up of 10.2 (8.6-11.9) years, a total of 7248 deaths occurred. During the course of follow-up, there were 5934 CVD events, 4107 CHD events, and 2880 stroke events. Compared with no stress and after adjustment for age, sex, education, marital status, location, abdominal obesity, hypertension, smoking, diabetes, and family history of CVD, as the level of stress increased, there were increases in risk of death (low stress: hazard ratio [HR], 1.09 [95% CI, 1.03-1.16]; high stress: 1.17 [95% CI, 1.06-1.29]) and CHD (low stress: HR, 1.09 [95% CI, 1.01-1.18]; high stress: HR, 1.24 [95% CI, 1.08-1.42]). High stress, but not low or moderate stress, was associated with CVD (HR, 1.22 [95% CI, 1.08-1.37]) and stroke (HR, 1.30 [95% CI, 1.09-1.56]) after adjustment. CONCLUSIONS AND RELEVANCE This cohort study found that higher psychosocial stress, measured as a composite score of self-perceived stress, life events, and financial stress, was significantly associated with mortality as well as with CVD, CHD, and stroke events.
- PublicaciónAcceso abiertoThe household economic burden of non-communicable diseases in 18 countries(BMJ Global Health, 2020-02-11) Murphy, Adrianna; Palafox, Benjamin; Walli-Attaei, Marjan; Powell-Jackson, Timothy; Rangarajan, Sumathy; Alhabib, Khalid F.; Avezum, Alvaro; Tumerdem Calik, Kevser Burcu; Chifamba, Jephat; Choudhury, Tarzia; Dagenais, Gilles; Dans, Antonio; Gupta, Rajeev; Iqbal, Romaina; Kaur, Manmeet; Kelishadi, Roya; Khatib, Rasha; Kruger, Iolanthe Marike; Raman Kutty, Vellappillil; Lear, Scott A.; Li, Wei; Lopez-Jaramillo, Patricio; Mohan, Viswanathan; Mony, Prem K.; Orlandin, Andres; Rosengren, Annika; Rosnah, Ismail; Seron, Pamela; Teo, Koon; Tse, Lap Ah; Tsolekile, Lungiswa; Wang, Yang; Wielgosz, Andreas; Yan, Ruohua; Yeates, Karen; Yusoff, Khalid; Zatonska, Katarzyna; Hanson, Kara; Yusuf, Salim; McKee, Martin; EverestAbstract 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.
- PublicaciónAcceso abiertoTiming and Length of Nocturnal Sleep and Daytime Napping and Associations with Obesity Types in High-, Middle-, and Low-Income Countries(JAMA, 2021-06-30) Tse, Lap Ah; Wang, Chuangshi; Rangarajan, Sumathy; Liu, Zhiguang; Teo, Koon; Yusufali, Afzalhussein; Avezum, Alvaro; Wielgosz, Andreas; Rosengren, Annika; Kruger, Iolanthé M.; Chifamba, Jephat; Tumerdem Calik, Kevser Burcu; Tumerdem Calik, Kevser Burcu; Zatońska, Katarzyna; AlHabib, Khalid F.; Yusoff, Khalid; Kaur, Manmeet; Ismail, Noorhassim; Seron, Pamela; Lopez-Jaramillo, Patricio; Poirier, Paul; Gupta, Rajeev; Khatib, Rasha; Kelishadi, Roya; Lear, Scott A.; Choudhury, Tarzia; Mohan, Viswanathan; Li, Wei; Yusuf, Salim; MasiraImportance 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.
- PublicaciónAcceso abiertoVariations in common diseases, hospital admissions, and deaths in middle-aged adults in 21 countries from five continents (PURE)(Elsevier Inc., 2019-09-03) Dagenais, Gilles R.; Leong, Darryl P.; Rangarajan, Sumathy; Lanas, Fernando; Lopez-Jaramillo, Patricio; Gupta, Rajeev; Diaz, Rafael; Avezum, Alvaro; Alhabib, Khalid F.; Temizhan, Ahmet; Ismail, Noorhassim; Chifamba, Jephat; Yeates, Karen; Khatib, Rasha; Rahman, Omar; Zatonska, Katarzyna; Kazmi, Khawar; Wei, Li; Zhu, Jun; Rosengren, Annika; Vijayakumar, K.; Kaur, Manmeet; Mohan, Viswanathan; Yusufali, AfzalHussein; Kelishadi, Roya; Teo, Koon K.; Joseph, Philip; Yusuf, Salim; Elsevier; EverestBackground 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).
- PublicaciónRestringidoWealth 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(2016-12-08) Lopez-Jaramillo, Patricio; Palafox, Benjamin; Balabanova, Dina; AlHabib, Khalid F.; Avezum, Alvaro; Bahonar, Ahmad; Ismail, Noorhassim; Chifamba, Jephat; Chow, Clara K.; Corsi, Daniel J.; Dagenais, Gilles; Diaz, Rafael; Gupta, Rajeev; Iqbal, Romaina; Kaur, Manmeet; Khatib, Rasha; Kruger, Annamarie; Kruger, Iolanthe Marike; Lanas, Fernando; Minfan, Fu; Mohan, Viswanathan; Mony, Prem; Oguz, Aytekin; Palileo Villaneuva, Lia; Perel, Pablo; Poirier, Paul P.; Rangarajan, Sumathy; Rensheng, Lei; Rosengren, Annika; Soman, Biju; Stuckler, David; Subramanian, S. V.; Teo, Koon; Tsolekile, Lungiswa P.; Wielgosz, Andreas; Yaguang, Peng; Yeates, Karen; Yongzhen, Mo; Yusoff, Khalid; Yusuf, Rita; Yusufali, Afzalhussein; Zatonska, Katarzyna; Yusuf, SalimBackground 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.