Examinando por Autor "Mony, Prem"
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- PublicaciónAcceso abiertoAssessing global risk factors for non-fatal injuries from road traffic accidents and falls in adults aged 35–70 years in 17 countries : A cross-sectional analysis of the prospective urban rural Epidemiological (PURE) study(2016) Raina, Parminder; Sohel, Nazmul; Oremus, Mark; Shannon, Harry; Mony, Prem; Kumar, Rajesh; Li, Wei; Wang, Yang; Wang, Xingyu; Yusoff, Khalid; Yusuf, Rita; Iqbal, Romaina; Szuba, Andrzej; Oguz, Aytekin; Rosengren, Annika; Kruger, Annamarie; Chifamba, Jephat; Mohammadifard, Noushin; Darwish, Ebtihal Ahmad; Dagenais, Gilles; Diaz, Rafael; Avezum, Alvaro; Lopez-Jaramillo, Patricio; Seron, Pamela; Rangarajan, Sumathy; Teo, Koon; Yusuf, Salim; The PURE (Prospective Urban Rural Epidemiology) Study investigatorsObjectives To assess risk factors associated with non-fatal injuries (NFIs) from road traffic accidents (RTAs) or falls. Methods Our study included 151 609 participants from the Prospective Urban Rural Epidemiological study. Participants reported whether they experienced injuries within the past 12 months that limited normal activities. Additional questions elicited data on risk factors. We employed multivariable logistic regression to analyse data. Results Overall, 5979 participants (3.9% of 151 609) reported at least one NFI. Total number of NFIs was 6300: 1428 were caused by RTAs (22.7%), 1948 by falls (30.9%) and 2924 by other causes (46.4%). Married/common law status was associated with fewer falls, but not with RTA. Age 65–70 years was associated with fewer RTAs, but more falls; age 55–64 years was associated with more falls. Male versus female was associated with more RTAs and fewer falls. In lower-middle-income countries, rural residence was associated with more RTAs and falls; in low-income countries, rural residence was associated with fewer RTAs. Previous alcohol use was associated with more RTAs and falls; current alcohol use was associated with more falls. Education was not associated with either NFI type. Conclusions This study of persons aged 35–70 years found that some risk factors for NFI differ according to whether the injury is related to RTA or falls. Policymakers may use these differences to guide the design of prevention policies for RTA-related or fall-related NFI.
- PublicaciónAcceso abiertoAssociation of dairy consumption with metabolic syndrome, hypertension and diabetes in 147 812 individuals from 21 countries(BMJ Journals, 2020-05-18) Bhavadharini, Balaji; Dehghan, Mahshid; Mente, Andrew; Rangarajan, Sumathy; Sheridan, Patrick; Mohan, Viswanathan; Iqbal, Romaina; Gupta, Rajeev; Lear, Scott; Wentzel-Viljoen, Edelweiss; Avezum, Alvaro; Lopez-Jaramillo, Patricio; Mony, Prem; Prasad Varma, Ravi; Kumar, Rajesh; Chifamba, Jephat; Alhabib, Khalid F; Mohammadifard, Noushin; Oguz, Aytekin; Lanas, Fernando; Rozanska, Dorota; Bengtsson Bostrom, Kristina; Yusoff, Khalid; Tsolkile, Lungiswa P; Dans, Antonio; Yusufali, Afzalhussein; Orlandini, Andres; Poirier, Paul; Khatib, Rasha; Hu, Bo; Wei, Li; Yin, Lu; Deeraili, Ai; Yeates, Karen; Yusuf, Rita; Ismail, Noorhassim; Mozaffarian, Dariush; Teo, Koon; Anand, Sonia S; Yusuf, Salim; EverestObjective Our aims were to assess the association of dairy intake with prevalence of metabolic syndrome (MetS) (cross-sectionally) and with incident hypertension and incident diabetes (prospectively) in a large multinational cohort study. Methods The Prospective Urban Rural Epidemiology (PURE) study is a prospective epidemiological study of individuals aged 35 and 70 years from 21 countries on five continents, with a median follow-up of 9.1 years. In the cross-sectional analyses, we assessed the association of dairy intake with prevalent MetS and its components among individuals with information on the five MetS components (n=112 922). For the prospective analyses, we examined the association of dairy with incident hypertension (in 57 547 individuals free of hypertension) and diabetes (in 131 481 individuals free of diabetes). Results In cross-sectional analysis, higher intake of total dairy (at least two servings/day compared with zero intake; OR 0.76, 95% CI 0.71 to 0.80, p-trend<0.0001) was associated with a lower prevalence of MetS after multivariable adjustment. Higher intakes of whole fat dairy consumed alone (OR 0.72, 95% CI 0.66 to 0.78, p-trend<0.0001), or consumed jointly with low fat dairy (OR 0.89, 95% CI 0.80 to 0.98, p-trend=0.0005), were associated with a lower MetS prevalence. Low fat dairy consumed alone was not associated with MetS (OR 1.03, 95% CI 0.77 to 1.38, p-trend=0.13). In prospective analysis, 13 640 people with incident hypertension and 5351 people with incident diabetes were recorded. Higher intake of total dairy (at least two servings/day vs zero serving/day) was associated with a lower incidence of hypertension (HR 0.89, 95% CI 0.82 to 0.97, p-trend=0.02) and diabetes (HR 0.88, 95% CI 0.76 to 1.02, p-trend=0.01). Directionally similar associations were found for whole fat dairy versus each outcome. Conclusions Higher intake of whole fat (but not low fat) dairy was associated with a lower prevalence of MetS and most of its component factors, and with a lower incidence of hypertension and diabetes. Our findings should be evaluated in large randomized trials of the effects of whole fat dairy on the risks of MetS, hypertension, and diabetes.
- PublicaciónAcceso abiertoAssociation of dairy intake with cardiovascular disease and mortality in 21 countries from five continents (PURE) : A prospective cohort study(2018-09-11) Dehghan, Mahshid; Mente, Andrew; Rangarajan, Sumathy; Sheridan, Patrick; Mohan, Viswanathan; Iqbal, Romaina; Gupta, Rajeev; Lear, Scott A.; Wentzel Viljoen, Edelweiss; Avezum, Alvaro; Lopez-Jaramillo, Patricio; Mony, Prem; Varma, Ravi Prasad; Kumar, Rajesh; Chifamba, Jephat; AlHabib, Khalid F.; Mohammadifard, Noushin; Oguz, Aytekin; Lanas, Fernando; Rozanska, Dorota; Bengtsson Bostrom, Kristina; Yusoff, Khalid; Tsolekile, Lungiswa P.; Dans, Antonio; Yusufali, Afzalhussein; Orlandini, Andres; Poirier, Paul P.; Khatib, Rasha; Hu, Bo; Wei, Li; Yin, Lu; Deeraili, Ai; Yeates, Karen; Yusuf, Rita; Ismail, Noorhassim; Mozaffarian, Dariush; Teo, Koon; Anand, Sonia S.; Yusuf, Salim; Prospective Urban Rural Epidemiology (PURE), Study investigatorsBackground Dietary guidelines recommend minimising consumption of whole-fat dairy products, as they are a source of saturated fats and presumed to adversely affect blood lipids and increase cardiovascular disease and mortality. Evidence for this contention is sparse and few data for the effects of dairy consumption on health are available from low-income and middle-income countries. Therefore, we aimed to assess the associations between total dairy and specific types of dairy products with mortality and major cardiovascular disease. Methods The Prospective Urban Rural Epidemiology (PURE) study is a large multinational cohort study of individuals aged 35–70 years enrolled from 21 countries in five continents. Dietary intakes of dairy products for 136 384 individuals were recorded using country-specific validated food frequency questionnaires. Dairy products comprised milk, yoghurt, and cheese. We further grouped these foods into whole-fat and low-fat dairy. The primary outcome was the composite of mortality or major cardiovascular events (defined as death from cardiovascular causes, non-fatal myocardial infarction, stroke, or heart failure). Hazard ratios (HRs) were calculated using multivariable Cox frailty models with random intercepts to account for clustering of participants by centre. Findings Between Jan 1, 2003, and July 14, 2018, we recorded 10 567 composite events (deaths [n=6796] or major cardiovascular events [n=5855]) during the 9·1 years of follow-up. Higher intake of total dairy (>2 servings per day compared with no intake) was associated with a lower risk of the composite outcome (HR 0·84, 95% CI 0·75–0·94; ptrend=0·0004), total mortality (0·83, 0·72–0·96; ptrend=0·0052), non-cardiovascular mortality (0·86, 0·72–1·02; ptrend=0·046), cardiovascular mortality (0·77, 0·58–1·01; ptrend=0·029), major cardiovascular disease (0·78, 0·67–0·90; ptrend=0·0001), and stroke (0·66, 0·53–0·82; ptrend=0·0003). No significant association with myocardial infarction was observed (HR 0·89, 95% CI 0·71–1·11; ptrend=0·163). Higher intake (>1 serving vs no intake) of milk (HR 0·90, 95% CI 0·82–0·99; ptrend=0·0529) and yogurt (0·86, 0·75–0·99; ptrend=0·0051) was associated with lower risk of the composite outcome, whereas cheese intake was not significantly associated with the composite outcome (0·88, 0·76–1·02; ptrend=0·1399). Butter intake was low and was not significantly associated with clinical outcomes (HR 1·09, 95% CI 0·90–1·33; ptrend=0·4113). Interpretation Dairy consumption was associated with lower risk of mortality and major cardiovascular disease events in a diverse multinational cohort. Funding Full funding sources are listed at the end of the paper (see Acknowledgments).
- PublicaciónAcceso abiertoAssociations of cereal grains intake with cardiovascular disease and mortality across 21 countries in prospective urban and rural epidemiology study(BMJ, 2021-02-03) Dehghan, Mahshid; Raj, John Michael; Thomas, Tinku; Rangarajan, Sumathy; Jenkins, David; Mony, Prem; Mohan, Viswanathan; Lear, Scott A.; Avezum, Alvaro; Lopez-Jaramillo, Patricio; Rosengren, Annika; Lanas, Fernando; AlHabib, Khalid F.; Dans, Antonio; Keskinler, Mirac Vural; Puoane, Thandi; Soman, Biju; Wei, Li; Zatonska, Katarzyna; Diaz, Rafael; Ismail, Noorhassim; Chifamba, Jephat; Kelishadi, Roya; Yusufali, Afzalhussein; Khatib, Rasha; Xiaoyun, Liu; Bo, Hu; Iqbal, Romaina; Yusuf, Rita; Yeates, Karen; Teo, Koon; Yusuf, Salim; MasiraObjective. To evaluate the association between intakes of refined grains, whole grains, and white rice with cardiovascular disease, total mortality, blood lipids, and blood pressure in the Prospective Urban and Rural Epidemiology (PURE) study. Design. Prospective cohort study. Setting PURE study in 21 countries. Participants 148858 participants with median follow-up of 9.5 years. Exposures Country specific validated food frequency questionnaires were used to assess intakes of refined grains, whole grains, and white rice. Main outcome measure Composite of mortality or major cardiovascular events (defined as death from cardiovascular causes, nonfatal myocardial infarction, stroke, or heart failure). Hazard ratios were estimated for associations of grain intakes with mortality, major cardiovascular events, and their composite by using multivariable Cox frailty models with random intercepts to account for clustering by centre. Results Analyses were based on 137130 participants after exclusion of those with baseline cardiovascular disease. During follow-up, 9.2% (n=12668) of these participants had a composite outcome event. The highest category of intake of refined grains (≥350 g/day or about 7 servings/day) was associated with higher risk of total mortality (hazard ratio 1.27, 95% confidence interval 1.11 to 1.46; P for trend=0.004), major cardiovascular disease events (1.33, 1.16 to 1.52; P for trend<0.001), and their composite (1.28, 1.15 to 1.42; P for trend<0.001) compared with the lowest category of intake (<50 g/day). Higher intakes of refined grains were associated with higher systolic blood pressure. No significant associations were found between intakes of whole grains or white rice and health outcomes. Conclusion High intake of refined grains was associated with higher risk of mortality and major cardiovascular disease events. Globally, lower consumption of refined grains should be considered.
- PublicaciónAcceso abiertoAssociations of urinary sodium excretion with cardiovascular events in individuals with and without hypertension : A pooled analysis of data from four studies(2016-07-30) Mente, Andrew; O’Donnell, Martin J.; Rangarajan, Sumathy; Dagenais, Gilles; Lear, Scott A.; McQueen, Matthew J.; Diaz, Rafael; Avezum, Alvaro; Lopez-Jaramillo, Patricio; Lanas, Fernando; Li, Wei; Lu, Yin; Yi, Sun; Rensheng, Lei; Iqbal, Romaina; Mony, Prem; Yusuf, Rita; Yusoff, Khalid; Szuba, Andrzej; Oguz, Aytekin; Rosengren, Annika; Bahonar, Ahmad; Yusufali, Afzalhussein; Schutte, Aletta Elisabeth; Chifamba, Jephat; Mann, Johannes F. E.; Anand, Sonia S.; Teo, Koon; Yusuf, Salim; The PURE, EPIDREAM, and ONTARGET/TRANSCEND InvestigatorsBackground: Several studies reported a U-shaped association between urinary sodium excretion and cardiovascular disease events and mortality. Whether these associations vary between those individuals with and without hypertension is uncertain. We aimed to explore whether the association between sodium intake and cardiovascular disease events and all-cause mortality is modified by hypertension status. Methods: In this pooled analysis, we studied 133118 individuals (63559 with hypertension and 69559 without hypertension), median age of 55 years (IQR 45–63), from 49 countries in four large prospective studies and estimated 24-h urinary sodium excretion (as group-level measure of intake). We related this to the composite outcome of death and major cardiovascular disease events over a median of 4·2 years (IQR 3·0–5·0) and blood pressure. Findings: Increased sodium intake was associated with greater increases in systolic blood pressure in individuals with hypertension (2·08 mm Hg change per g sodium increase) compared with individuals without hypertension (1·22 mm Hg change per g; pinteraction<0·0001). In those individuals with hypertension (6835 events), sodium excretion of 7 g/day or more (7060 [11%] of population with hypertension: hazard ratio [HR] 1·23 [95% CI 1·11–1·37]; p<0·0001) and less than 3 g/day (7006 [11%] of population with hypertension: 1·34 [1·23–1·47]; p<0·0001) were both associated with increased risk compared with sodium excretion of 4–5 g/day (reference 25% of the population with hypertension). In those individuals without hypertension (3021 events), compared with 4–5 g/day (18508 [27%] of the population without hypertension), higher sodium excretion was not associated with risk of the primary composite outcome (≥7 g/day in 6271 [9%] of the population without hypertension; HR 0·90 [95% CI 0·76–1·08]; p=0·2547), whereas an excretion of less than 3 g/day was associated with a significantly increased risk (7547 [11%] of the population without hypertension; HR 1·26 [95% CI 1·10–1·45]; p=0·0009). Interpretation: Compared with moderate sodium intake, high sodium intake is associated with an increased risk of cardiovascular events and death in hypertensive populations (no association in normotensive population), while the association of low sodium intake with increased risk of cardiovascular events and death is observed in those with or without hypertension. These data suggest that lowering sodium intake is best targeted at populations with hypertension who consume high sodium diets. Funding: Full funding sources listed at end of paper (see Acknowledgments).
- 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.
- PublicaciónAcceso abiertoAvailability and affordability of medicines and cardiovascular outcomes in 21 high-income, middle-income and low-income countries(BMJ Journals, 2020-11-05) Chow, Clara Kayei; Nguyen, Ngoc; Marschner, Simone; Diaz, Rafael; Rahman, Omar; Avezum, Alvaro; Lear, Scott A.; Teo, Koon; Yeates, Karen; Lanas, Fernando; Li, Wei; Hu, Bo; Lopez-Jaramillo, Patricio; Gupta, Rajeev; Kumar, Rajesh; Mony, Prem; Bahonar, Ahmad; Yusoff, Khalid; Khatib, Rasha; Kazmi, Khawar; Dans, Antonio; Zatonska, Katarzyna; Alhabib, Khalid F.; Kruger, Iolanthe Marike; Rosengren, Annika; Yusufali, Afzalhussein; Chifamba, Jephat; Rangarajan, Sumathy; McKee, Martin; Yusuf, Salim; MasiraObjectives We aimed to examine the relationship between access to medicine for cardiovascular disease (CVD) and major adverse cardiovascular events (MACEs) among people at high risk of CVD in high-income countries (HICs), upper and lower middle-income countries (UMICs, LMICs) and low-income countries (LICs) participating in the Prospective Urban Rural Epidemiology (PURE) study. Methods We defined high CVD risk as the presence of any of the following: hypertension, coronary artery disease, stroke, smoker, diabetes or age >55 years. Availability and affordability of blood pressure lowering drugs, antiplatelets and statins were obtained from pharmacies. Participants were categorised: group 1—all three drug types were available and affordable, group 2—all three drugs were available but not affordable and group 3—all three drugs were not available. We used multivariable Cox proportional hazard models with nested clustering at country and community levels, adjusting for comorbidities, sociodemographic and economic factors. Results Of 163 466 participants, there were 93 200 with high CVD risk from 21 countries (mean age 54.7,49% female). Of these, 44.9% were from group 1, 29.4% from group 2 and 25.7% from group 3. Compared with participants from group 1, the risk of MACEs was higher among participants in group 2 (HR 1.19, 95% CI 1.07 to 1.31), and among participants from group 3 (HR 1.25, 95% CI 1.08 to 1.50). Conclusion Lower availability and affordability of essential CVD medicines were associated with higher risk of MACEs and mortality. Improving access to CVD medicines should be a key part of the strategy to lower CVD globally.
- 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 abiertoCardiovascular risk and events in 17 low-, middle-, and high-income countries(2014-08-28) Yusuf, Salim; Rangarajan, Sumathy; Teo, Koon; Islam, Shofiqul; Li, Wei; Liu, Lisheng; Bo, Jian; Lou, Qinglin; Lu, Fanghong; Liu, Tianlu; Yu, Liu; Zhang, Shiying; Mony, Prem; Swaminathan, Sumathi; Mohan, Viswanathan; Gupta, Rajeev; Kumar, Rajesh; Vijayakumar, Krishnapillai; Lear, Scott A.; Anand, Sonia S.; Wielgosz, Andreas; Diaz, Rafael; Avezum, Alvaro; Lopez-Jaramillo, Patricio; Lanas, Fernando; Yusoff, Khalid; Ismail, Noorhassim; Iqbal, Romaina; Rahman, Omar; Rosengren, Annika; Yusufali, Afzalhussein; Kelishadi, Roya; Kruger, Annamarie; Puoane, Thandi; Szuba, Andrzej; Chifamba, Jephat; Oguz, Aytekin; McQueen, Matthew J.; McKee, Martin; Dagenais, Gilles; The PURE (Prospective Urban Rural Epidemiology) Study investigatorsBACKGROUND 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.)
- PublicaciónAcceso abiertoContrasting associations between diabetes and cardiovascular mortality rates in low-, middle-, and high-income countries: Cohort study data from 143,567 individuals in 21 countries in the pure study(American Diabetes Association, 2020-10-15) Mohan Anjana, Ranjit; Mohan, Viswanathan; Rangarajan, Sumathy; Gerstein, Hertzel C.; Venkatesan, Ulagamadesan; Sheridan, Patrick; Dagenais, Gilles R.; Lear, Scott A.; Teo, Koon; Karsidag, Kubilay; Alhabib, Khalid F.; Yusoff, Khalid; Ismail, Noorhassim; Mony, Prem; Lopez-Jaramillo, Patricio; Chifamba, Jephat; Palileo-Villanueva, Lia M.; Iqbal, Romaina; Yusufali, Afzalhussein; Kruger, Iolanthe M.; Rosengren, Annika; Bahonar, Ahmad; Zatonska, Katarzyna; Yeates, Karen; Gupta, Rajeev; Li, Wei; Hu, Lihua; Rahman, M. Omar; Lakshmi, P.V.M.; Iype, Thomas; Avezum, Alvaro; Diaz, Rafael; Lanas, Fernando; Yusuf, Salim; MasiraOBJECTIVE We aimed to compare cardiovascular (CV) events, all-cause mortality, and CV mortality rates among adults with and without diabetes in countries with differing levels of income. RESEARCH DESIGN AND METHODS The Prospective Urban Rural Epidemiology (PURE) study enrolled 143,567 adults aged 35–70 years from 4 high-income countries (HIC), 12 middle-income countries (MIC), and 5 low-income countries (LIC). The mean follow-up was 9.0 6 3.0 years. RESULTS Among those with diabetes, CVD rates (LIC 10.3, MIC 9.2, HIC 8.3 per 1,000 personyears, P < 0.001), all-cause mortality (LIC 13.8, MIC 7.2, HIC 4.2 per 1,000 personyears, P < 0.001), and CV mortality (LIC 5.7, MIC 2.2, HIC 1.0 per 1,000 person-years, P < 0.001) were considerably higher in LIC compared with MIC and HIC. Within LIC, mortality was higher in those in the lowest tertile of wealth index (low 14.7%, middle 10.8%, and high 6.5%). In contrast to HIC and MIC, the increased CV mortality in those with diabetes in LIC remained unchanged even after adjustment for behavioral risk factors and treatments (hazard ratio [95% CI] 1.89 [1.58–2.27] to 1.78 [1.36–2.34]). CONCLUSIONS CVD rates, all-cause mortality, and CV mortality were markedly higher among those with diabetes in LIC compared with MIC and HIC with mortality risk remaining unchanged even after adjustment for risk factors and treatments. There is an urgent need to improve access to care to those with diabetes in LIC to reduce the excess mortality rates, particularly among those in the poorer strata of society.
- PublicaciónRestringidoThe environmental profile of a community’s health : A cross-sectional study on tobacco marketing in 16 countries(2015-07) Savell, Emily; Gilmore, Anna B.; Sims, Michelle; Mony, Prem; Koon, Teo; Yusoff, Khalid; Lear, Scott A.; Seron, Pamela; Ismail, Noorhassim; Tumerdem Calik, K Burcu; Rosengren, Annika; Bahonar, Ahmad; Kumar, Rajesh; Vijayakumar, Krishnapillai; Kruger, Annamarie; Swidan, Hany; Gupta, Rajeev; Igumbor, Ehimario; Afridi, Asad; Rahman, Omar; Chifamba, Jephat; Zatonska, Katarzyna; Mohan, Viswanathan; Mohan, Deepa; Lopez-Jaramillo, PatricioObjective To examine and compare tobacco marketing in 16 countries while the Framework Convention on Tobacco Control requires parties to implement a comprehensive ban on such marketing. Methods Between 2009 and 2012, a kilometre-long walk was completed by trained investigators in 462 communities across 16 countries to collect data on tobacco marketing. We interviewed community members about their exposure to traditional and non-traditional marketing in the previous six months. To examine differences in marketing between urban and rural communities and between high-, middle- and low-income countries, we used multilevel regression models controlling for potential confounders. Findings Compared with high-income countries, the number of tobacco advertisements observed was 81 times higher in low-income countries (incidence rate ratio, IRR: 80.98; 95% confidence interval, CI: 4.15–1578.42) and the number of tobacco outlets was 2.5 times higher in both low- and lower-middle-income countries (IRR: 2.58; 95% CI: 1.17–5.67 and IRR: 2.52; CI: 1.23–5.17, respectively). Of the 11842 interviewees, 1184 (10%) reported seeing at least five types of tobacco marketing. Self-reported exposure to at least one type of traditional marketing was 10 times higher in low-income countries than in high-income countries (odds ratio, OR: 9.77; 95% CI: 1.24–76.77). For almost all measures, marketing exposure was significantly lower in the rural communities than in the urban communities. Conclusion Despite global legislation to limit tobacco marketing, it appears ubiquitous. The frequency and type of tobacco marketing varies on the national level by income group and by community type, appearing to be greatest in low-income countries and urban communities.
- PublicaciónAcceso abiertoGlobal variations in the prevalence, treatment, and impact of atrial fibrillation in a multi-national cohort of 153 152 middle-aged individuals(Oxford Academic, 2021-06-05) Joseph, Philip; Healey, Jeffrey S.; Raina, Parminder; Connolly, Stuart J.; Ibrahim, Quazi; Gupta, Rajeev; Avezum, Alvaro; Dans, Antonio; Lopez-Jaramillo, Patricio; Yeates, Karen; Teo, Koon; Douma, Reuben; Bahonar, Ahmad; Chifamba, Jephat; Lanas, Fernando; Dagenais, Gilles R.; Lear, Scott; Kumar, Rajesh; Kengne, Andre P.; Keskinler, Mirac; Mohan, Viswanathan; Mony, Prem; Alhabib, Khalid F.; Huisman, Hugo; Iype, Thomas; Zatonska, Katarzyna; Ismail, Rosnah; Kazmi, Khawar; Rosengren, Annika; Rahman, Omar; Yusufali, Afzalhussein; Wei, Li; Orlandini, Andres; Islam, Shofiqul; Rangarajan, Sumathy; Yusuf, Salim; The PURE Investigators; MasiraAims To compare the prevalence of electrocardiogram (ECG)-documented atrial fibrillation (or flutter) (AF) across eight regions of the world, and to examine antithrombotic use and clinical outcomes. Methods and results Baseline ECGs were collected in 153 152 middle-aged participants (ages 35–70 years) to document AF in two community-based studies, spanning 20 countries. Medication use and clinical outcome data (mean follow-up of 7.4 years) were available in one cohort. Cross-sectional analyses were performed to document the prevalence of AF and medication use, and associations between AF and clinical events were examined prospectively. Mean age of participants was 52.1 years, and 57.7% were female. Age and sex-standardized prevalence of AF varied 12-fold between regions; with the highest in North America, Europe, China, and Southeast Asia (270–360 cases per 100 000 persons); and lowest in the Middle East, Africa, and South Asia (30–60 cases per 100 000 persons) (P < 0.001). Compared with low-income countries (LICs), AF prevalence was 7-fold higher in middle-income countries (MICs) and 11-fold higher in high-income countries (HICs) (P < 0.001). Differences in AF prevalence remained significant after adjusting for traditional AF risk factors. In LICs/MICs, 24% of participants with AF and a CHADS2 score ≥1 received antithrombotic therapy, compared with 85% in HICs. AF was associated with an increased risk of stroke [hazard ratio (HR) 2.29; 95% confidence interval (CI) 1.49–3.52] and death (HR 2.97; 95% CI 2.25–3.93); with similar rates in different countries grouped by income level. Conclusions Large variations in AF prevalence occur in different regions and countries grouped by income level, but this is only partially explained by traditional AF risk factors. Antithrombotic therapy is infrequently used in poorer countries despite the high risk of stroke associated with AF.
- 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 abiertoMultinational prediction of household and personal exposure to fine particulate matter (PM2.5) in the PURE cohort study(Elsevier, 2022-01-15) Shupler, Matthew; Hystad, Perry; Birch, Aaron; Li Chu, Yen; Jeronimo, Matthew; Miller-Lionberg, Daniel; Gustafson, Paul; Rangarajan, Sumathy; Mustaha, Maha; Heenan, Laura; Seron, Pamela; Lanas, Fernando; Cazor, Fairuz; Oliveros, Maria Jose; Lopez-Jaramillo, Patricio; Camacho López, Paul Anthony; Otero, Johanna; Perez, Maritza; Yeates, Karen; West, Nicola; Ncube, Tatenda; Ncube, Brian; Chifamba, Jephat; Yusuf, Rita; Khan, Afreen; Liu, Zhiguang; Wu, Shutong; Wei, Li; Tse, Lap Ah; Mohan, Deepa; Kuma, Parthiban; Gupta, Rajeev; Mohan, Indu; Jayachitra, K.G.; Mony, Prem; Rammohan, Kamala; Nair, Sanjeev; Lakshmi, P.V.M.; Sagar, Vivek; Khawaja, Rehman; Iqbal, Romaina; Kazmi, Khawar; Yusuf, Salim; Brauer, Michael; PURE-AIR study investigators; MasiraAbstract Introduction Use of polluting cooking fuels generates household air pollution (HAP) containing health-damaging levels of fine particulate matter (PM2.5). Many global epidemiological studies rely on categorical HAP exposure indicators, which are poor surrogates of measured PM2.5 levels. To quantitatively characterize HAP levels on a large scale, a multinational measurement campaign was leveraged to develop household and personal PM2.5 exposure models. Methods The Prospective Urban and Rural Epidemiology (PURE)-AIR study included 48-hour monitoring of PM2.5 kitchen concentrations (n = 2,365) and male and/or female PM2.5 exposure monitoring (n = 910) in a subset of households in Bangladesh, Chile, China, Colombia, India, Pakistan, Tanzania and Zimbabwe. PURE-AIR measurements were combined with survey data on cooking environment characteristics in hierarchical Bayesian log-linear regression models. Model performance was evaluated using leave-one-out cross validation. Predictive models were applied to survey data from the larger PURE cohort (22,480 households; 33,554 individuals) to quantitatively estimate PM2.5 exposures. Results The final models explained half (R2 = 54%) of the variation in kitchen PM2.5 measurements (root mean square error (RMSE) (log scale):2.22) and personal measurements (R2 = 48%; RMSE (log scale):2.08). Primary cooking fuel type, heating fuel type, country and season were highly predictive of PM2.5 kitchen concentrations. Average national PM2.5 kitchen concentrations varied nearly 3-fold among households primarily cooking with gas (20 μg/m3 (Chile); 55 μg/m3 (China)) and 12-fold among households primarily cooking with wood (36 μg/m3 (Chile)); 427 μg/m3 (Pakistan)). Average PM2.5 kitchen concentration, heating fuel type, season and secondhand smoke exposure were significant predictors of personal exposures. Modeled average PM2.5 female exposures were lower than male exposures in upper-middle/high-income countries (India, China, Colombia, Chile). Conclusion Using survey data to estimate PM2.5 exposures on a multinational scale can cost-effectively scale up quantitative HAP measurements for disease burden assessments. The modeled PM2.5 exposures can be used in future epidemiological studies and inform policies targeting HAP reduction.
- PublicaciónRestringidoPrevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries(2013-09-04) Chow, Clara K.; Teo, Koon; Rangarajan, Sumathy; Islam, Shofiqul; Gupta, Rajeev; Avezum, Alvaro; Bahonar, Ahmad; Chifamba, Jephat; Dagenais, Gilles; Diaz, Rafael; Kazmi, Khawar; Lanas, Fernando; Wei, Li; Lopez-Jaramillo, Patricio; Fanghong, Lu; Ismail, Noorhassim; Puoane, Thandi; Rosengren, Annika; Szuba, Andrzej; Temizhan, Ahmet; Wielgosz, Andy; Yusuf, Rita; Yusufali, Afzalhussein; McKee, Martin; Liu, Lisheng; Mony, Prem; Yusuf, Salim; The PURE (Prospective Urban Rural Epidemiology) Study investigatorsImportance Hypertension is the most important preventable cause of morbidity and mortality globally, yet there are relatively few data collected using standardized methods. Objective To examine hypertension prevalence, awareness, treatment, and control in participants at baseline in the Prospective Urban Rural Epidemiology (PURE) study. Design, Setting, and Participants A cross-sectional study of 153 996 adults (complete data for this analysis on 142 042) aged 35 to 70 years, recruited between January 2003 and December 2009. Participants were from 628 communities in 3 high-income countries (HIC), 10 upper–middle-income and low–middle-income countries (UMIC and LMIC), and 4 low-income countries (LIC). Main Outcomes and Measures Hypertension was defined as individuals with self-reported treated hypertension or with an average of 2 blood pressure measurements of at least 140/90 mm Hg using an automated digital device. Awareness was based on self-reports, treatment was based on the regular use of blood pressure–lowering medications, and control was defined as individuals with blood pressure lower than 140/90 mm Hg. Results Among the 142 042 participants, 57 840 (40.8%; 95% CI, 40.5%-41.0%) had hypertension and 26 877 (46.5%; 95% CI, 46.1%-46.9%) were aware of the diagnosis. Of those who were aware of the diagnosis, the majority (23 510 [87.5%; 95% CI, 87.1%-87.9%] of those who were aware) were receiving pharmacological treatments, but only a minority of those receiving treatment were controlled (7634 [32.5%; 95% CI, 31.9%-33.1%]). Overall, 30.8%, 95% CI, 30.2%-31.4% of treated patients were taking 2 or more types of blood pressure–lowering medications. The percentages aware (49.0% [95% CI, 47.8%-50.3%] in HICs, 52.5% [95% CI, 51.8%-53.2%] in UMICs, 43.6% [95% CI, 42.9%-44.2%] in LMICs, and 40.8% [95% CI, 39.9%-41.8%] in LICs) and treated (46.7% [95% CI, 45.5%-47.9%] in HICs, 48.3%, [95% CI, 47.6%-49.1%] in UMICs, 36.9%, [95% CI, 36.3%-37.6%] in LMICs, and 31.7% [95% CI, 30.8%-32.6%] in LICs) were lower in LICs compared with all other countries for awareness (P <.001) and treatment (P <.001). Awareness, treatment, and control of hypertension were higher in urban communities compared with rural ones in LICs (urban vs rural, P <.001) and LMICs (urban vs rural, P <.001), but similar for other countries. Low education was associated with lower rates of awareness, treatment, and control in LICs, but not in other countries. Conclusions and Relevance Among a multinational study population, 46.5% of participants with hypertension were aware of the diagnosis, with blood pressure control among 32.5% of those being treated. These findings suggest substantial room for improvement in hypertension diagnosis and treatment. High blood pressure is the leading cause of cardiovascular disease (CVD) and deaths globally. It is associated with at least 7.6 million deaths per year worldwide (13.5% of all deaths), making it the leading risk factor for CVD.1 The majority of CVD occurs in low-, low–middle-, and upper–middle-income countries (LIC, LMIC, and UMIC).1,2 The importance of blood pressure as a modifiable risk factor for CVD is well-recognized and many effective and inexpensive blood pressure–lowering treatments are available. Therefore, hypertension control and prevention of subsequent morbidity and mortality clearly should be achievable. Information on hypertension prevalence, awareness, treatment, and control in multiple countries and different types of communities is necessary to provide a baseline for monitoring and also to inform the development of new strategies for improving hypertension control. A number of initiatives from the World Health Organization (WHO) have documented prevalence of hypertension and some have recorded treatment rates.3-5 The largest systematic analysis of health surveys from 199 countries for individuals aged 25 years and older was conducted in 2008 and reported the prevalence and mean of hypertension.6 However, most studies were limited to few countries and were conducted at least 2 decades ago, few reported awareness, and none reported on variations between urban vs rural settings, economic status and other variables, rates of blood pressure control, or the types of treatments used. Such information is key to developing strategies for better detection and control of hypertension globally. The overall Prospective Urban Rural Epidemiology (PURE) study is a prospective, standardized collaborative study7,8 in which we report a cross-sectional analysis of baseline data to assess the prevalence, awareness, treatment, and control of hypertension by the economic status of countries and by sex, age group, location (urban vs rural), and education of the participants.
- PublicaciónRestringidoPrognostic validation of a non-laboratory and a laboratory based cardiovascular disease risk score in multiple regions of the world(2018) Joseph, Philip; Yusuf, Salim; Lee, Shun Fu; Ibrahim, Quazi; Teo, Koon; Rangarajan, Sumathy; Gupta, Rajeev; Rosengren, Annika; Lear, Scott A.; Avezum, Alvaro; Lopez-Jaramillo, Patricio; Gulec, Sadi; Yusufali, Afzalhussein; Chifamba, Jephat; Lanas, Fernando; Kumar, Rajesh; Mohammadifard, Noushin; Mohan, Viswanathan; Mony, Prem; Kruger, Annamarie; Liu, Xu; Guo, Baoxia; Zhao, Wenqi; Yang, Youzhu; Pillai, Rajamohanan; Diaz, Rafael; Krishnapillai, Ambigga; Iqbal, Romaina; Yusuf, Rita; Szuba, Andrzej; Anand, Sonia S.Objective To evaluate the performance of the non-laboratory INTERHEART risk score (NL-IHRS) to predict incident cardiovascular disease (CVD) across seven major geographic regions of the world. The secondary objective was to evaluate the performance of the fasting cholesterol-based IHRS (FC-IHRS). Methods Using measures of discrimination and calibration, we tested the performance of the NL-IHRS (n=100 475) and FC-IHRS (n=107 863) for predicting incident CVD in a community-based, prospective study across seven geographic regions: South Asia, China, Southeast Asia, Middle East, Europe/North America, South America and Africa. CVD was defined as the composite of cardiovascular death, myocardial infarction, stroke, heart failure or coronary revascularisation. Results Mean age of the study population was 50.53 (SD 9.79) years and mean follow-up was 4.89 (SD 2.24) years. The NL-IHRS had moderate to good discrimination for incident CVD across geographic regions (concordance statistic (C-statistic) ranging from 0.64 to 0.74), although recalibration was necessary in all regions, which improved its performance in the overall cohort (increase in C-statistic from 0.69 to 0.72, p<0.001). Regional recalibration was also necessary for the FC-IHRS, which also improved its overall discrimination (increase in C-statistic from 0.71 to 0.74, p<0.001). In 85 078 participants with complete data for both scores, discrimination was only modestly better with the FC-IHRS compared with the NL-IHRS (0.74 vs 0.73, p<0.001). Conclusions External validations of the NL-IHRS and FC-IHRS suggest that regionally recalibrated versions of both can be useful for estimating CVD risk across a diverse range of community-based populations. CVD prediction using a non-laboratory score can provide similar accuracy to laboratory-based methods.
- PublicaciónAcceso abiertoProspective Urban Rural Epidemiology (PURE) study : Baseline characteristics of the household sample and comparative analyses with national data in 17 countries(2013-10) Corsi, Daniel J.; Subramanian, S. V.; Chow, Clara K.; McKee, Martin; Chifamba, Jephat; Dagenais, Gilles; Diaz, Rafael; Iqbal, Romaina; Kelishadi, Roya; Kruger, Annamarie; Lanas, Fernando; Lopez-Jaramillo, Patricio; Mony, Prem; Mohan, Viswanathan; Avezum, Alvaro; Oguz, Aytekin; Rahman, M. Omar; Rosengren, Annika; Szuba, Andrej; Li, Wei; Yusoff, Khalid; Yusufali, Afzalhussein; Rangarajan, Sumathy; Teo, Koon; Yusuf, SalimBackground The PURE study was established to investigate associations between social, behavioural, genetic, and environmental factors and cardiovascular diseases in 17 countries. In this analysis we compare the age, sex, urban/rural, mortality, and educational profiles of the PURE participants to national statistics. Methods PURE employed a community-based sampling and recruitment strategy where urban and rural communities were selected within countries. Within communities, representative samples of adults aged 35 to 70 years and their household members (n = 424,921) were invited for participation. Results The PURE household population compared to national statistics had more women (sex ratio 95.1 men per 100 women vs 100.3) and was older (33.1 years vs 27.3), although age had a positive linear relationship between the two data sources (Pearson's r = 0.92). PURE was 59.3% urban compared to an average of 63.1% in participating countries. The distribution of education was less than 7% different for each category, although PURE households typically had higher levels of education. For example, 37.8% of PURE household members had completed secondary education compared to 31.3% in the national data. Age-adjusted annual mortality rates showed positive correlation for men (r = 0.91) and women (r = 0.92) but were lower in PURE compared to national statistics (7.9 per 1000 vs 8.7 for men; 6.7 vs 8.1 for women). Conclusions These findings indicate that modest differences exist between the PURE household population and national data for the indicators studied. These differences, however, are unlikely to have much influence on exposure-disease associations derived in PURE. Further, incidence estimates from PURE, stratified according to sex and/or urban/rural location will enable valid comparisons of the relative rates of various cardiovascular outcomes across countries.
- PublicaciónAcceso abiertoUrinary sodium and potassium excretion, mortality, and cardiovascular events(2014-08-14) O’Donnell, Martin J.; Mente, Andrew; Rangarajan, Sumathy; McQueen, Matthew J.; Wang, Xingyu; Liu, Lisheng; Yan, Hou; Lee, Shun Fu; Mony, Prem; Devanath, Anitha; Rosengren, Annika; Lopez-Jaramillo, Patricio; Diaz, Rafael; Avezum, Alvaro; Lanas, Fernando; Yusoff, Khalid; Iqbal, Romaina; Ilow, Rafal; Mohammadifard, Noushin; Gulec, Sadi; Yusufali, Afzalhussein; Kruger, Lanthe; Yusuf, Rita; Chifamba, Jephat; Kabali, Conrad; Dagenais, Gilles; Lear, Scott A.; Teo, Koon; Yusuf, Salim; The PURE (Prospective Urban Rural Epidemiology) Study investigatorsBACKGROUND The optimal range of sodium intake for cardiovascular health is controversial. METHODS We obtained morning fasting urine samples from 101,945 persons in 17 countries and estimated 24-hour sodium and potassium excretion (used as a surrogate for intake). We examined the association between estimated urinary sodium and potassium excretion and the composite outcome of death and major cardiovascular events. RESULTS The mean estimated sodium and potassium excretion were 4.93 g per day and 2.12 g per day, respectively. With a mean follow-up of 3.7 years, the composite outcome occurred in 3317 participants (3.3%). As compared with an estimated sodium excretion of 4.00 to 5.99 g per day (reference range), a higher estimated sodium excretion (≥7.00 g per day) was associated with an increased risk of the composite outcome (odds ratio, 1.15; 95% confidence interval [CI], 1.02 to 1.30), as well as increased risks of death and major cardiovascular events considered separately. The association between a high estimated sodium excretion and the composite outcome was strongest among participants with hypertension (P=0.02 for interaction). As compared with the reference range, an estimated sodium excretion that was below 3.00 g per day was also associated with an increased risk of the composite outcome (odds ratio, 1.27; 95% CI, 1.12 to 1.44). As compared with an estimated potassium excretion that was less than 1.50 g per day, higher potassium excretion was associated with a reduced risk of the composite outcome. CONCLUSIONS In this study in which sodium intake was estimated on the basis of measured urinary excretion, an estimated sodium intake between 3 g per day and 6 g per day was associated with a lower risk of death and cardiovascular events, as compared with either a higher or lower estimated level of intake. As compared with an estimate potassium excretion that was less than 1.50 g per day, higher potassium excretion was associated with a lower risk of death and cardiovascular events. (Funded by the Population Health Research Institute and others.)
- PublicaciónAcceso abiertoVariations 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, 2022-02-24) Sathish, Thirunavukkarasu; Teo, Koon; Britz-McKibbin, Philip; Gill, Biban; Islam, Shofiqul; Pare, Guillaume; Rangarajan, Sumathy; Duong, MyLinh; Lanas, Fernando; Lopez-Jaramillo, Patricio; Mony, Prem; Pinnaka, Lakshmi; Raman Kutty, Vellappillil; Orlandini, Andres; Avezum, Alvaro; Wielgosz, Andreas; Poirier, Paul; Alhabib, Khalid F.; Temizhan, Ahmet; Chifamba, Jephat; Yeates, Karen; Kruger, Iolanthé M.; Khatib, Rasha; Yusuf, Rita; Rosengren, Annika; Zatonska, Katarzyna; Iqbal, Romaina; Lui, Weida; Lang, Xinyue; Li, Sidong; Hu, Bo; Dans, Antonio; Yusufali, Afzalhussein; Bahonar, Ahmad; O’Donnell, Martin J.; McKee, Martin; Yusuf, Salim; MasiraBackground Separate studies suggest that the risks from smoking might vary between high-income (HICs), middle-income (MICs), and low-income (LICs) countries, but this has not yet been systematically examined within a single study using standardised approaches. We examined the variations in risks from smoking across different country income groups and some of their potential reasons. Methods We analysed data from 134 909 participants from 21 countries followed up for a median of 11·3 years in the Prospective Urban Rural Epidemiology (PURE) cohort study; 9711 participants with myocardial infarction and 11 362 controls from 52 countries in the INTERHEART case-control study; and 11 580 participants with stroke and 11 331 controls from 32 countries in the INTERSTROKE case-control study. In PURE, all-cause mortality, major cardiovascular disease, cancers, respiratory diseases, and their composite were the primary outcomes for this analysis. Biochemical verification of urinary total nicotine equivalent was done in a substudy of 1000 participants in PURE. Findings In PURE, the adjusted hazard ratio (HR) for the composite outcome in current smokers (vs never smokers) was higher in HICs (HR 1·87, 95% CI 1·65–2·12) than in MICs (1·41, 1·34–1·49) and LICs (1·35, 1·25–1·46; interaction p<0·0001). Similar patterns were observed for each component of the composite outcome in PURE, myocardial infarction in INTERHEART, and stroke in INTERSTROKE. The median levels of tar, nicotine, and carbon monoxide displayed on the cigarette packs from PURE HICs were higher than those on the packs from MICs. In PURE, the proportion of never smokers reporting high second-hand smoke exposure (≥1 times/day) was 6·3% in HICs, 23·2% in MICs, and 14·0% in LICs. The adjusted geometric mean total nicotine equivalent was higher among current smokers in HICs (47·2 μM) than in MICs (31·1 μM) and LICs (25·2 μM; ANCOVA p<0·0001). By contrast, it was higher among never smokers in LICs (18·8 μM) and MICs (11·3 μM) than in HICs (5·0 μM; ANCOVA p=0·0001). Interpretation The variations in risks from smoking between country income groups are probably related to the higher exposure of tobacco-derived toxicants among smokers in HICs and higher rates of high second-hand smoke exposure among never smokers in MICs and LICs.
- PublicaciónAcceso abiertoVariations in the financial impact of the COVID-19 pandemic across 5 continents. A cross-sectional, individual level analysis(ScienceDirect, 2022-01-28) Khetan, Aditya K.; Yusuf, Salim; Lopez-Jaramillo, Patricio; Szuba, Andrzej; Orlandini, Andres; Mat-Nasir, Nafiza; Oguz, Aytekin; Gupta, Rajeev; Avezum, Alvaro; Rosnah, Ismail; Poirier, Paul; Teo, Koon; Wielgosz, Andreas; Lear, Scott A.; Palileo-Villanueva, Lia M.; Seron, Pamela; Chifamba, Jephat; Rangarajan, Sumathy; Mushtaha, Maha; Mohan, Deepa; Yeates, Karen; McKee, Martin; Mony, Prem; Walli-Attaei, Marjan; Khansaheb, Hamda; Rosengren, Annika; AlHabib, Khalid F.; Kruger, Iolanthe M.; Paucar, María-Jose; Mirrakhimov, Erkin; Assembekov, Batyrbek; Leong, Darryl P.; MasiraBackground 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.