Examinando por Autor "Rahman, Omar"
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- PublicaciónAcceso abiertoAssociation of Sitting Time with Mortality and Cardiovascular Events in High-Income, Middle-Income, and Low-Income Countries(2022-06-15) Li, Sidong; Lear, Scott A.; Rangarajan, Sumathy; Hu, Bo; Yin, Lu; Bangdiwala, Shrikant I.; Alhabib, Khalid F.; Rosengren, Annika; Gupta, Rajeev; Mony, Prem K.; Wielgosz, Andreas; Rahman, Omar; Mazapuspavina, M. Y.; Avezum, Alvaro; Oguz, Aytekin; Yeates, Karen; Lanas, Fernando; Dans, Antonio; Evans, Marc; Abat, M.; Yusufali, Afzalhussein; Rafael, Diaz; Lopez-Jaramillo, Patricio; Leach, Lloyd; Lakshmi, P. V. M.; Iqbal, Romaina; Kelishadi, Roya; Chifamba, Jephat; Khatib, Rasha; Li, Wei; Yusuf, Salim; MasiraImportance High amounts of sitting time are associated with increased risks of cardiovascular disease (CVD) and mortality in high-income countries, but it is unknown whether risks also increase in low- and middle-income countries. Objective To investigate the association of sitting time with mortality and major CVD in countries at different economic levels using data from the Prospective Urban Rural Epidemiology study. Design, Setting, and Participants This population-based cohort study included participants aged 35 to 70 years recruited from January 1, 2003, and followed up until August 31, 2021, in 21 high-income, middle-income, and low-income countries with a median follow-up of 11.1 years. Exposures Daily sitting time measured using the International Physical Activity Questionnaire. Main Outcomes and Measures The composite of all-cause mortality and major CVD (defined as cardiovascular death, myocardial infarction, stroke, or heart failure). Results Of 105 677 participants, 61 925 (58.6%) were women, and the mean (SD) age was 50.4 (9.6) years. During a median follow-up of 11.1 (IQR, 8.6-12.2) years, 6233 deaths and 5696 major cardiovascular events (2349 myocardial infarctions, 2966 strokes, 671 heart failure, and 1792 cardiovascular deaths) were documented. Compared with the reference group (<4 hours per day of sitting), higher sitting time (≥8 hours per day) was associated with an increased risk of the composite outcome (hazard ratio [HR], 1.19; 95% CI, 1.11-1.28; Pfor trend < .001), all-cause mortality (HR, 1.20; 95% CI, 1.10-1.31; Pfor trend < .001), and major CVD (HR, 1.21; 95% CI, 1.10-1.34; Pfor trend < .001). When stratified by country income levels, the association of sitting time with the composite outcome was stronger in low-income and lower-middle–income countries (≥8 hours per day: HR, 1.29; 95% CI, 1.16-1.44) compared with high-income and upper-middle–income countries (HR, 1.08; 95% CI, 0.98-1.19; P for interaction = .02). Compared with those who reported sitting time less than 4 hours per day and high physical activity level, participants who sat for 8 or more hours per day experienced a 17% to 50% higher associated risk of the composite outcome across physical activity levels; and the risk was attenuated along with increased physical activity levels. Conclusions and Relevance High amounts of sitting time were associated with increased risk of all-cause mortality and CVD in economically diverse settings, especially in low-income and lower-middle–income countries. Reducing sedentary time along with increasing physical activity might be an important strategy for easing the global burden of premature deaths and CVD.
- PublicaciónAcceso abiertoAssociation of Symptoms of Depression with Cardiovascular Disease and Mortality in Low-, Middle-, and High-Income Countries(American Medical Association, 2020-06-10) Rajan, Selina; McKee, Martin; Rangarajan, Sumathy; Bangdiwala, Shrikant; Rosengren, Annika; Gupta, Rajeev; Kutty, Vellappillil Raman; Wielgosz, Andreas; Lear, Scott; AlHabib, Khalid F.; Co, Homer U.; Lopez-Jaramillo, Patricio; Avezum, Alvaro; Seron, Pamela; Oguz, Aytekin; Kruger, Iolanthé M.; Diaz, Rafael; Nafiza, Mat-Nasir; Chifamba, Jephat; Yeates, Karen; Kelishadi, Roya; Sharief, Wadeia Mohammed; Szuba, Andrzej; Khatib, Rasha; Rahman, Omar; Iqbal, Romaina; Bo, Hu; Yibing, Zhu; Wei, Li; Yusuf, Salim; The Prospective Urban Rural Epidemiology (PURE) Study Investigators; EverestIMPORTANCE Depression is associated with incidence of and premature death from cardiovascular disease (CVD) and cancer in high-income countries, but it is not known whether this is true in low- and middle-income countries and in urban areas, where most people with depression now live. OBJECTIVE To identify any associations between depressive symptoms and incident CVD and all-cause mortality in countries at different levels of economic development and in urban and rural areas. DESIGN, SETTING, AND PARTICIPANTS This multicenter, population-based cohort study was conducted between January 2005 and June 2019 (median follow-up, 9.3 years) and included 370 urban and 314 rural communities from 21 economically diverse countries on 5 continents. Eligible participants aged 35 to 70 years were enrolled. Analysis began February 2018 and ended September 2019. EXPOSURES Four or more self-reported depressive symptoms from the Short-Form Composite International Diagnostic Interview. MAIN OUTCOMES AND MEASURES Incident CVD, all-cause mortality, and a combined measure of either incident CVD or all-cause mortality. RESULTS Of 145 862 participants, 61 235 (58%) were male and the mean (SD) age was 50.05 (9.7) years. Of those, 15 983 (11%) reported 4 or more depressive symptoms at baseline. Depression was associated with incident CVD (hazard ratio [HR], 1.14; 95% CI, 1.05-1.24), all-cause mortality (HR, 1.17; 95% CI, 1.11-1.25), the combined CVD/mortality outcome (HR, 1.18; 95% CI, 1.11-1.24), myocardial infarction (HR, 1.23; 95% CI, 1.10-1.37), and noncardiovascular death (HR, 1.21; 95% CI, 1.13-1.31) in multivariable models. The risk of the combined outcome increased progressively with number of symptoms, being highest in those with 7 symptoms (HR, 1.24; 95% CI, 1.12-1.37) and lowest with 1 symptom (HR, 1.05; 95% CI, 0.92 -1.19; P for trend < .001). The associations between having 4 or more depressive symptoms and the combined outcome were similar in 7 different geographical regions and in countries at all economic levels but were stronger in urban (HR, 1.23; 95% CI, 1.13-1.34) compared with rural (HR, 1.10; 95% CI, 1.02-1.19) communities (P for interaction = .001) and in men (HR, 1.27; 95% CI, 1.13-1.38) compared with women (HR, 1.14; 95% CI, 1.06-1.23; P for interaction < .001). CONCLUSIONS AND RELEVANCE In this large, population-based cohort study, adults with depressive symptoms were associated with having increased risk of incident CVD and mortality in economically diverse settings, especially in urban areas. Improving understanding and awareness of these physical health risks should be prioritized as part of a comprehensive strategy to reduce the burden of noncommunicable diseases worldwide.
- PublicaciónAcceso abiertoAssociations of outdoor fine particulate air pollution and cardiovascular disease in 157 436 individuals from 21 high-income, middle-income, and low-income countries (PURE)(Elsevier, 2020-06-01) Hystad, Perry; Larkin, Andrew; Rangarajan, Sumathy; AlHabib, Khalid F; Avezum, Alvaro; Tumerdem Calik, Kevser Burcu; Chifamba, Jephat; Dans, Antonio; Diaz, Rafael; Du Plessis, Johan L; Gupta, Rajeev; Iqbal, Romaina; Khatib, Rasha; Kelishadi, Roya; Lanas, Fernando; Liu, Zhiguang; Lopez-Jaramillo, Patricio; Nair, Sanjeev; Poirier, Paul; Rahman, Omar; Rosengren, Annika; Swidan, Hany; Tse, Lap Ah; Wei, Li; Wielgosz, Andreas; Yeates, Karen; Yusoff, Khalid; Zatoński, Tomasz; Burnett, Rick; Yusuf, Salim; Brauer, Michael; EverestBackground: Most studies of long-term exposure to outdoor fine particulate matter (PM2·5) and cardiovascular disease are from high-income countries with relatively low PM2·5 concentrations. It is unclear whether risks are similar in low-income and middle-income countries (LMICs) and how outdoor PM2·5 contributes to the global burden of cardiovascular disease. In our analysis of the Prospective Urban and Rural Epidemiology (PURE) study, we aimed to investigate the association between long-term exposure to PM2·5 concentrations and cardiovascular disease in a large cohort of adults from 21 high-income, middle-income, and low-income countries. Methods: In this multinational, prospective cohort study, we studied 157 436 adults aged 35-70 years who were enrolled in the PURE study in countries with ambient PM2·5 estimates, for whom follow-up data were available. Cox proportional hazard frailty models were used to estimate the associations between long-term mean community outdoor PM2·5 concentrations and cardiovascular disease events (fatal and non-fatal), cardiovascular disease mortality, and other non-accidental mortality. Findings: Between Jan 1, 2003, and July 14, 2018, 157 436 adults from 747 communities in 21 high-income, middle-income, and low-income countries were enrolled and followed up, of whom 140 020 participants resided in LMICs. During a median follow-up period of 9·3 years (IQR 7·8-10·8; corresponding to 1·4 million person-years), we documented 9996 non-accidental deaths, of which 3219 were attributed to cardiovascular disease. 9152 (5·8%) of 157 436 participants had cardiovascular disease events (fatal and non-fatal incident cardiovascular disease), including 4083 myocardial infarctions and 4139 strokes. Mean 3-year PM2·5 at cohort baseline was 47·5 μg/m3 (range 6-140). In models adjusted for individual, household, and geographical factors, a 10 μg/m3 increase in PM2·5 was associated with increased risk for cardiovascular disease events (hazard ratio 1·05 [95% CI 1·03-1·07]), myocardial infarction (1·03 [1·00-1·05]), stroke (1·07 [1·04-1·10]), and cardiovascular disease mortality (1·03 [1·00-1·05]). Results were similar for LMICs and communities with high PM2·5 concentrations (>35 μg/m3). The population attributable fraction for PM2·5 in the PURE cohort was 13·9% (95% CI 8·8-18·6) for cardiovascular disease events, 8·4% (0·0-15·4) for myocardial infarction, 19·6% (13·0-25·8) for stroke, and 8·3% (0·0-15·2) for cardiovascular disease mortality. We identified no consistent associations between PM2·5 and risk for non-cardiovascular disease deaths. Interpretation: Long-term outdoor PM2·5 concentrations were associated with increased risks of cardiovascular disease in adults aged 35-70 years. Air pollution is an important global risk factor for cardiovascular disease and a need exists to reduce air pollution concentrations, especially in LMICs, where air pollution levels are highest. Funding: Full funding sources are listed at the end of the paper (see Acknowledgments).
- 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.)
- 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.
- PublicaciónRestringidoFruit, vegetable, and legume intake, and cardiovascular disease and deaths in 18 countries (PURE) : A prospective cohort study(2017-11-04) Lopez-Jaramillo, Patricio; Miller, Victoria; Mente, Andrew; Dehghan, Mahshid; Rangarajan, Sumathy; Zhang, Xiaohe; Swaminathan, Sumathi; Dagenais, Gilles; Gupta, Rajeev; Mohan, Viswanathan; Lear, Scott A.; Bangdiwala, Shrikant I.; Schutte, Aletta Elisabeth; Wentzel Viljoen, Edelweiss; Avezum, Alvaro; Altuntas, Yuksel; Yusoff, Khalid; Ismail, Noorhassim; Peer, Nasheeta; Chifamba, Jephat; Diaz, Rafael; Rahman, Omar; Mohammadifard, Noushin; Lanas, Fernando; Zatonska, Katarzyna; Wielgosz, Andreas; Yusufali, Afzalhussein; Iqbal, Romaina; Khatib, Rasha; Rosengren, Annika; Kutty, V. Raman; Li, Wei; Liu, Jiankang; Liu, Xiaoyun; Yin, Lu; Teo, Koon; Anand, Sonia S.; Yusuf, Salim; The Prospective Urban Rural Epidemiology (PURE) study investigatorsBackground The association between intake of fruits, vegetables, and legumes with cardiovascular disease and deaths has been investigated extensively in Europe, the USA, Japan, and China, but little or no data are available from the Middle East, South America, Africa, or south Asia. Methods We did a prospective cohort study (Prospective Urban Rural Epidemiology [PURE] in 135335 individuals aged 35 to 70 years without cardiovascular disease from 613 communities in 18 low-income, middle-income, and highincome countries in seven geographical regions: North America and Europe, South America, the Middle East, south Asia, China, southeast Asia, and Africa. We documented their diet using country-specific food frequency questionnaires at baseline. Standardised questionnaires were used to collect information about demographic factors, socioeconomic status (education, income, and employment), lifestyle (smoking, physical activity, and alcohol intake), health history and medication use, and family history of cardiovascular disease. The follow-up period varied based on the date when recruitment began at each site or country. The main clinical outcomes were major cardiovascular disease (defined as death from cardiovascular causes and non-fatal myocardial infarction, stroke, and heart failure), fatal and non-fatal myocardial infarction, fatal and non-fatal strokes, cardiovascular mortality, non-cardiovascular mortality, and total mortality. Cox frailty models with random effects were used to assess associations between fruit, vegetable, and legume consumption with risk of cardiovascular disease events and mortality. Findings Participants were enrolled into the study between Jan 1, 2003, and March 31, 2013. For the current analysis, we included all unrefuted outcome events in the PURE study database through March 31, 2017. Overall, combined mean fruit, vegetable and legume intake was 3·91 (SD 2·77) servings per day. During a median 7·4 years (5·5–9·3) of followup, 4784 major cardiovascular disease events, 1649 cardiovascular deaths, and 5796 total deaths were documented. Higher total fruit, vegetable, and legume intake was inversely associated with major cardiovascular disease, myocardial infarction, cardiovascular mortality, non-cardiovascular mortality, and total mortality in the models adjusted for age, sex, and centre (random effect). The estimates were substantially attenuated in the multivariable adjusted models for major cardiovascular disease (hazard ratio [HR] 0·90, 95% CI 0·74–1·10, ptrend=0·1301), myocardial infarction (0·99, 0·74–1·31; ptrend=0·2033), stroke (0·92, 0·67–1·25; ptrend=0·7092), cardiovascular mortality (0·73, 0·53–1·02; ptrend=0·0568), non-cardiovascular mortality (0·84, 0·68–1·04; ptrend =0·0038), and total mortality (0·81, 0·68–0·96; ptrend<0·0001). The HR for total mortality was lowest for three to four servings per day (0·78, 95% CI 0·69–0·88) compared with the reference group, with no further apparent decrease in HR with higher consumption. When examined separately, fruit intake was associated with lower risk of cardiovascular, non-cardiovascular, and total mortality, while legume intake was inversely associated with non-cardiovascular death and total mortality (in fully adjusted models). For vegetables, raw vegetable intake was strongly associated with a lower risk of total mortality, whereas cooked vegetable intake showed a modest benefit against mortality. Interpretation Higher fruit, vegetable, and legume consumption was associated with a lower risk of non-cardiovascular, and total mortality. Benefits appear to be maximum for both non-cardiovascular mortality and total mortality at three to four servings per day (equivalent to 375–500 g/day). Funding Full funding sources listed at the end of the paper (see Acknowledgments).
- 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 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 abiertoPrognostic value of grip strength : Findings from the Prospective Urban Rural Epidemiology (PURE) study(2015-07) Leong, Darryl P.; Teo, Koon; Rangarajan, Sumathy; Lopez-Jaramillo, Patricio; Avezum, Alvaro; Orlandini, Andres; Seron, Pamela; Ahmed, Suad H.; Rosengren, Annika; Kelishadi, Roya; Rahman, Omar; Swaminathan, Sumathi; Iqbal, Romaina; Gupta, Rajeev; Lear, Scott A.; Oguz, Aytekin; Yusoff, Khalid; Zatonska, Katarzyna; Chifamba, Jephat; Igumbor, Ehimario; Mohan, Viswanathan; Anjana, Ranjit Mohan; Gu, Hongqiu; Li, Wei; Yusuf, Salim; The PURE (Prospective Urban Rural Epidemiology) Study investigatorsBackground Reduced muscular strength, as measured by grip strength, has been associated with an increased risk of all-cause and cardiovascular mortality. Grip strength is appealing as a simple, quick, and inexpensive means of stratifying an individual's risk of cardiovascular death. However, the prognostic value of grip strength with respect to the number and range of populations and confounders is unknown. The aim of this study was to assess the independent prognostic importance of grip strength measurement in socioculturally and economically diverse countries. Methods The Prospective Urban-Rural Epidemiology (PURE) study is a large, longitudinal population study done in 17 countries of varying incomes and sociocultural settings. We enrolled an unbiased sample of households, which were eligible if at least one household member was aged 35–70 years and if household members intended to stay at that address for another 4 years. Participants were assessed for grip strength, measured using a Jamar dynamometer. During a median follow-up of 4·0 years (IQR 2·9–5·1), we assessed all-cause mortality, cardiovascular mortality, non-cardiovascular mortality, myocardial infarction, stroke, diabetes, cancer, pneumonia, hospital admission for pneumonia or chronic obstructive pulmonary disease (COPD), hospital admission for any respiratory disease (including COPD, asthma, tuberculosis, and pneumonia), injury due to fall, and fracture. Study outcomes were adjudicated using source documents by a local investigator, and a subset were adjudicated centrally. Findings Between January, 2003, and December, 2009, a total of 142 861 participants were enrolled in the PURE study, of whom 139 691 with known vital status were included in the analysis. During a median follow-up of 4·0 years (IQR 2·9–5·1), 3379 (2%) of 139 691 participants died. After adjustment, the association between grip strength and each outcome, with the exceptions of cancer and hospital admission due to respiratory illness, was similar across country-income strata. Grip strength was inversely associated with all-cause mortality (hazard ratio per 5 kg reduction in grip strength 1·16, 95% CI 1·13–1·20; p<0·0001), cardiovascular mortality (1·17, 1·11–1·24; p<0·0001), non-cardiovascular mortality (1·17, 1·12–1·21; p<0·0001), myocardial infarction (1·07, 1·02–1·11; p=0·002), and stroke (1·09, 1·05–1·15; p<0·0001). Grip strength was a stronger predictor of all-cause and cardiovascular mortality than systolic blood pressure. We found no significant association between grip strength and incident diabetes, risk of hospital admission for pneumonia or COPD, injury from fall, or fracture. In high-income countries, the risk of cancer and grip strength were positively associated (0·916, 0·880–0·953; p<0·0001), but this association was not found in middle-income and low-income countries. Interpretation This study suggests that measurement of grip strength is a simple, inexpensive risk-stratifying method for all-cause death, cardiovascular death, and cardiovascular disease. Further research is needed to identify determinants of muscular strength and to test whether improvement in strength reduces mortality and cardiovascular disease. Funding Full funding sources listed at end of paper (see Acknowledgments).
- PublicaciónRestringidoReference ranges of handgrip strength from 125,462 healthy adults in 21 countries : A prospective urban rural epidemiologic (PURE) study(2016-03-14) Lopez-Jaramillo, Patricio; Leong, Darryl P.; Teo, Koon; Rangarajan, Sumathy; Raman Kutty, V.; Lanas, Fernando; Hui, Chen; Quanyong, Xiang; Zhenzhen, Qian; Jinhua, Tang; Noorhassim, Ismail; AlHabib, Khalid F.; Moss, Sarah J.; Rosengren, Annika; Arzu Akalin, Ayse; Rahman, Omar; Chifamba, Jephat; Orlandini, Andres; Kumar, Rajesh; Yeates, Karen; Gupta, Rajeev; Yusufali, Afzalhussein; Dans, Antonio; Avezum, Alvaro; Poirier, Paul P.; Heidari, Hosein; Zatonska, Katarzyna; Iqbal, Romaina; Khatib, Rasha; Yusuf, SalimBackground The measurement of handgrip strength (HGS) has prognostic value with respect to all-cause mortality, cardiovascular mortality and cardiovascular disease, and is an important part of the evaluation of frailty. Published reference ranges for HGS are mostly derived from Caucasian populations in high-income countries. There is a paucity of information on normative HGS values in non-Caucasian populations from low- or middle-income countries. The objective of this study was to develop reference HGS ranges for healthy adults from a broad range of ethnicities and socioeconomically diverse geographic regions. Methods HGS was measured using a Jamar dynamometer in 125,462 healthy adults aged 35-70 years from 21 countries in the Prospective Urban Rural Epidemiology (PURE) study. Results HGS values differed among individuals from different geographic regions. HGS values were highest among those from Europe/North America, lowest among those from South Asia, South East Asia and Africa, and intermediate among those from China, South America, and the Middle East. Reference ranges stratified by geographic region, age, and sex are presented. These ranges varied from a median (25th–75th percentile) 50 kg (43–56 kg) in men <40 years from Europe/North America to 18 kg (14–20 kg) in women >60 years from South East Asia. Reference ranges by ethnicity and body-mass index are also reported. Conclusions Individual HGS measurements should be interpreted using region/ethnic-specific reference ranges.
- 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).