Variations in common diseases, hospital admissions, and deaths in middle-aged adults in 21 countries from five continents (PURE): a prospective cohort study

BACKGROUND: To our knowledge, no previous study has prospectively documented the incidence of common diseases and related mortality in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) with standardised approaches. Such information is key to developing global and context-specific health strategies. In our analysis of the Prospective Urban Rural Epidemiology (PURE) study, we aimed to evaluate differences in the incidence of common diseases, related hospital admissions, and related mortality in a large contemporary cohort of adults from 21 HICs, MICs, and LICs across five continents by use of standardised approaches. METHODS: The PURE study is a prospective, population-based cohort study of individuals aged 35-70 years who have been enrolled from 21 countries across five continents. The key outcomes were the incidence of fatal and non-fatal cardiovascular diseases, cancers, injuries, respiratory diseases, and hospital admissions, and we calculated the age-standardised and sex-standardised incidence of these events per 1000 person-years. FINDINGS: This analysis assesses the incidence of events in 162 534 participants who were enrolled in the first two phases of the PURE core study, between Jan 6, 2005, and Dec 4, 2016, and who were assessed for a median of 9·5 years (IQR 8·5-10·9). During follow-up, 11 307 (7·0%) participants died, 9329 (5·7%) participants had cardiovascular disease, 5151 (3·2%) participants had a cancer, 4386 (2·7%) participants had injuries requiring hospital admission, 2911 (1·8%) participants had pneumonia, and 1830 (1·1%) participants had chronic obstructive pulmonary disease (COPD). Cardiovascular disease occurred more often in LICs (7·1 cases per 1000 person-years) and in MICs (6·8 cases per 1000 person-years) than in HICs (4·3 cases per 1000 person-years). However, incident cancers, injuries, COPD, and pneumonia were most common in HICs and least common in LICs. Overall mortality rates in LICs (13·3 deaths per 1000 person-years) were double those in MICs (6·9 deaths per 1000 person-years) and four times higher than in HICs (3·4 deaths per 1000 person-years). This pattern of the highest mortality in LICs and the lowest in HICs was observed for all causes of death except cancer, where mortality was similar across country income levels. Cardiovascular disease was the most common cause of deaths overall (40%) but accounted for only 23% of deaths in HICs (vs 41% in MICs and 43% in LICs), despite more cardiovascular disease risk factors (as judged by INTERHEART risk scores) in HICs and the fewest such risk factors in LICs. The ratio of deaths from cardiovascular disease to those from cancer was 0·4 in HICs, 1·3 in MICs, and 3·0 in LICs, and four upper-MICs (Argentina, Chile, Turkey, and Poland) showed ratios similar to the HICs. Rates of first hospital admission and cardiovascular disease medication use were lowest in LICs and highest in HICs. INTERPRETATION: Among adults aged 35-70 years, cardiovascular disease is the major cause of mortality globally. However, in HICs and some upper-MICs, deaths from cancer are now more common than those from cardiovascular disease, indicating a transition in the predominant causes of deaths in middle-age. As cardiovascular disease decreases in many countries, mortality from cancer will probably become the leading cause of death. The high mortality in poorer countries is not related to risk factors, but it might be related to poorer access to health care. (AU)

The environmental profile of a community's health: a cross-sectional study on tobacco marketing in 16 countries

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 11,842 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.

Psychosocial factors and obesity in 17 high-, middle- andlow-income countries: the Prospective Urban RuralEpidemiologic study

Psychosocial stress has been proposed to contribute to obesity, particularly abdominal, or centralobesity, through chronic activation of the neuroendocrine systems. However, these putative relationships are complex anddependent on country and cultural context. We investigated the association between psychosocial factors and general andabdominal obesity in the Prospective Urban Rural Epidemiologic study.SUBJECTS/METHODS: This observational, cross-sectional study enrolled 151 966 individuals aged 35–70 years from 628 urban andrural communities in 17 high-, middle- and low-income countries. Data were collected for 125 290 individuals regarding education,anthropometrics, hypertension/diabetes, tobacco/alcohol use, diet and psychosocial factors (self-perceived stress and depression).RESULTS: After standardization for age, sex, country income and urban/rural location, the proportion with obesity (body massindex ⩾ 30 kgm−2) increased from 15.7% in 40 831 individuals with no stress to 20.5% in 7720 individuals with permanent stress,with corresponding proportions for ethnicity- and sex-specific central obesity of 48.6% and 53.5%, respectively (Po0.0001 forboth). Associations between stress and hypertension/diabetes tended to be inverse. Estimating the total effect of permanent stresswith age, sex, physical activity, education and region as confounders, no relationship between stress and obesity persisted(adjusted prevalence ratio (PR) for obesity 1.04 (95% confidence interval: 0.99–1.10)). There was no relationship between ethnicityandsex-specific central obesity (adjusted PR 1.00 (0.97–1.02)). Stratification by region yielded inconsistent associations. Depressionwas weakly but independently linked to obesity (PR 1.08 (1.04–1.12)), and very marginally to abdominal obesity (PR 1.01(1.00–1.03)).

Cardiovascular risk and events in 17 low-,middle-, and high-income countries

BACKGROUNDMore than 80% of deaths from cardiovascular disease are estimated to occur inlow-income and middle-income countries, but the reasons are unknown.METHODSWe 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 assessedtheir cardiovascular risk using the INTERHEART Risk Score, a validated score forquantifying risk-factor burden without the use of laboratory testing (with higherscores indicating greater risk-factor burden). Participants were followed for incidentcardiovascular disease and death for a mean of 4.1 years.RESULTSThe mean INTERHEART Risk Score was highest in high-income countries, intermediatein middle-income countries, and lowest in low-income countries (P<0.001).However, the rates of major cardiovascular events (death from cardiovascularcauses, myocardial infarction, stroke, or heart failure) were lower in high-incomecountries than in middle- and low-income countries (3.99 events per 1000 personyearsvs. 5.38 and 6.43 events per 1000 person-years, respectively; P<0.001). Casefatality 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 communitieshad a higher risk-factor burden than rural communities but lower ratesof cardiovascular events (4.83 vs. 6.25 events per 1000 person-years, P<0.001) andcase fatality rates (13.52% vs. 17.25%, P<0.001). The use of preventive medicationsand revascularization procedures was significantly more common in high-incomecountries than in middle- or low-income countries (P<0.001).CONCLUSIONSAlthough the risk-factor burden was lowest in low-income countries, the rates ofmajor cardiovascular disease and death were substantially higher in low-incomecountries than in high-income countries. The high burden of risk factors in highincome...