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Contrasting 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

Anjana RM 1 , Mohan V 2 , Rangarajan S 3 , Gerstein HC 3 , Venkatesan U 1 , Sheridan P 3 Show all authors , Dagenais GR 4 , Lear SA 5 , Teo K 3 , Karsidag K 6 , Alhabib KF 7 , Yusoff K 8 , Ismail N 9 , Mony PK 10 , Lopez-Jaramillo P 11 , Chifamba J 12 , Palileo-Villanueva LM 13 , Iqbal R 14 , Yusufali A 15 , Kruger IM 16 , Rosengren A 17 , Bahonar A 18 , Zatonska K 19 , Yeates K 20 , Gupta R 21 , Li W 22 , Hu L 23 , Rahman MO 24 , Lakshmi PVM 25 , Iype T 26 , Avezum A 27 , Diaz R 28 , Lanas F 29 , Yusuf S 3

Affiliations 

  • 1 Madras Diabetes Research Foundation and Dr. Mohan's Diabetes Specialities Centre, Chennai, India
  • 2 Madras Diabetes Research Foundation and Dr. Mohan's Diabetes Specialities Centre, Chennai, India drmohans@diabetes.ind.in
  • 3 Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
  • 4 Institut universitaire de Cardiologie et Pneumologie de Québec-Université Laval, Québec, Québec, Canada
  • 5 Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
  • 6 Department of Internal Medicine, Division of Endocrinology, Istanbul, Turkey
  • 7 Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
  • 8 Department of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
  • 9 Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
  • 10 Division of Epidemiology and Population Health, St. John's Medical College and Research Institute, Bangalore, India
  • 11 Masira Research Institute, Universidad de Santander (UDES), Bucaramanga, Colombia
  • 12 College of Health Sciences, Physiology Department, University of Zimbabwe, Harare, Zimbabwe
  • 13 UP College of Medicine, University of the Philippines Manila, Manila, Philippines
  • 14 Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
  • 15 Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
  • 16 Africa Unit for Transdisciplinary Health Research, Department of Medicine, Faculty of Health Sciences, North-West University, Mmabatho, South Africa
  • 17 Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
  • 18 Hypertension Research Center, Cardiovascular Research Institute, Department of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
  • 19 Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
  • 20 Department of Medicine, Queen's University, Kingston, Ontario, Canada
  • 21 Eternal Heart Care Centre and Research Institute, Jaipur, India
  • 22 Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Beijing, China
  • 23 Nanchang County Center for Disease Prevention and Control, Nanchang, Jiangxi Province, China
  • 24 Independent University, Dhaka, Bangladesh
  • 25 School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
  • 26 Health Action by People and Government Medical College, Thiruvanthapuram, Kerala, India
  • 27 Hospital Alemão Oswaldo Cruz and UNISA, São Paulo, Brazil
  • 28 Estudios Clínicos Latino America, Instituto Cardiovascular de Rosario, Rosario, Santa Fe, Argentina
  • 29 Universidad de La Frontera, Temuco, Chile
Diabetes Care, 2020 12;43(12):3094-3101.
PMID: 33060076 DOI: 10.2337/dc20-0886

Abstract

OBJECTIVE: 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 ± 3.0 years.

RESULTS: Among those with diabetes, CVD rates (LIC 10.3, MIC 9.2, HIC 8.3 per 1,000 person-years, P < 0.001), all-cause mortality (LIC 13.8, MIC 7.2, HIC 4.2 per 1,000 person-years, 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.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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