Association Between Diabetes and Cause-Specific Mortality in Rural and Urban Areas of China
Fiona Bragg, Michael V Holmes, Andri Iona, Yu Guo, Huaidong Du, Yiping Chen, Zheng Bian, Ling Yang, William Herrington, Derrick Bennett, Iain Turnbull, Yongmei Liu, Shixian Feng, Junshi Chen, Robert Clarke, Rory Collins, Richard Peto, Liming Li, Zhengming Chen, China Kadoorie Biobank Collaborative Group, Fiona Bragg, Michael V Holmes, Andri Iona, Yu Guo, Huaidong Du, Yiping Chen, Zheng Bian, Ling Yang, William Herrington, Derrick Bennett, Iain Turnbull, Yongmei Liu, Shixian Feng, Junshi Chen, Robert Clarke, Rory Collins, Richard Peto, Liming Li, Zhengming Chen, China Kadoorie Biobank Collaborative Group
Abstract
Importance: In China, diabetes prevalence has increased substantially in recent decades, but there are no reliable estimates of the excess mortality currently associated with diabetes.
Objectives: To assess the proportional excess mortality associated with diabetes and estimate the diabetes-related absolute excess mortality in rural and urban areas of China.
Design, setting, and participants: A 7-year nationwide prospective study of 512 869 adults aged 30 to 79 years from 10 (5 rural and 5 urban) regions in China, who were recruited between June 2004 and July 2008 and were followed up until January 2014.
Exposures: Diabetes (previously diagnosed or detected by screening) recorded at baseline.
Main outcomes and measures: All-cause and cause-specific mortality, collected through established death registries. Cox regression was used to estimate adjusted mortality rate ratio (RR) comparing individuals with diabetes vs those without diabetes at baseline.
Results: Among the 512 869 participants, the mean (SD) age was 51.5 (10.7) years, 59% (n = 302 618) were women, and 5.9% (n = 30 280) had diabetes (4.1% in rural areas, 8.1% in urban areas, 5.8% of men, 6.1% of women, 3.1% had been previously diagnosed, and 2.8% were detected by screening). During 3.64 million person-years of follow-up, there were 24 909 deaths, including 3384 among individuals with diabetes. Compared with adults without diabetes, individuals with diabetes had a significantly increased risk of all-cause mortality (1373 vs 646 deaths per 100 000; adjusted RR, 2.00 [95% CI, 1.93-2.08]), which was higher in rural areas than in urban areas (rural RR, 2.17 [95% CI, 2.07-2.29]; urban RR, 1.83 [95% CI, 1.73-1.94]). Presence of diabetes was associated with increased mortality from ischemic heart disease (3287 deaths; RR, 2.40 [95% CI, 2.19-2.63]), stroke (4444 deaths; RR, 1.98 [95% CI, 1.81-2.17]), chronic liver disease (481 deaths; RR, 2.32 [95% CI, 1.76-3.06]), infections (425 deaths; RR, 2.29 [95% CI, 1.76-2.99]), and cancer of the liver (1325 deaths; RR, 1.54 [95% CI, 1.28-1.86]), pancreas (357 deaths; RR, 1.84 [95% CI, 1.35-2.51]), female breast (217 deaths; RR, 1.84 [95% CI, 1.24-2.74]), and female reproductive system (210 deaths; RR, 1.81 [95% CI, 1.20-2.74]). For chronic kidney disease (365 deaths), the RR was higher in rural areas (18.69 [95% CI, 14.22-24.57]) than in urban areas (6.83 [95% CI, 4.73-9.88]). Among those with diabetes, 10% of all deaths (16% rural; 4% urban) were due to definite or probable diabetic ketoacidosis or coma (408 deaths).
Conclusions and relevance: Among adults in China, diabetes was associated with increased mortality from a range of cardiovascular and noncardiovascular diseases. Although diabetes was more common in urban areas, it was associated with greater excess mortality in rural areas.
Conflict of interest statement
Conflicts of interest: We declare that we have no conflict of interest.
Figures
References
- Pan XR, Yang WY, Li GW, Liu J. Prevalence of diabetes and its risk factors in China, 1994. Diabetes Care. 1997;20:1664–9.
- Li LM, Rao KQ, Kong LZ, et al. A description on the Chinese national nutrition and health survey in 2002. Chin Epidemiol J. 2005;26:478–84.
- Yang W, Lu J, Weng J, et al. Prevalence of diabetes among men and women in China. N Engl J Med. 2010;362:1090–101.
- Xu Y, Wang L, He J, et al. Prevalence and control of diabetes in Chinese adults. JAMA. 2013;310:948–59.
- Yang G, Wang Y, Zeng Y, et al. Rapid health transition in China, 1990-2010: findings from the Global Burden of Disease Study 2010. Lancet. 2010;381:1987–2015.
- Sarwar N, Gao P, Seshasai SR, et al. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet. 2010;375:2215–22.
- Seshasai SR, Kaptoge S, Thompson A, et al. Diabetes mellitus, fasting glucose, and risk of cause-specific death. N Engl J Med. 2011;364:829–41.
- Campbell PT, Newton CC, Patel AV, Jacobs EJ, Gapstur SM. Diabetes and cause-specific mortality in a prospective cohort of one million U.S. adults. Diabetes Care. 2012;35:1835–44.
- Woodward M, Zhang X, Barzi F, et al. The effects of diabetes on the risks of major cardiovascular diseases and death in the Asia-Pacific region. Diabetes Care. 2003;26:360–6.
- Liu J, Grundy SM, Wang W, et al. Ten-year risk of cardiovascular incidence related to diabetes, prediabetes, and the metabolic syndrome. Am Heart J. 2007;153:552–8.
- Shen C, Schooling CM, Chan WM, Lee SY, Leung GM, Lam TH. Self-reported diabetes and mortality in a prospective Chinese elderly cohort study in Hong Kong. Prev Med. 2014;64:20–6.
- An Y, Zhang P, Wang J, et al. Cardiovascular and all-cause mortality over a 23-year period among Chinese with newly diagnosed diabetes in the Da Qing IGT and Diabetes Study. Diabetes Care. 2015;38:1365–71.
- Zhou M, Wang H, Zhu J, et al. Cause-specific mortality for 240 causes in China during 1990-2013: a systematic subnational analysis for the Global Burden of Disease Study 2013. Lancet. 387:251–72.
- Chen Z, Lee L, Chen J, et al. Cohort profile: The Kadoorie Study of Chronic Disease in China (KSCDC) Int J Epidemiol. 2005;34:1243–9.
- Chen Z, Chen J, Collins R, et al. China Kadoorie Biobank of 0.5 million people: survey methods, baseline characteristics and long-term follow-up. Int J Epidemiol. 2011;40:1652–66.
- Bragg F, Li L, Smith M, et al. Associations of blood glucose and prevalent diabetes with risk of cardiovascular disease in 500 000 adult Chinese: the China Kadoorie Biobank. Diabet Med. 2014;31:540–51.
- Yang GH, Stroup DF, Thacker SB. National public health surveillance in China: implications for public health in China and the United States. Biomed Environ Sci. 1997;10:1–13.
- Yang G, Rao C, Ma J, et al. Validation of verbal autopsy procedures for adult deaths in China. Int J Epidemiol. 2006;35:741–8.
- Easton DF, Peto J, Babiker AG. Floating absolute risk: an alternative to relative risk in survival and case-control analysis avoiding an arbitrary reference group. Stat Med. 1991;10:1025–35.
- Rockhill B, Newman B, Weinberg C. Use and misuse of population attributable fractions. Am J Public Health. 1998;88:15–9.
- Diabetes Public Health Resource: Diabetes Complications. [Accessed 10 March, 2016];2016 .
- Ali MK, Bullard KM, Saaddine JB, Cowie CC, Imperatore G, Gregg EW. Achievement of goals in U.S. diabetes care, 1999–2010. N Engl J Med. 2013;368:1613–24.
- Tancredi M, Rosengren A, Svensson A-M, et al. Excess mortality among persons with type 2 diabetes. N Engl J Med. 2015;373:1720–32.
- Peters SA, Huxley RR, Woodward M. Diabetes as a risk factor for stroke in women compared with men: a systematic review and meta-analysis of 64 cohorts, including 775,385 individuals and 12,539 strokes. Lancet. 2014;383:1973–80.
- Peters SA, Huxley RR, Woodward M. Diabetes as risk factor for incident coronary heart disease in women compared with men: a systematic review and meta-analysis of 64 cohorts including 858,507 individuals and 28,203 coronary events. Diabetologia. 2014;57:1542–51.
- Chinese Ministry of Health. China Statistical Yearbook of Health. Beijing: Publishing House of Peking Union Medical College; 2011.
- Gu D, Reynolds K, Duan X, et al. Prevalence of diabetes and impaired fasting glucose in the Chinese adult population: International Collaborative Study of Cardiovascular Disease in Asia (InterASIA) Diabetologia. 2003;46:1190–8.
- Zhang L, Wang F, Wang L, et al. Prevalence of chronic kidney disease in China: a cross-sectional survey. Lancet. 379:815–22.
- Norheim OF, Jha P, Admasu K, et al. Avoiding 40% of the premature deaths in each country, 2010-30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health. Lancet. 385:239–52.
- Chen Z, Peto R, Zhou M, et al. Contrasting male and female trends in tobacco-attributed mortality in China: evidence from successive nationwide prospective cohort studies. Lancet. 386:1447–56.
- UN Population Division. World population prospects: The 2012 Revision. New York: United Nations; 2012.
Source: PubMed