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JAMA Netw Open. 2019 Apr 5;2(4):e192696. doi: 10.1001/jamanetworkopen.2019.2696.

Association of Diabetes With All-Cause and Cause-Specific Mortality in Asia: A Pooled Analysis of More Than 1 Million Participants.

Yang JJ1, Yu D1, Wen W1, Saito E2, Rahman S3, Shu XO1, Chen Y4,5, Gupta PC6, Gu D7, Tsugane S8, Xiang YB9,10, Gao YT9,10, Yuan JM11, Tamakoshi A12, Irie F13, Sadakane A14, Tomata Y15, Kanemura S15, Tsuji I15, Matsuo K16,17, Nagata C18, Chen CJ19, Koh WP20,21, Shin MH22, Park SK23,24,25, Wu PE26, Qiao YL27, Pednekar MS6, He J28, Sawada N8, Li HL9,10, Gao J9,10, Cai H1, Wang R11, Sairenchi T29, Grant E14, Sugawara Y15, Zhang S15, Ito H16,17, Wada K18, Shen CY30,31, Pan WH30, Ahn YO23, You SL32, Fan JH27, Yoo KY23,33, Ashan H34,35,36,37, Chia KS21, Boffetta P38, Inoue M8, Kang D23,24,25, Potter JD39,40,41, Zheng W1.

Author information

1
Division of Epidemiology, Department of Medicine, Vanderbilt Epidemiology Center, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee.
2
Division of Cancer Statistics Integration, Center for Cancer Control and Information Services, National Cancer Center, Tokyo, Japan.
3
Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
4
Department of Population Health, New York University School of Medicine, New York.
5
Department of Environmental Medicine, New York University School of Medicine, New York.
6
Healis-Sekhsaria Institute for Public Health, Mahape, Navi Mumbai, India.
7
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
8
Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan.
9
State Key Laboratory of Oncogene and Related Genes, Shanghai Cancer Institute, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China.
10
Department of Epidemiology, Shanghai Cancer Institute, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China.
11
Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania.
12
Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
13
Department of Health and Welfare, Ibaraki Prefectural Office, Mito, Japan.
14
Radiation Effects Research Foundation, Hiroshima, Japan.
15
Tohoku University Graduate School of Medicine, Sendai, Japan.
16
Division of Molecular & Clinical Epidemiology, Aichi Cancer Center Research Institute, Nagoya, Japan.
17
Department of Epidemiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
18
Graduate School of Medicine, Gifu University, Gifu City, Japan.
19
Academia Sinica, Taipei City, Taiwan.
20
Health Services and Systems Research, Duke-NUS Medical School Singapore, Singapore, Republic of Singapore.
21
Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Republic of Singapore.
22
Department of Social and Preventive Medicine, Sungkyunkwan University School of Medicine, Seoul, South Korea.
23
Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, South Korea.
24
Department of Biomedical Sciences, Seoul National University Graduate School, Seoul, South Korea.
25
Cancer Research Institute, Seoul National University, Seoul, South Korea.
26
Taiwan Biobank, Institute of Biomedical Sciences, Academia Sinica, Taipei city, Taiwan.
27
National Cancer Center, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, People's Republic of China.
28
Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana.
29
Department of Public Health, Dokkyo Medical University School of Medicine, Mibu, Japan.
30
Institute of Biomedical Sciences, Academia Sinica, Taipei City, Taiwan.
31
College of Public Health, China Medical University, Taichung, Taiwan.
32
School of Medicine & Big Data Research Center, Fu Jen Catholic University, Taipei City, Taiwan.
33
Armed Forces Capital Hospital, Seongnam, South Korea.
34
Department of Health Studies, University of Chicago, Chicago, Illinois.
35
Department of Medicine, University of Chicago, Chicago, Illinois.
36
Department of Human Genetics, University of Chicago, Chicago, Illinois.
37
Cancer Research Center, University of Chicago, Chicago, Illinois.
38
Icahn School of Medicine at Mount Sinai, New York, New York.
39
Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington.
40
Centre for Public Health Research, Massey University, Wellington, New Zealand.
41
Department of Epidemiology, University of Washington, Seattle.

Abstract

Importance:

Asia is home to the largest diabetic populations in the world. However, limited studies have quantified the association of diabetes with all-cause and cause-specific mortality in Asian populations.

Objectives:

To evaluate the association of diabetes with all-cause and cause-specific mortality in Asia and to investigate potential effect modifications of the diabetes-mortality associations by participants' age, sex, education level, body mass index, and smoking status.

Design, Setting, and Participants:

This pooled analysis incorporated individual participant data from 22 prospective cohort studies of the Asia Cohort Consortium conducted between 1963 and 2006. A total of 1 002 551 Asian individuals (from mainland China, Japan, South Korea, Singapore, Taiwan, India, and Bangladesh) were followed up for more than 3 years. Cohort-specific hazard ratios and 95% confidence intervals for all-cause and cause-specific mortality were estimated using Cox regression models and then pooled using random-effects meta-analysis. Analysis was conducted between January 10, 2018, and August 31, 2018.

Exposures:

Doctor-diagnosed diabetes, age, sex, education level, body mass index, and smoking status.

Main Outcomes and Measures:

All-cause and cause-specific mortality.

Results:

Of 1 002 551 participants (518 537 [51.7%] female; median [range] age, 54.0 [30.0-98.0] years), 148 868 deaths were ascertained during a median (range) follow-up of 12.6 (3.0-38.9) years. The overall prevalence of diabetes reported at baseline was 4.8% for men and 3.6% for women. Patients with diabetes had a 1.89-fold risk of all-cause death compared with patients without diabetes (hazard ratio [HR], 1.89; 95% CI, 1.74-2.04), with the highest relative risk of death due to diabetes itself (HR, 22.8; 95% CI, 18.5-28.1), followed by renal disease (HR, 3.08; 95% CI, 2.50-3.78), coronary heart disease (HR, 2.57; 95% CI, 2.19-3.02), and ischemic stroke (HR, 2.15; 95% CI, 1.85-2.51). The adverse diabetes-mortality associations were more evident among women (HR, 2.09; 95% CI, 1.89-2.32) than among men (HR, 1.74; 95% CI, 1.62-1.88) (P for interaction < .001) and more evident among adults aged 30 to 49 years (HR, 2.43; 95% CI, 2.08-2.84) than among adults aged 70 years and older (HR, 1.51; 95% CI, 1.40-1.62) (P for interaction < .001). A similar pattern of association was found between diabetes and cause-specific mortality, with significant variations noted by sex and age.

Conclusions and Relevance:

This study found that diabetes was associated with increased risk of death from several diseases among Asian populations. Development and implementation of diabetes management programs are urgently needed to reduce the burden of diabetes in Asia.

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