The 2012 World Health Assembly set a target for Member States to reduce premature non-communicable disease (NCD) mortality by 25% over the period 2010 to 2025. This reflected concerns about increasing NCD mortality burdens among productive adults globally. This article first considers whether the WHO target of a 25% reduction in the unconditional probability of dying between ages of 30 and 70 from NCDs (cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases) has already taken place in Sweden during an equivalent 15-year period. Secondly, it assesses which population sub-groups have been more or less successful in contributing to overall changes in premature NCD mortality in Sweden.
A retrospective dynamic cohort database was constructed from Swedish population registers in the Linnaeus database, covering the entire population in the age range 30 to 69 years for the period 1991 to 2006, which was used directly to measure reductions in premature NCD mortality using a life table method as specified by the WHO. Multivariate Poisson regression models were used to assess the contributions of individual background factors to decreases in premature NCD mortality.
A total of 292,320 deaths occurred in the 30 to 69 year age group during the period 1991 to 2006, against 70,768,848 person-years registered. The crude all-cause mortality rate declined from 5.03 to 3.72 per 1,000 person-years, a 26% reduction. Within this, the unconditional probability of dying between the ages of 30 and 70 from NCD causes as defined by the WHO fell by 30.0%. Age was consistently the strongest determinant of NCD mortality. Background determinants of NCD mortality changed significantly over the four time periods 1991-1994, 1995-1998, 1999-2002, and 2003-2006.
Sweden, now at a late stage of epidemiological transition, has already exceeded the 25% premature NCD mortality reduction target during an earlier 15-year period. This should be encouraging news for countries currently implementing premature NCD mortality reduction programmes. Our findings suggest, however, that it may be difficult for Sweden and other late-transition countries to reach the current 25?×?25 target, particularly where substantial premature mortality reductions have already been achieved.
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Cites: J Epidemiol Community Health. 2015 Mar;69(3):207-17; discussion 205-624964740
In two counties of Sweden, Gotland and Umeå, lower leg or thigh amputations were performed during 1971-1980 in 111 and 71 diabetic patients, respectively. These figures correspond to 20.5 and 6.5 per 100 000 inhabitants and year, respectively. The corresponding incidence for Umeå city and the rural area surrounding Umeå was 3.1 and 13.8/100 000 inhabitants and year, respectively. The lower frequency of amputations in Umeå was probably the consequence of a restricted period of systematic search for early signs of gangrene, as a part of a research program, but other factors could also be of importance and these are discussed. The death rate of the patients was high in both series, after 2 years only about one third of the patients were still alive.
An international comparison study indicated physicians' habits in reporting diabetes in part I of death certificate affected reported national diabetes mortality.
BACKGROUND AND OBJECTIVE: Physicians may find it confusing to decide whether to report diagnoses in part I or part II of the death certificate. The aim of this study was to contrast differences in diabetes mortality through a comparison of physicians' habits in reporting diabetes in part I of death certification among Taiwan, Australia, and Sweden. METHODS: A cross-sectional, intercountry comparison study. We calculated the proportion of deaths with mention of diabetes in which diabetes was reported in part I of the death certificate and the proportion of deaths with mention of diabetes in which diabetes was selected as underlying cause of death. RESULTS: We found that half of the differences in reported diabetes mortality among Taiwan, Australia, and Sweden were due to differences in reporting deaths with mention of diabetes anywhere on the certificate, and half due to differences in proportion of deaths with mention of diabetes in which diabetes was reported in part I of the death certificate. CONCLUSION: Differences in the reporting of diabetes in part I of the death certificate among physicians in Taiwan, Australia, and Sweden was one of the factors that affected differing reported diabetes mortality in Taiwan, Australia, and Sweden.
AIMS: Impaired fasting glucose (IFG) below the diagnostic threshold for diabetes mellitus (DM) is associated with macrovascular pathology and increased mortality after percutaneous coronary interventions. The study goal was to determine whether pre-operative fasting blood glucose (fB-glu) is associated with an increased mortality after coronary artery bypass grafting (CABG). METHODS AND RESULTS: During 2001-03, 1895 patients underwent primary CABG [clinical DM (CDM) in 440/1895; complete data on fB-glu for n=1375/1455]. Using pre-operative fB-glu, non-diabetics were categorized as having normal fB-glu ( or =6.1 mmol/L). fB-glu was normal in 59%. The relative risks of 30 day and 1 year mortality compared with patients with normal fB-glu was 1.7 [95% confidence interval (CI): 0.5-5.5] and 2.9 (CI: 0.8-11.2) with IFG, 2.8 (CI: 1.1-7.2) and 1.9 (CI: 0.5-6.3) with SDM vs. 1.8 (CI: 0.8-4.0) and 1.6 (CI: 0.6-4.3) if CDM, respectively. The receiver operator characteristic area for the continuous variable fB-glu and 1 year mortality was 0.65 (P=0.002). CONCLUSION: The elevated risk of death after CABG surgery known previously to be associated with CDM seems also to be shared by a group of similar size that includes patients with IFG and undiagnosed DM.
Assessment of the CHA2DS2-VASc Score in Predicting Ischemic Stroke, Thromboembolism, and Death in Patients With Heart Failure With and Without Atrial Fibrillation.
The CHA2DS2-VASc score (congestive heart failure, hypertension, age =75 years [doubled], diabetes, stroke/transient ischemic attack/thromboembolism [doubled], vascular disease [prior myocardial infarction, peripheral artery disease, or aortic plaque], age 65-75 years, sex category [female]) is used clinically for stroke risk stratification in atrial fibrillation (AF). Its usefulness in a population of patients with heart failure (HF) is unclear.
To investigate whether CHA2DS2-VASc predicts ischemic stroke, thromboembolism, and death in a cohort of patients with HF with and without AF.
Nationwide prospective cohort study using Danish registries, including 42?987 patients (21.9% with concomitant AF) not receiving anticoagulation who were diagnosed as having incident HF during 2000-2012. End of follow-up was December 31, 2012.
Levels of the CHA2DS2-VASc score (based on 10 possible points, with higher scores indicating higher risk), stratified by concomitant AF at baseline. Analyses took into account the competing risk of death.
Ischemic stroke, thromboembolism, and death within 1 year after HF diagnosis.
In patients without AF, the risks of ischemic stroke, thromboembolism, and death were 3.1% (n?=?977), 9.9% (n?=?3187), and 21.8% (n?=?6956), respectively; risks were greater with increasing CHA2DS2-VASc scores as follows, for scores of 1 through 6, respectively: (1) ischemic stroke with concomitant AF: 4.5%, 3.7%, 3.2%, 4.3%, 5.6%, and 8.4%; without concomitant AF: 1.5%, 1.5%, 2.0%, 3.0%, 3.7%, and 7% and (2) all-cause death with concomitant AF: 19.8%, 19.5%, 26.1%, 35.1%, 37.7%, and 45.5%; without concomitant AF: 7.6%, 8.3%, 17.8%, 25.6%, 27.9%, and 35.0%. At high CHA2DS2-VASc scores (=4), the absolute risk of thromboembolism was high regardless of presence of AF (for a score of 4, 9.7% vs 8.2% for patients without and with concomitant AF, respectively; overall P
This study was undertaken to determine whether variations in concentrations of particulates in the ambient air of Montreal, Quebec, during the period 1984 to 1993, were associated with daily variations in cause-specific daily mortality. Fixed-site air pollution monitors in Montreal provided daily mean levels of various measures of particles and gaseous pollutants. Total sulfate was also measured daily (1986-1993) at a monitoring station 150 km southeast of the city (Sutton, Quebec). We used coefficient of haze (COH), extinction coefficient, and sulfate from the Sutton station to predict fine particles and sulfate from fine particles for days that were missing. We estimated associations between cause-specific mortality and PM(2.5), PM(10), predicted fine particles and fine sulfate particles, total suspended particles, coefficient of haze, extinction coefficient, and total sulfate measured at the Sutton station. We selected a set of underlying causes of death, as recorded on the death certificates, as the endpoint and then regressed the logarithm of daily counts of cause-specific mortality on the daily mean levels for the above measures of particulates, after accounting for seasonal and subseasonal fluctuations in the mortality time series, non-Poisson dispersion, weather variables, and gaseous pollutants. We found positive and statistically significant associations between the daily measures of ambient particle mass and sulfate mass and the deaths from respiratory diseases and diabetes. The mean percentage change in daily mortality (MPC), evaluated at the interquartile range for pollutants averaged over the day of death and the preceding 2 days, for deaths from respiratory diseases was MPC(COH)=6.90% (95% CI: 3.69-10.21%), MPC(Predicted PM2.5)= 9.03% (95% CI: 5.83- 12.33%), and MPC(Sutton sulfate)=4.64% (95% CI: 2.46-6.86%). For diabetes, the corresponding estimates were MPC(COH)=7.50% (95% CI: 1.96-13.34%), MPC(Predicted PM2.5)=7.59% (95% CI: 2.36-13.09%), and MPC(Sutton sulfate)=4.48% (95% CI: 1.08-7.99%). Among individuals older than 65 years at time of death, we found consistent associations across our metrics of particles for neoplasms and coronary artery diseases. Associations with sulfate mass were also found among elderly persons who died of cardiovascular diseases and of lung cancer. These associations were consistent with linear relationships. The associations found for respiratory diseases and for cardiovascular diseases, especially in the elderly, are in line with some of the current hypotheses regarding mechanisms by which ambient particles may increase daily mortality. The positive associations found for cancer and for diabetes may be understood through a general hypothesis proposed by Frank and Tankersley, who suggested that persons in failing health may be at higher risk for external insults through the failure of regulating physiological set points. The association with diabetes may be interpreted in light of recent toxicological findings that inhalation of urban particles in animals increases blood pressure and plasmatic levels of endothelins that enhance vasoconstriction and alter electrophysiology. Further research to confirm these findings and to determine whether they are causal is warranted.
Department of Medicine, McGill University, Montreal, Quebec, Canada; Division of Clinical Epidemiology, McGill University Health Centre, 687 Pine Ave. W., R4.29, Montreal, Quebec H3A 1A1, Canada. Electronic address: mark.goldberg@mcgill.ca.
Persons with underlying health conditions may be at higher risk for the short-term effects of air pollution. We have extended our original mortality time series study in Montreal, Quebec, among persons 65 years of age and older, for an additional 10 years (1990-2003) to assess whether these associations persisted and to investigate new health conditions.
We created subgroups of subjects diagnosed with major health conditions one year before death using billing and prescription data from the Quebec Health Insurance Plan. We used parametric log-linear Poisson models within the distributed lag non-linear models framework, that were adjusted for long-term temporal trends and daily maximum temperature, for which we assessed associations with NO2, O3, CO, SO2, and particles with aerodynamic diameters 2.5 µm in diameter or less (PM2.5). We found positive associations between daily non-accidental mortality and all air pollutants but O3 (e.g., for a cumulative effect over a 3-day lag, with a mean percent change (MPC) in daily mortality of 1.90% [95% confidence interval: 0.73, 3.08%] for an increase of the interquartile range (17.56 µg m(-3)) of NO2). Positive associations were found amongst persons having cardiovascular disease (cumulative MPC for an increase equal to the interquartile range of NO2=2.67%), congestive heart failure (MPC=3.46%), atrial fibrillation (MPC=4.21%), diabetes (MPC=3.45%), and diabetes and cardiovascular disease (MPC=3.50%). Associations in the warm season were also found for acute and chronic coronary artery disease, hypertension, and cancer. There was no persuasive evidence to conclude that there were seasonal associations for cerebrovascular disease, acute lower respiratory disease (defined within 2 months of death), airways disease, and diabetes and airways disease.
These data indicate that individuals with certain health conditions, especially those with diabetes and cardiovascular disease, hypertension, atrial fibrillation, and cancer, may be susceptible to the short-term effects of air pollution.
The associations of metabolic syndrome (MetS) or diabetes mellitus (DM) on long-term survival after coronary artery bypass grafting (CABG) have not been extensively evaluated. The aim of the present study was to assess the impact of MetS and DM on the 16-year survival after CABG.
Diabetic and metabolic status together with relevant cardiovascular data was established in 910 CABG patients operated in 1993-94. They were divided in three groups as follows: neither DM nor MetS (375 patients), MetS alone (279 patients) and DM with or without MetS (256 patients). The 16-year follow-up of patient survival was carried out using national health databases. The relative survival rates were analyzed using the Life Table method comparing the observed survival rates of three patient groups to the rates based on age-, sex- and time-specific life tables for the whole population in Finland. To study the independent significance of MetS and DM for clinical outcome, multivariate analysis was made using an optimizing stepwise procedure based on the Bayesian approach.
Bayesian multivariate analysis revealed together six variables to predict clinical outcome (2 months to 16 years) in relation to the national background population, i.e. age, diabetes, left ventricular ejection fraction, BMI, perfusion time during the CABG and peripheral arterial disease. Our principal finding was that after postoperative period the 16-year prognosis of patients with neither DM nor MetS was better than that of the age-, sex-and time-matched background population (relative survival against background population 1.037, p
The population aged 85 years or over (n = 674) living in Tampere, Finland was surveyed in 1977-1978. In an investigation of the prognostic survival of new and previously diagnosed diabetic patients, the levels of blood glucose were analysed in 558 persons, 99 men and 459 women. The relative sex- and age-adjusted survival rates were evaluated at the 5-year follow-up. The mortality after 5 years of the 17 new diabetics at home did not differ significantly from that of the 225 non-diabetics at home. The mortality of 30 patients with previously diagnosed diabetes mellitus was higher than that of the non-diabetics. The survival prognosis of the diabetics on antidiabetic medication did not differ from that of those on diet. An increased risk of mortality was found in this series in previously diagnosed diabetics and--most unexpectedly--in non-diabetics with the lowest fasting blood-glucose levels.
Blood glucose, glucose tolerance and manifest diabetes in relation to cardiovascular disease and death in women. A 12-year follow-up of participants in the population study of women in Gothenburg, Sweden.
A longitudinal population study of 1462 women, aged 38-60, was carried out in Gothenburg, Sweden in 1968-69. Women with initially manifest diabetes mellitus had significantly increased 12-year incidence of myocardial infarction and increased mortality while no increased incidence of angina pectoris, ECG changes indicating ischaemic heart disease or stroke was observed. The association to myocardial infarction remained in multivariate analyses and was independent of age, body fat distribution, smoking, serum cholesterol and systolic blood pressure. The association to mortality was independent of these factors and also of serum triglycerides. Women who were diagnosed as "new diabetics" during the 12-year follow-up had a significantly increased 12-year incidence of myocardial infarction but no significant increase was observed for any of the other end-points studied. When women with initially manifest diabetes mellitus were excluded, no association was found between initial fasting blood glucose concentration and the end-points studied. A negative significant association was found between initial fasting blood glucose concentration and smoking.
