Causes and predictors of mortality in Asian Indians with and without diabetes–10 year follow-up of the Chennai Urban Rural Epidemiology Study (CURES - 150)

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Abstract

Background

The incidence and prevalence of diabetes is increasing worldwide and it is the fifth leading cause of mortality accounting for over 3.8 million deaths annually. Despite the enormity of the diabetes-related health burdens, very few studies have evaluated the factors associated with mortality among people with diabetes in India. We sought to study the causes and predictors of mortality among urban Asian Indians with and without diabetes.

Methods and findings

Of 2273 adults (27,850 person-years of follow-up) from the 10-year follow-up of the Chennai Urban Rural Epidemiology Study (CURES), the cause of death could be ascertained in 552 individuals out of the 671 who had died (response rate 82.3%). Verbal autopsy was obtained from the family members of the deceased and this was adjudicated by trained physicians. The age-standardized mortality rate was 28.2 (95%CI 25.9–30.6) per 100,000 population. Mortality rates were significantly higher in individuals with diabetes compared to those without [27.9(95% CI 25.5–30.6) vs. 8.0 (6.6–9.9) per 1000 person years]. Compared to individuals of normal body mass index, underweight individuals had higher risk of mortality (Hazard ratio 1.49; 95% CI 1.11–2.0), whereas overweight and obese individuals did not show a higher risk. The population-attributable risk for all-cause mortality in the entire study cohort was highest for ischemic heart disease and diabetes. The excess mortality attributable to diabetes was highest in the age group of 51 to 70 years, and was mostly accounted for by renal disease (Rate ratio 5.68, 95%CI 2.43–6.23), ischemic heart disease (4.23,2.78–6.67), and cerebrovascular disease (4.00,1.87–9.81).

Conclusion

Underweight (but not overweight or obesity) was strongly associated with mortality in this Asian Indian population. Ischemic heart disease and diabetes contributed the most to risk for all cause mortality. Excess mortality due to diabetes was higher in relatively younger individuals and was mostly accounted for by renal disease.

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Most cited references 28

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Global prevalence of diabetes: estimates for the year 2000 and projections for 2030.

Sarah Wild, Gojka Roglic, Anders Green … (2004)

The goal of this study was to estimate the prevalence of diabetes and the number of people of all ages with diabetes for years 2000 and 2030. Data on diabetes prevalence by age and sex from a limited number of countries were extrapolated to all 191 World Health Organization member states and applied to United Nations' population estimates for 2000 and 2030. Urban and rural populations were considered separately for developing countries. The prevalence of diabetes for all age-groups worldwide was estimated to be 2.8% in 2000 and 4.4% in 2030. The total number of people with diabetes is projected to rise from 171 million in 2000 to 366 million in 2030. The prevalence of diabetes is higher in men than women, but there are more women with diabetes than men. The urban population in developing countries is projected to double between 2000 and 2030. The most important demographic change to diabetes prevalence across the world appears to be the increase in the proportion of people >65 years of age. These findings indicate that the "diabetes epidemic" will continue even if levels of obesity remain constant. Given the increasing prevalence of obesity, it is likely that these figures provide an underestimate of future diabetes prevalence.

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Excess deaths associated with underweight, overweight, and obesity.

Katherine Flegal (2005)

As the prevalence of obesity increases in the United States, concern over the association of body weight with excess mortality has also increased. To estimate deaths associated with underweight (body mass index [BMI] or =30) in the United States in 2000. We estimated relative risks of mortality associated with different levels of BMI (calculated as weight in kilograms divided by the square of height in meters) from the nationally representative National Health and Nutrition Examination Survey (NHANES) I (1971-1975) and NHANES II (1976-1980), with follow-up through 1992, and from NHANES III (1988-1994), with follow-up through 2000. These relative risks were applied to the distribution of BMI and other covariates from NHANES 1999-2002 to estimate attributable fractions and number of excess deaths, adjusted for confounding factors and for effect modification by age. Number of excess deaths in 2000 associated with given BMI levels. Relative to the normal weight category (BMI 18.5 to or =30) was associated with 111,909 excess deaths (95% confidence interval [CI], 53,754-170,064) and underweight with 33,746 excess deaths (95% CI, 15,726-51,766). Overweight was not associated with excess mortality (-86,094 deaths; 95% CI, -161,223 to -10,966). The relative risks of mortality associated with obesity were lower in NHANES II and NHANES III than in NHANES I. Underweight and obesity, particularly higher levels of obesity, were associated with increased mortality relative to the normal weight category. The impact of obesity on mortality may have decreased over time, perhaps because of improvements in public health and medical care. These findings are consistent with the increases in life expectancy in the United States and the declining mortality rates from ischemic heart disease.

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Risk of cardiovascular and all-cause mortality in individuals with diabetes mellitus, impaired fasting glucose, and impaired glucose tolerance: the Australian Diabetes, Obesity, and Lifestyle Study (AusDiab).

Elizabeth L M Barr, Paul Zimmet, Timothy Welborn … (2007)

Diabetes mellitus increases the risk of cardiovascular disease (CVD) and all-cause mortality. The relationship between milder elevations of blood glucose and mortality is less clear. This study investigated whether impaired fasting glucose and impaired glucose tolerance, as well as diabetes mellitus, increase the risk of all-cause and CVD mortality. In 1999 to 2000, glucose tolerance status was determined in 10,428 participants of the Australian Diabetes, Obesity, and Lifestyle Study (AusDiab). After a median follow-up of 5.2 years, 298 deaths occurred (88 CVD deaths). Compared with those with normal glucose tolerance, the adjusted all-cause mortality hazard ratios (HRs) and 95% confidence intervals (CIs) for known diabetes mellitus and newly diagnosed diabetes mellitus were 2.3 (1.6 to 3.2) and 1.3 (0.9 to 2.0), respectively. The risk of death was also increased in those with impaired fasting glucose (HR 1.6, 95% CI 1.0 to 2.4) and impaired glucose tolerance (HR 1.5, 95% CI 1.1 to 2.0). Sixty-five percent of all those who died of CVD had known diabetes mellitus, newly diagnosed diabetes mellitus, impaired fasting glucose, or impaired glucose tolerance at baseline. Known diabetes mellitus (HR 2.6, 95% CI 1.4 to 4.7) and impaired fasting glucose (HR 2.5, 95% CI 1.2 to 5.1) were independent predictors for CVD mortality after adjustment for age, sex, and other traditional CVD risk factors, but impaired glucose tolerance was not (HR 1.2, 95% CI 0.7 to 2.2). This study emphasizes the strong association between abnormal glucose metabolism and mortality, and it suggests that this condition contributes to a large number of CVD deaths in the general population. CVD prevention may be warranted in people with all categories of abnormal glucose metabolism.

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Author and article information

Contributors

Ranjit Mohan Anjana:

ORCID: http://orcid.org/0000-0002-4843-1374

Role: ConceptualizationRole: Data curationRole: MethodologyRole: Writing – original draft

Ranjit Unnikrishnan: Role: Data curationRole: Writing – review & editing

Poongkunran Mugilan: Role: Methodology

Padoor Sethuraman Jagdish: Role: Investigation

Balasubramanian Parthasarathy: Role: Investigation

Mohan Deepa: Role: Writing – review & editing

Geetha Loganathan: Role: Methodology

Rajendran Ashok Kumar: Role: Methodology

Thangarajan Rahulashankiruthiyayan: Role: Methodology

Ganesan Uma Sankari: Role: Methodology

Ulagamathesan Venkatesan: Role: Formal analysis

Viswanathan Mohan: Role: SupervisionRole: Writing – review & editing

Coimbatore Subramanian Shanthi Rani: Role: Data curationRole: MethodologyRole: Writing – original draft

Noël C. Barengo: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 9 July 2018

Publication date Collection: 2018

Volume: 13

Issue: 7

Electronic Location Identifier: e0197376

Affiliations

[001]Madras Diabetes Research Foundation & Dr. Mohan’s Diabetes Specialities Centre, WHO Collaborating Centre for Non-communicable Diseases Prevention and Control &ICMR Center for Advanced Research on Diabetes, Chennai, India

Florida International University Herbert Wertheim College of Medicine, UNITED STATES

Author notes

Competing Interests: The authors have declared that no competing interests exist.

* E-mail: dranjana@ 123456drmohans.com

Author information

Ranjit Mohan Anjana http://orcid.org/0000-0002-4843-1374

Article

Publisher ID: PONE-D-17-37058

DOI: 10.1371/journal.pone.0197376

PMC ID: 6037346

PubMed ID: 29985959

SO-VID: a2f2e707-fa81-4789-9e9c-08e7d50f9fee

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 26 October 2017

Date accepted : 1 May 2018

Page count

Figures: 3, Tables: 5, Pages: 15

Funding

The authors received no funding for this work.

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Data Availability All relevant data are within the paper and its Supporting Information file.

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Causes and predictors of mortality in Asian Indians with and without diabetes–10 year follow-up of the Chennai Urban Rural Epidemiology Study (CURES - 150)

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Abstract

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Most cited references 28

Global prevalence of diabetes: estimates for the year 2000 and projections for 2030.

Excess deaths associated with underweight, overweight, and obesity.

Risk of cardiovascular and all-cause mortality in individuals with diabetes mellitus, impaired fasting glucose, and impaired glucose tolerance: the Australian Diabetes, Obesity, and Lifestyle Study (AusDiab).

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