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墨西哥城的糖尿病与死因别死亡率研究
Diabetes and Cause-Specific Mortality in Mexico City


Jesus Alegre-Díaz ... 糖尿病 • 2016.11.17

糖尿病对发展中国家的巨大挑战

 

刘远立†,马晶‡*

† 北京协和医学院公共卫生学院;‡ Harvard Medical School

* 通讯作者

 

在相当长一段时间里,糖尿病被认为是“富人病”。但本期《新英格兰医学杂志》发表的一篇基于1998—2004年期间做的墨西哥城十五万居民的糖尿病患病调查和随后的12年死亡原因跟踪研究的报告1,清楚地揭示了糖尿病对发展中国家所造成的疾病负担(特别是在全死因中所占比重)要明显高于发达国家。该项研究表明:受调查人群体质指数高(27~29 kg/m2),糖尿病患病率高(1/4的60~74岁人群患有糖尿病),其患病率远远高于同龄的英国人(7%)和美国人(15%);同时,糖尿病患者的糖化血红蛋白控制不好。在随后的12年间,因糖尿病导致的全死亡危险性在35~59岁年龄组高达5.4倍,其次是60~74岁年龄组(3.1倍)和75~84岁年龄组(1.9倍)。死亡原因的主要贡献依次是糖尿病肾病、心血管疾病、感染和急性糖尿病危象。高患病率、高肥胖率,再加上未及时得到诊断、缺乏有效的糖尿病及合并症的治疗和危险因素的管理,尤其是因缺乏常规蛋白尿的检查和肾透析治疗使得肾病患者的预后一般都很差,这些都增加了因糖尿病而导致死亡的风险。

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摘要


背景

大部分关于糖尿病对死亡率影响的大型前瞻性研究集中在高收入国家,在这些国家患者能获得良好合理的医疗护理,并得到可建立并维持良好血糖控制的治疗。高收入国家中糖尿病的死亡率低于任意原因所致死亡的1/2。中等收入国家进行的大型前瞻性研究很少,而在这些国家肥胖及糖尿病已变得普遍,且血糖控制可能欠佳。

 

方法

从1998年至2004年,我们招募了年龄≥35岁的约50,000例男性及100,000例女性入组墨西哥墨西哥城的前瞻性研究。我们记录了参与者既往是否诊断为糖尿病、进行血样抽取及储存,且追踪参与者12年的疾病特异性死亡至2014年1月1日。仅对急性糖尿病危象所致死亡,我们才将糖尿病作为死亡根本原因。我们以招募时诊断糖尿病的参与者死亡率对比招募时未诊断糖尿病的参与者死亡率建立率比,罹患糖尿病之外的慢性疾病参与者数据被排除在主要分析之外。

 

结果

招募时,参与者普遍肥胖,且糖尿病发病率随着年龄增加急剧上升(35~39岁为3%,而到60岁者>20%)。糖尿病参与者的血糖控制不良(糖化血红蛋白均数±标准差为9.0%±2.4%),心血管保护药使用率也低(如招募时仅23%的糖尿病参与者在服用降压药物,而降脂药物的使用率仅为1%)。既往诊断糖尿病与任意原因死亡的率比相关,这些率比在35~59岁为5.4(95%可信区间[CI]为5.0~6.0)、60~74岁为3.1(95% CI为2.9~3.3)、75~84岁为1.9(95% CI为1.8~2.1)。35~74岁与既往诊断糖尿病相关的过量死亡占所有死亡的1/3,过量死亡的最大绝对风险来自肾脏疾病(率比为20.1,95% CI 17.2~23.4)、心脏疾病(率比为3.7,95% CI 3.2~4.2)、感染(率比为4.7,95% CI 4.0~5.5)、急性糖尿病危象(占既往诊断糖尿病参与者所有死亡的8%)及其他血管疾病(主要为卒中)。我们在糖尿病与肝硬化、癌症或慢性阻塞性肺疾病所致死亡之间几乎未观察到相关性。

 

结论

在墨西哥这个肥胖率高且糖尿病普遍的中等收入国家,本研究发现糖尿病患者血糖控制不良,且其预后远差于高收入国家患者;糖尿病至少占35~74岁所有死因的1/3(本研究由惠康基金会[Wellcome Trust]及其他机构赞助)。





作者信息

Jesus Alegre-Díaz, M.D., William Herrington, M.D., Malaquías López-Cervantes, Ph.D., Louisa Gnatiuc, M.Sc., Raul Ramirez, Michael Hill, D.Phil., Colin Baigent, F.R.C.P., Mark I. McCarthy, M.D., Sarah Lewington, D.Phil., Rory Collins, F.R.S., Gary Whitlock, Ph.D., Roberto Tapia-Conyer, Ph.D., Richard Peto, F.R.S., Pablo Kuri-Morales, M.D., and Jonathan R. Emberson, Ph.D.
From the School of Medicine, National Autonomous University of Mexico (UNAM), Mexico City (J.A.-D., M.L.-C., R.R., R.T.-C., P.K.-M.); and the Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU) (W.H., L.G., M.H., C.B., S.L., R.C., G.W., R.P., J.R.E.) and the Medical Research Council Population Health Research Unit (M.H., C.B., S.L., J.R.E.), Nuffield Department of Population Health, and the Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM), Nuffield Department of Medicine (M.I.M.), University of Oxford, Oxford, United Kingdom. Address reprint requests to Dr. Emberson at CTSU, Richard Doll Bldg., Old Road Campus, Oxford OX3 7LF, United Kingdom, or at jonathan.emberson@ndph.ox.ac.uk.

 

参考文献

1. International Diabetes Federation diabetes atlas — 7th edition. Brussels: International Diabetes Federation, 2015 (http://www.diabetesatlas.org/).

2. Danaei G, Finucane MM, Lu Y, et al. National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants. Lancet 2011;378:31-40

3. The Emerging Risk Factors Collaboration. Diabetes mellitus, fasting glucose, and risk of cause-specific death. N Engl J Med 2011;364:829-841

4. The Emerging Risk Factors Collaboration. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet 2010;375:2215-2222

5. Yusuf S, Islam S, Chow CK, et al. Use of secondary prevention drugs for cardiovascular disease in the community in high-income, middle-income, and low-income countries (the PURE study): a prospective epidemiological survey. Lancet 2011;378:1231-1243

6. The World Bank. Mexico data (http://data.worldbank.org/country/mexico).

7. World Health Organization. Global database on body mass index (http://apps.who.int/bmi/index.jsp).

8. Flores-Hernández S, Saturno-Hernández PJ, Reyes-Morales H, Barrientos-Gutiérrez T, Villalpando S, Hernández-Ávila M. Quality of diabetes care: the challenges of an increasing epidemic in Mexico — results from two national health surveys (2006 and 2012). PLoS One 2015;10:e0133958-e0133958

9. Tapia-Conyer R, Kuri-Morales P, Alegre-Díaz J, et al. Cohort profile: the Mexico City Prospective Study. Int J Epidemiol 2006;35:243-249

10. Youngman LD, Clark S, Manley S, Peto R, Collins R. Reliable measurement of glycated hemoglobin in frozen blood samples: implications for epidemiologic studies. Clin Chem 2002;48:1627-1629

11. National Glycohemoglobin Standardization Program. International Federation of Clinical Chemistry (IFCC) standardization of HbA1c (http://www.ngsp.org/docs/IFCCstd.pdf).

12. Mikkelsen L, Phillips DE, AbouZahr C, et al. A global assessment of civil registration and vital statistics systems: monitoring data quality and progress. Lancet 2015;386:1395-1406

13. International statistical classification of diseases and related health problems: 10th revision (ICD-10). Vol. 2. Geneva: World Health Organization, 2004.

14. World Health Organization. Global Health Observatory data repository — life tables by country: Mexico (http://apps.who.int/gho/data/?theme=main&vid=61060).

15. Menke A, Casagrande S, Geiss L, Cowie CC. Prevalence of and trends in diabetes among adults in the United States, 1988-2012. JAMA 2015;314:1021-1029

16. Tancredi M, Rosengren A, Svensson AM, et al. Excess mortality among persons with type 2 diabetes. N Engl J Med 2015;373:1720-1732

17. Hippisley-Cox J, Ryan R. Diabetes in the United Kingdom: analysis of QRESEARCH data — report to the Department of Health. 2007 (http://www.qresearch.org).

18. Ray KK, Seshasai SR, Wijesuriya S, et al. Effect of intensive control of glucose on cardiovascular outcomes and death in patients with diabetes mellitus: a meta-analysis of randomised controlled trials. Lancet 2009;373:1765-1772

19. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977-986

20. Hoerger TJ, Segel JE, Gregg EW, Saaddine JB. Is glycemic control improving in U.S. adults? Diabetes Care 2008;31:81-86

21. Centers for Disease Control and Prevention. Diabetes public health resource: mortality due to hyperglycemic crises (http://www.cdc.gov/diabetes/statistics/mortalitydka/index.htm).

22. Hernández B, Ramírez-Villalobos D, Romero M, Gómez S, Atkinson C, Lozano R. Assessing quality of medical death certification: concordance between gold standard diagnosis and underlying cause of death in selected Mexican hospitals. Popul Health Metr 2011;9:38-38

23. Vázquez-Martínez JL, Gómez-Dantés H, Fernández-Cantón S. Diabetes mellitus in an adult population of the IMSS (Mexican Institute of Social Security): results of the National Health Survey 2000. Rev Med Inst Mex Seguro Soc 2006;44:13-26. (In Spanish.)

24. Roglic G, Unwin N. Mortality attributable to diabetes: estimates for the year 2010. Diabetes Res Clin Pract 2010;87:15-19

25. King G, Gakidou E, Imai K, et al. Public policy for the poor? A randomised assessment of the Mexican universal health insurance programme. Lancet 2009;373:1447-1454

26. Bonilla-Chacín ME, Aguilera N. Universal health coverage studies series 1: the Mexican social protection system in health. Washington, DC: World Bank, 2013 (http://documents.worldbank.org/curated/en/2013/01/17286333/mexican-social-protection-system-health).

27. Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA. 10-Year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008;359:1577-1589

28. Garcia-Garcia G, Briseño-Rentería G, Luquín-Arellan VH, Gao Z, Gill J, Tonelli M. Survival among patients with kidney failure in Jalisco, Mexico. J Am Soc Nephrol 2007;18:1922-1927

29. Astudillo O. Country in focus: Mexico’s growing obesity problem. Lancet Diabetes Endocrinol 2014;2:15-16

30. Colchero MA, Popkin BM, Rivera JA, Ng SW. Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study. BMJ 2016;352:h6704-h6704

31. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403

32. Pirie K, Peto R, Reeves GK, Green J, Beral V. The 21st century hazards of smoking and benefits of stopping: a prospective study of one million women in the UK. Lancet 2013;381:133-141

33. Ettehad D, Emdin CA, Kiran A, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet 2016;387:957-967

34. Cholesterol Treatment Trialists’ (CTT) Collaborators. Efficacy of cholesterol-lowering therapy in 18,686 people with diabetes in 14 randomised trials of statins: a meta-analysis. Lancet 2008;371:117-125

35. Lewis EJ, Hunsicker LG, Clarke WR, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med 2001;345:851-860

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