National trends in total cholesterol obscure heterogeneous changes in HDL and non-HDL cholesterol and total-to-HDL cholesterol ratio : a pooled analysis of 458 population-based studies in Asian and Western countries

Background: Although high-density lipoprotein (HDL) and non-HDL cholesterol have opposite associations with coronary heart disease, multi-country reports of lipid trends only use total cholesterol (TC). Our aim was to compare trends in total, HDL and nonHDL cholesterol and the total-to-HDL cholesterol ratio in Asian and Western countries. Methods: We pooled 458 population-based studies with 82.1 million participants in 23 Asian and Western countries. We estimated changes in mean total, HDL and non-HDL cholesterol and mean total-to-HDL cholesterol ratio by country, sex and age group. Results: Since similar to 1980, mean TC increased in Asian countries. In Japan and South Korea, the TC rise was due to rising HDL cholesterol, which increased by up to 0.17 mmol/L per decade in Japanese women; in China, it was due to rising non-HDL cholesterol. TC declined in Western countries, except in Polish men. The decline was largest in Finland and Norway, at similar to 0.4 mmol/L per decade. The decline in TC in most Western countries was the net effect of an increase in HDL cholesterol and a decline in non-HDL cholesterol, with the HDL cholesterol increase largest in New Zealand and Switzerland. Mean total-to-HDL cholesterol ratio declined in Japan, South Korea and most Western countries, by as much as similar to 0.7 per decade in Swiss men (equivalent to similar to 26% decline in coronary heart disease risk per decade). The ratio increased in China. Conclusions: HDL cholesterol has risen and the total-to-HDL cholesterol ratio has declined in many Western countries, Japan and South Korea, with only a weak correlation with changes in TC or non-HDL cholesterol.Peer reviewe

Sex-specific relevance of diabetes to occlusive vascular and other mortality: a collaborative meta-analysis of individual data from 980793 adults from 68 prospective studies

Background Several studies have shown that diabetes confers a higher relative risk of vascular mortality among women than among men, but whether this increased relative risk in women exists across age groups and within defined levels of other risk factors is uncertain. We aimed to determine whether differences in established risk factors, such as blood pressure, BMI, smoking, and cholesterol, explain the higher relative risks of vascular mortality among women than among men. Methods In our meta-analysis, we obtained individual participant-level data from studies included in the Prospective Studies Collaboration and the Asia Pacific Cohort Studies Collaboration that had obtained baseline information on age, sex, diabetes, total cholesterol, blood pressure, tobacco use, height, and weight. Data on causes of death were obtained from medical death certificates. We used Cox regression models to assess the relevance of diabetes (any type) to occlusive vascular mortality (ischaemic heart disease, ischaemic stroke, or other atherosclerotic deaths) by age, sex, and other major vascular risk factors, and to assess whether the associations of blood pressure, total cholesterol, and body-mass index (BMI) to occlusive vascular mortality are modified by diabetes. Results Individual participant-level data were analysed from 980 793 adults. During 9·8 million person-years of follow-up, among participants aged between 35 and 89 years, 19 686 (25·6%) of 76 965 deaths were attributed to occlusive vascular disease. After controlling for major vascular risk factors, diabetes roughly doubled occlusive vascular mortality risk among men (death rate ratio [RR] 2·10, 95% CI 1·97–2·24) and tripled risk among women (3·00, 2·71–3·33; χ2 test for heterogeneity p<0·0001). For both sexes combined, the occlusive vascular death RRs were higher in younger individuals (aged 35–59 years: 2·60, 2·30–2·94) than in older individuals (aged 70–89 years: 2·01, 1·85–2·19; p=0·0001 for trend across age groups), and, across age groups, the death RRs were higher among women than among men. Therefore, women aged 35–59 years had the highest death RR across all age and sex groups (5·55, 4·15–7·44). However, since underlying confounder-adjusted occlusive vascular mortality rates at any age were higher in men than in women, the adjusted absolute excess occlusive vascular mortality associated with diabetes was similar for men and women. At ages 35–59 years, the excess absolute risk was 0·05% (95% CI 0·03–0·07) per year in women compared with 0·08% (0·05–0·10) per year in men; the corresponding excess at ages 70–89 years was 1·08% (0·84–1·32) per year in women and 0·91% (0·77–1·05) per year in men. Total cholesterol, blood pressure, and BMI each showed continuous log-linear associations with occlusive vascular mortality that were similar among individuals with and without diabetes across both sexes. Interpretation Independent of other major vascular risk factors, diabetes substantially increased vascular risk in both men and women. Lifestyle changes to reduce smoking and obesity and use of cost-effective drugs that target major vascular risks (eg, statins and antihypertensive drugs) are important in both men and women with diabetes, but might not reduce the relative excess risk of occlusive vascular disease in women with diabetes, which remains unexplained. Funding UK Medical Research Council, British Heart Foundation, Cancer Research UK, European Union BIOMED programme, and National Institute on Aging (US National Institutes of Health)

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Estrogen as a determinant of femoral neck bone strength in elderly men

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Sex-specific relevance of diabetes to occlusive vascular and other mortality: Meta-analysis of individual data from 68 prospective studies with 77,000 deaths among 1 million adults

Background Several studies have shown that diabetes confers a higher relative risk of vascular mortality among women compared to men, but whether this exists across age groups and within levels of other risk factors is uncertain. Methods Individual data were obtained on 980,793 adults in 68 prospective studies. Cox models assessed the relevance of diabetes to occlusive vascular mortality (ischaemic heart disease, ischaemic stroke or other atherosclerotic deaths) by age, sex and other major vascular risk factors, and were also used to assess whether the associations of blood pressure, total cholesterol and body-mass index (BMI) to occlusive vascular mortality are modified by diabetes. Results During 9.8 million person-years of follow-up at ages 35-89 years, 19,686/76,965 (26%) deaths were attributed to occlusive vascular disease. Even after controlling for major vascular risk factors, diabetes conferred a doubling in occlusive vascular mortality risk among men (death rate ratio, RR=2·10; 95% CI 1·97-2·24) and a tripling among women (3·00; 2·71-3·33). RRs were more extreme at younger than at older ages (2·60 [2·30-2·94] at ages 35-59 versus 2·01 [1·85-2·19] at ages 70-89, ptrend=0·0001), and, at all ages, were more extreme in women than in men. So, among women aged 35-59, diabetes conferred nearly 6-fold increased risk. Because the occlusive vascular mortality rates at any given age were generally higher among men than women, the absolute excess mortality rates associated with diabetes were similar for men versus women: 0.08 %/year (0.05-0.10) versus 0.05 %/year (0.03-0.07) at ages 40-59; and 0.91 %/year (0.77-1.05) versus 1.08 %/year (0.84-1.08) at ages 70-89, respectively. Total cholesterol, blood pressure and BMI each displayed continuous log-linear associations with occlusive vascular mortality that were similar among those with and without diabetes. Interpretation Independently of other major vascular risk factors, diabetes substantially increased vascular risk in both men and women. Lifestyle changes (to reduce smoking and obesity) and wide use of cost-effective medications (especially statins and BP-lowering drugs) are important among both men and women with diabetes, but may not reduce the relative excess risk of occlusive vascular disease in women with diabetes.</p