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ARTICLES | VOLUME 395, ISSUE 10226, P785-794, MARCH 07, 2020

Variations in common diseases, hospital admissions, and deaths in middle-

aged adults in 21 countries from five continents (PURE): a prospective
cohort study
Prof Gilles R Dagenais, MD • Darryl P Leong, PhD † • Sumathy Rangarajan, MSc • Fernando Lanas, PhD •
†

Prof Patricio Lopez-Jaramillo, PhD • Prof Rajeev Gupta, PhD • et al. Show all authors • Show footnotes
Published: September 03, 2019 • DOI: https://doi.org/10.1016/S0140-6736(19)32007-0 •

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Summary
Background

To our knowledge, no previous study has prospectively documented the incidence of common diseases and
related mortality in high-income countries (HICs), middle-income countries (MICs), and low-income countries
(LICs) with standardised approaches. Such information is key to developing global and context-specific health
strategies. In our analysis of the Prospective Urban Rural Epidemiology (PURE) study, we aimed to evaluate
di erences in the incidence of common diseases, related hospital admissions, and related mortality in a large
contemporary cohort of adults from 21 HICs, MICs, and LICs across five continents by use of standardised
approaches.

Methods

The PURE study is a prospective, population-based cohort study of individuals aged 35–70 years who have been
enrolled from 21 countries across five continents. The key outcomes were the incidence of fatal and non-fatal
cardiovascular diseases, cancers, injuries, respiratory diseases, and hospital admissions, and we calculated the
age-standardised and sex-standardised incidence of these events per 1000 person-years.

Findings

This analysis assesses the incidence of events in 162 534 participants who were enrolled in the first two phases of
the PURE core study, between Jan 6, 2005, and Dec 4, 2016, and who were assessed for a median of 9·5 years (IQR
8·5–10·9). During follow-up, 11 307 (7·0%) participants died, 9329 (5·7%) participants had cardiovascular disease,

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5151 (3·2%) participants had a cancer, 4386 (2·7%) participants had injuries requiring hospital admission, 2911
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10/3/2020 Variations in common diseases, hospital admissions, and deaths in middle-aged adults in 21 countries from five continents (PURE): a pro…

(1·8%) participants had pneumonia, and 1830 (1·1%) participants had chronic obstructive pulmonary disease
(COPD). Cardiovascular disease occurred more o en in LICs (7·1 cases per 1000 person-years) and in MICs (6·8
cases per 1000 person-years) than in HICs (4·3 cases per 1000 person-years). However, incident cancers, injuries,
COPD, and pneumonia were most common in HICs and least common in LICs. Overall mortality rates in LICs (13·3
deaths per 1000 person-years) were double those in MICs (6·9 deaths per 1000 person-years) and four times
higher than in HICs (3·4 deaths per 1000 person-years). This pattern of the highest mortality in LICs and the lowest
in HICs was observed for all causes of death except cancer, where mortality was similar across country income
levels. Cardiovascular disease was the most common cause of deaths overall (40%) but accounted for only 23% of
deaths in HICs ( vs 41% in MICs and 43% in LICs), despite more cardiovascular disease risk factors (as judged by
INTERHEART risk scores) in HICs and the fewest such risk factors in LICs. The ratio of deaths from cardiovascular
disease to those from cancer was 0·4 in HICs, 1·3 in MICs, and 3·0 in LICs, and four upper-MICs (Argentina, Chile,
Turkey, and Poland) showed ratios similar to the HICs. Rates of first hospital admission and cardiovascular
disease medication use were lowest in LICs and highest in HICs.

Interpretation

Among adults aged 35–70 years, cardiovascular disease is the major cause of mortality globally. However, in HICs
and some upper-MICs, deaths from cancer are now more common than those from cardiovascular disease,
indicating a transition in the predominant causes of deaths in middle-age. As cardiovascular disease decreases in
many countries, mortality from cancer will probably become the leading cause of death. The high mortality in
poorer countries is not related to risk factors, but it might be related to poorer access to health care.

Funding

Full funding sources are listed at the end of the paper (see Acknowledgments).

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Article Info
Publication History

Published: September 03, 2019

Identification

DOI: https://doi.org/10.1016/S0140-6736(19)32007-0

Copyright

© 2019 Elsevier Ltd. All rights reserved.

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