Clinical, socioeconomic, and behavioural factors at age 50 years and risk of cardiometabolic multimorbidity and mortality: A cohort study.
Clinical, socioeconomic, and behavioural factors at age 50 years and risk of cardiometabolic multimorbidity and mortality: A cohort study.
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DOI：
10.1371/journal.pmed.1002571
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发表时间：
2018-05
期刊：
影响因子：
15.8
通讯作者：
Kivimäki M
中科院分区：
文献类型：
--
作者：
Singh-Manoux A;Fayosse A;Sabia S;Tabak A;Shipley M;Dugravot A;Kivimäki M
多病越来越普遍，并与不良健康结果有关，这突出表明有必要扩大主导医学研究的单一疾病框架。我们研究了中年临床特征、社会经济地位和行为因素在心脏代谢多病（至少2种糖尿病、冠心病和中风）发展中的作用，以及这些因素如何改变死亡风险。8270名男性和女性的数据来自白厅II队列研究，平均随访时间为23.7年（1985年至2017年）。在50岁时对三组风险因素进行评估，每组以5分制进行评估：临床概况（高血压、高胆固醇血症、超重/肥胖、心脏代谢疾病家族史）、职业地位和行为因素（吸烟、饮酒、饮食、体育活动）。研究结果包括心脏代谢疾病（糖尿病、冠心病、中风）、心脏代谢多发病和死亡率。我们使用多状态模型来检查危险因素在心脏代谢疾病轨迹的5个组成部分中的作用：从健康状态到首次心脏代谢疾病，从首次心脏代谢疾病到心脏代谢多病，从健康状态到死亡，从首次心脏代谢疾病到死亡，以及从心脏代谢多病到死亡。共有2501名参与者患上了三种心脏代谢疾病中的一种，511人患上了心脏代谢多病，1406人死亡。当单独考虑行为和临床风险因素时，只有吸烟与这五种转变有关。在包含所有3个风险因素量表的模型中，在无疾病参与者中，中年临床状况是第一种心脏代谢疾病的最强预测因子（最不利状况与最有利状况的风险比：3.74;95% CI: 3.14-4.45）。在患有1种心脏代谢疾病的参与者中，不良的中年社会经济因素（1.54;95% CI: 1.10-2.15）和行为因素（2.00;95% CI: 1.40-2.85）与心脏代谢多病的进展相关，但与临床特征无关。只有中年行为因素能预测心脏代谢疾病（2.12;95% CI: 1.41-3.18）或心脏代谢多病（3.47;95% CI: 1.81-6.66）患者的死亡率。局限性在于，该研究的规模不够大，无法估计每种疾病及其后续结果之间以及所有可能的疾病对之间的转变。特定中年因素在疾病进展中的重要性，从无疾病状态到单一疾病、多重疾病和死亡，取决于疾病阶段。虽然50岁时的临床危险因素决定了无疾病人群发生心脏代谢疾病的风险，但中年时的社会经济和行为因素是心脏代谢疾病患者进展为多病和死亡的更强预测因素。Archana Singh-Manoux及其同事报告了中年社会经济和行为因素对心脏代谢疾病患者的多重发病率和死亡率的影响。心脏代谢多病的患病率随着年龄的增长而增加，糖尿病、中风和冠心病的任何组合都与成倍的死亡风险相关。以前的研究已经检查了多重发病的危险因素或多重发病形成不良健康结果的方式。据我们所知，以前没有研究调查过社会经济、行为和临床风险因素如何影响心脏代谢多病的发展、进展和结果。收集了来自Whitehall II研究的8270名参与者在50岁时的社会经济、行为和临床风险因素的数据，并对参与者进行了平均23.7年的心脏代谢疾病（糖尿病、冠心病或中风）、心脏代谢多发病（2种或2种以上心脏代谢疾病）和死亡率的随访。临床危险因素（高血压、超重和肥胖、高胆固醇、糖尿病或心血管疾病家族史）是首次心脏代谢疾病的重要预测因素。然而，社会经济和行为因素（身体活动、饮酒、饮食和吸烟）决定了多病的进展，只有行为风险因素可以预测心脏代谢疾病或心脏代谢多病参与者的死亡率。当单独考虑危险因素时，吸烟与从第一次心脏代谢疾病发展到多重发病和死亡的轨迹加速转变有关。通过考虑从无病状态到死亡过程中的危险因素，我们确定了社会经济、行为和临床危险因素的变化影响。我们的研究结果表明，简单地关注个人健康轨迹中的一点，忽略了危险因素在心脏代谢多病的发生、进展和结果中的变化作用，这是全球范围内的一个主要公共卫生挑战。
Multimorbidity is increasingly common and is associated with adverse health outcomes, highlighting the need to broaden the single-disease framework that dominates medical research. We examined the role of midlife clinical characteristics, socioeconomic position, and behavioural factors in the development of cardiometabolic multimorbidity (at least 2 of diabetes, coronary heart disease, and stroke), along with how these factors modify risk of mortality. Data on 8,270 men and women were drawn from the Whitehall II cohort study, with mean follow-up of 23.7 years (1985 to 2017). Three sets of risk factors were assessed at age 50 years, each on a 5-point scale: clinical profile (hypertension, hypercholesterolemia, overweight/obesity, family history of cardiometabolic disease), occupational position, and behavioural factors (smoking, alcohol consumption, diet, physical activity). The outcomes examined were cardiometabolic disease (diabetes, coronary heart disease, stroke), cardiometabolic multimorbidity, and mortality. We used multi-state models to examine the role of risk factors in 5 components of the cardiometabolic disease trajectory: from healthy state to first cardiometabolic disease, from first cardiometabolic disease to cardiometabolic multimorbidity, from healthy state to death, from first cardiometabolic disease to death, and from cardiometabolic multimorbidity to death. A total of 2,501 participants developed 1 of the 3 cardiometabolic diseases, 511 developed cardiometabolic multimorbidity, and 1,406 died. When behavioural and clinical risk factors were considered individually, only smoking was associated with all five transitions. In a model containing all 3 risk factor scales, midlife clinical profile was the strongest predictor of first cardiometabolic disease (hazard ratio for the least versus most favourable profile: 3.74; 95% CI: 3.14–4.45) among disease-free participants. Among participants with 1 cardiometabolic disease, adverse midlife socioeconomic (1.54; 95% CI: 1.10–2.15) and behavioural factors (2.00; 95% CI: 1.40–2.85), but not clinical characteristics, were associated with progression to cardiometabolic multimorbidity. Only midlife behavioural factors predicted mortality among participants with cardiometabolic disease (2.12; 95% CI: 1.41–3.18) or cardiometabolic multimorbidity (3.47; 95% CI: 1.81–6.66). A limitation is that the study was not large enough to estimate transitions between each disease and subsequent outcomes and between all possible pairs of diseases. The importance of specific midlife factors in disease progression, from disease-free state to single disease, multimorbidity, and death, varies depending on the disease stage. While clinical risk factors at age 50 determine the risk of incident cardiometabolic disease in a disease-free population, midlife socioeconomic and behavioural factors are stronger predictors of progression to multimorbidity and mortality in people with cardiometabolic disease. Archana Singh-Manoux and colleagues report on the contribution that midlife socioeconomic and behavioural factors make to multimorbidity and mortality in those with cardiometabolic disease. The prevalence of cardiometabolic multimorbidity increases with age, and any combination of diabetes, stroke, and coronary heart disease is associated with multiplicative mortality risk. Previous studies have examined either risk factors for multimorbidity or the manner in which multimorbidity shapes adverse health outcomes. No previous study to our knowledge has examined how socioeconomic, behavioural, and clinical risk factors shape the development, progression, and outcome of cardiometabolic multimorbidity. Data were collected on socioeconomic, behavioural, and clinical risk factors at age 50 years on 8,270 participants from the Whitehall II study, and the participants were followed over a mean 23.7 years for incident cardiometabolic disease (diabetes, coronary heart disease, or stroke), cardiometabolic multimorbidity (2 or more cardiometabolic diseases), and mortality. Clinical risk factors (hypertension, overweight and obesity, high cholesterol, and family history of diabetes or cardiovascular disease) were important predictors of first cardiometabolic disease. However, socioeconomic and behavioural factors (physical activity, alcohol consumption, diet, and smoking) determined progression to multimorbidity, and only behavioural risk factors predicted mortality among participants with cardiometabolic disease or cardiometabolic multimorbidity. When risk factors were considered individually, smoking was associated with accelerated transitions in the trajectory from the development of a first cardiometabolic disease to multimorbidity and death. By considering risk factors in the progression from a disease-free state to death, we determined the changing influence of socioeconomic, behavioural, and clinical risk factors. Our findings demonstrate that a simple focus on one point in the health trajectory of individuals misses the changing role of risk factors in the development, progression, and outcome of cardiometabolic multimorbidity, a major public health challenge worldwide.
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DOI：
10.1136/bmj.e5205
发表时间：
2012-09-03
期刊：
BMJ (Clinical research ed.)
影响因子：
--
作者：
Smith SM;Soubhi H;Fortin M;Hudon C;O'Dowd T
通讯作者：
O'Dowd T
影响因子：
2.2
作者：
Bayliss, Elizabeth A.;Edwards, Allison E.;Main, Deborah S.
通讯作者：
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影响因子：
14.6
作者：
Sabia, Severine;Singh-Manoux, Archana;Kivimaki, Mika
通讯作者：
Kivimaki, Mika
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10.1016/s0140-6736(16)32380-7
发表时间：
2017-03-25
期刊：
Lancet (London, England)
影响因子：
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LIFEPATH consortium
DOI：
10.1016/s2468-2667(17)30074-9
发表时间：
2017-06
期刊：
The Lancet. Public health
影响因子：
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Jokela M