Association of Diabetes With All-Cause and Cause-Specific Mortality in Asia

Key Points Question What is the association between diabetes and mortality in Asian populations? Findings In this pooled analysis of data from more than 1 million individual participants of 22 studies in Asia, diabetes was associated with substantially increased risk of death from a broad spectrum of diseases, particularly diabetes itself, renal disease, coronary heart disease, and ischemic stroke. The associations were more evident among women and younger patients than among men and elderly patients. Meaning The study’s findings suggest the urgent need for developing diabetes management programs that are tailored to Asian populations and the subsequent strong implementation of these programs in Asia.


Japan Collaborative Cohort Study
-A total of 110,585 participants (46,395 men and 64,190 women) from the 45 areas of Japan were included in this study. Baseline information was collected from 1988 through 1990, using a self-administered questionnaire. Investigators reviewed the population registry information of survivors. This study was terminated at the end of 2009: a total of 27,410 deaths were identified during the median follow-up of 18 years. The main cause of death was cancer and circulatory diseases.
The Japan Public Health Center-based Prospective Study 9 -Based on 11 public health center areas in Japan, this study was launched in 1990 (JPHC I) and 1993 (JPHC II). A total of 140,420 subjects aged 40-59 were enrolled with a self-administered questionnaire survey. Repeated follow-up surveys were also conducted after five and ten years. Study participants were followed-up for the incidence of cancer and cardiovascular diseases and death by data linkage to cancer and residential registries. This study is still ongoing. 10 -In 1984, residents of the Miyagi Prefecture (Sendai City and Wakuya/Tajiri Town), aged ≥40 years, were invited to participate in the study. Self-administered questionnaires in sealed envelopes were distributed to all residents aged ≥40, and a total of 31,769 responded to the questionnaires (response rate: ~97%). In cases of duplication or not providing basic information, some subjects were excluded from the cohort. Study participants were followed for death and cancer incidence through record linkage to residence certificates, death certificates, and local cancer registry data. This study was terminated in 1999. 11 -In 1990, this study was initiated in 14 municipalities of Miyagi Prefecture, Japan. A total of 47,605 residents aged 40-64 (coverage rate 91.7%: 13,992 men and 17,353 women) participated in this study. Two self-administered questionnaires regarding lifestyle and personality were used to collect baseline information. Through data linkage to cancer and death registries, study participants were followed-up for cancer and death. This study is still ongoing.

Miyagi Cohort Study
Ohsaki National Health Insurance Cohort Study 12 -In 1995, subjects who were National Health Insurance beneficiaries and received care at the Ohsaki Public Health Center were enrolled in this study. A total of 51,253 men and women aged 40-79 were recruited. Participants were regularly followed-up for death and other diseases via reviews of death certificates and National Health Insurance files. For cancer incidence, data linkage to the local cancer registry was conducted. This study is still ongoing. 13 -This study consists of 120,000 persons including atomic bomb survivors, 94,000 of whom were in the city at the time of the bombing. Another 26,000 were age-and sex-matched residents who were not in Hiroshima or Nagasaki at the time of the bombing. This cohort was established based on the 1950 Japanese national census. Participants were followed-up for mortality and cancer incidence. Lifestyle information was collected via a clinical sub-study and mailed questionnaires. For this unique cohort, participants were restricted to those who were exposed to less than 0.1 grays of bomb radiation. This study is still ongoing.

Life Span Study
Takayama study 14 -This study was initiated on September 1, 1992. At the baseline survey, a total of 31,552 Takayama residents, aged ≥35 years (14,427 men and 17,125 women, representing 85.3% of the total population), completed a self-administered questionnaire. Study participants were followed-up for cancer diagnosis, death, or emigration. The most recent follow-up was completed in 2008. 15 -Between 1993 and2004, 19,688 men and women over 18 years of age were recruited from four areas (Haman, Choongju, Uljin, and Pohang) of the Republic of Korea.

Korea Multi-Center Cancer Cohort
Baseline information on general lifestyle, physical activity, diet, reproductive factors, and others were collected by direct interview. Blood (plasma, or serum buffy coat, packed erythrocytes) and urine samples were also obtained. Based on data linkage with the national cancer registry, death-certificate system, and health-insurance databases, study participants were regularly followed-up. The final updates were done to identify all deaths that occurred until the end of 2014 and cancers that occurred until the end of 2013. This study is still ongoing. 16 -This study was initiated in 1992, with an enrollment of a total of 29,918 men aged 40-59. Baseline information was collected by self-administered questionnaires from 14,533 participants. Death certificates from the National Statistics Office were used to ascertain vital status. Study participants were followed-up from January 1, 1993, to December 31, 2008.

Seoul Male Cohort Study
Singapore Chinese Health Study 17 -This study aims to investigate the role of diet and genetic factors in cancer etiology. Between 1993 and 1999, a total of 63,257 men and women, aged 45-74, were recruited for this cohort. At the recruitment, participants were interviewed using staff-administered questionnaires including a validated Food Frequency Questionnaire. Biologic samples were also obtained from consenting cohort members. Study participants were regularly followed-up for cancer incidence and mortality via record linkages to local cancer and vital status registries. 18 -From January 1991 to December 1992, a total of 23,820 individuals, aged 30-65, were recruited from seven townships in Taiwan. Using structured questionnaires, baseline and follow-up information were administered by trained staff. Participants were followed-up for cancer incidence and death through health examination, medical record review, and data linkage to the national cancer registry and death certification systems. 19 -Between 1990-1993, a total of 5,160 adults were recruited from Chu-Don, a Hakka community in northwest Taiwan and from Pu-Tze, a Fukien community in southern Taiwan. In each of the two communities, five villages with >1,000 people or with a population density >200 per square kilometer were randomly selected for this study. Follow-up is conducted every three years using death certificates provided by the Department of Health in Taiwan. 20 -Between 2000 and 2002, 11,746 married men and women, aged ≥18, were recruited for the study (response rate=97.5%). At the baseline survey, data on demographic and lifestyle factors were collected. Using an automatic sphygmomanometer, blood pressure was measured by trained clinicians. Study participants were actively followed-up every two years with in-person visits that include a physical examination and urine collection. This study is still ongoing. 21 -This study recruited participants in two phases, 1991-1994 and 1994-1996. Participants were residents of Mumbai and ≥35 years of age. About 150,000 subjects were interviewed at baseline. To ascertain participants' vital status, an active house-to-house follow-up was done after an average of 5.5 years. Data on cause of death was obtained from the local death registry. Cancer incidence was ascertained by data linkage to cancer registry databases. This study is still ongoing. eTable 1. ICD-9 and ICD-10 codes for causes of death

Other known diseases
Mental disorder 290-319 F00-F99 Nervous system disorder 520-529 G00-G99 ICD-9, the 9 th revision of the International Statistical Classification of Diseases and Related Health Problems; ICD-10, the 10 th revision of the International Statistical Classification of Diseases and Related Health Problems; a Malignant neoplasms of vagina, cervix uteri, corpus uteri, uterus, ovary, vulva, and other female genital organs b Liver cirrhosis, hepatic failure, chronic hepatitis, fibrosis, alcoholic/toxic liver disease, and other kinds of liver disorders