title: Risk of cardiovascular events and mortality among a population-based cohort of immigrants and long-term residents with diabetes: Are all immigrants healthier and if so, for how long?
abstract: BACKGROUND
  Cardiovascular events are responsible for half of all deaths among individuals with diabetes. Immigrants to Western countries may experience an acceleration of cardiovascular risk in the first 10 years of arrival because of a sedentary lifestyle, poor diet, or barriers to accessing care, leading to higher levels of obesity and diabetes.
  
  
  OBJECTIVE
  To compare the risk of cardiovascular events and mortality between immigrants to Canada and long-term residents with diabetes and to assess whether immigrants experience acceleration in risk after arrival.
  
  
  METHODS
  We conducted a population-based retrospective cohort study using linked health and immigration data from Ontario, Canada, of 87,707 immigrants who immigrated to Canada between 1985 and 2005 matched to 87,707 long-term residents with diabetes (age ≥20 years). Individuals were followed up from April 1, 2005, until February 29, 2012, for the primary composite outcome of a cardiovascular event (acute myocardial infarction, unstable angina, congestive heart failure, transient ischemic attack, stroke) or all-cause mortality.
  
  
  RESULTS
  There was a lower adjusted risk of cardiovascular events or mortality among immigrants (adjusted hazard ratio [HR] 0.76, 95% CI 0.74-0.78) after accounting for differences in baseline age, gender, socioeconomic status, neighborhood, and health care utilization-which persisted beyond 10 years from immigration. However, this healthy immigrant advantage was not found among more recent refugees (HR 0.93, 95% CI 0.81-1.08), immigrants with no previous education (HR 1.08, 95% CI 0.84-1.40), and those who were unmarried (HR 0.80, 95% CI 0.62-1.03).
  
  
  CONCLUSIONS
  Immigrants with diabetes are at lower risk for cardiovascular events and mortality compared with long-term residents, an effect that persists more than 10 years after arrival. Not all immigrants demonstrate this health advantage.
authors.affiliation: University Health Network, Toronto, Ontario, Canada; Mount Sinai Hospital and Samuel Lunenfeld Research Institute of Mount Sinai Hospital, Toronto, Ontario, Canada. Electronic address: karen.okrainec@uhn.ca.
authors.forename: Karen
authors.initials: K
authors.lastname: Okrainec
authors.affiliation: Mount Sinai Hospital and Samuel Lunenfeld Research Institute of Mount Sinai Hospital, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Chaim M
authors.initials: CM
authors.lastname: Bell
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Simon
authors.initials: S
authors.lastname: Hollands
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada.
authors.forename: Gillian L
authors.initials: GL
authors.lastname: Booth
mesh_terms: D000328:Adult; D000349:Africa / Q000208:ethnology; D000368:Aged; D000789:Angina, Unstable / Q000453:epidemiology / Q000401:mortality; D001208:Asia / Q000208:ethnology; D002318:Cardiovascular Diseases / Q000453:epidemiology* / Q000401:mortality; D016022:Case-Control Studies; D015331:Cohort Studies; D015897:Comorbidity; D003920:Diabetes Mellitus / Q000453:epidemiology*; D054242:Emigrants and Immigrants / Q000706:statistics & numerical data*; D005060:Europe / Q000208:ethnology; D005260:Female; D006333:Heart Failure / Q000453:epidemiology / Q000401:mortality; D006801:Humans; D015994:Incidence; D007182:Income / Q000706:statistics & numerical data; D002546:Ischemic Attack, Transient / Q000453:epidemiology / Q000401:mortality; D007843:Latin America / Q000208:ethnology; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology / Q000401:mortality; D009765:Obesity / Q000453:epidemiology; D009864:Ontario / Q000453:epidemiology; D016016:Proportional Hazards Models; D012111:Residence Characteristics; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000453:epidemiology / Q000401:mortality; D013997:Time Factors