title: Association Between Diabetes and Cause-Specific Mortality in Rural and Urban Areas of China.
abstract: In China, diabetes prevalence has increased substantially in recent decades, but there are no reliable estimates of the excess mortality currently associated with diabetes.
  
  
  
  To assess the proportional excess mortality associated with diabetes and estimate the diabetes-related absolute excess mortality in rural and urban areas of China.
  
  
  
  A 7-year nationwide prospective study of 512 869 adults aged 30 to 79 years from 10 (5 rural and 5 urban) regions in China, who were recruited between June 2004 and July 2008 and were followed up until January 2014.
  
  
  
  Diabetes (previously diagnosed or detected by screening) recorded at baseline.
  
  
  
  All-cause and cause-specific mortality, collected through established death registries. Cox regression was used to estimate adjusted mortality rate ratio (RR) comparing individuals with diabetes vs those without diabetes at baseline.
  
  
  
  Among the 512 869 participants, the mean (SD) age was 51.5 (10.7) years, 59% (n = 302 618) were women, and 5.9% (n = 30 280) had diabetes (4.1% in rural areas, 8.1% in urban areas, 5.8% of men, 6.1% of women, 3.1% had been previously diagnosed, and 2.8% were detected by screening). During 3.64 million person-years of follow-up, there were 24 909 deaths, including 3384 among individuals with diabetes. Compared with adults without diabetes, individuals with diabetes had a significantly increased risk of all-cause mortality (1373 vs 646 deaths per 100 000; adjusted RR, 2.00 [95% CI, 1.93-2.08]), which was higher in rural areas than in urban areas (rural RR, 2.17 [95% CI, 2.07-2.29]; urban RR, 1.83 [95% CI, 1.73-1.94]). Presence of diabetes was associated with increased mortality from ischemic heart disease (3287 deaths; RR, 2.40 [95% CI, 2.19-2.63]), stroke (4444 deaths; RR, 1.98 [95% CI, 1.81-2.17]), chronic liver disease (481 deaths; RR, 2.32 [95% CI, 1.76-3.06]), infections (425 deaths; RR, 2.29 [95% CI, 1.76-2.99]), and cancer of the liver (1325 deaths; RR, 1.54 [95% CI, 1.28-1.86]), pancreas (357 deaths; RR, 1.84 [95% CI, 1.35-2.51]), female breast (217 deaths; RR, 1.84 [95% CI, 1.24-2.74]), and female reproductive system (210 deaths; RR, 1.81 [95% CI, 1.20-2.74]). For chronic kidney disease (365 deaths), the RR was higher in rural areas (18.69 [95% CI, 14.22-24.57]) than in urban areas (6.83 [95% CI, 4.73-9.88]). Among those with diabetes, 10% of all deaths (16% rural; 4% urban) were due to definite or probable diabetic ketoacidosis or coma (408 deaths).
  
  
  
  Among adults in China, diabetes was associated with increased mortality from a range of cardiovascular and noncardiovascular diseases. Although diabetes was more common in urban areas, it was associated with greater excess mortality in rural areas.
authors.affiliation: Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England.
authors.forename: Fiona
authors.initials: F
authors.lastname: Bragg
authors.affiliation: Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England2Medical Research Council Population Health Research Unit, University of Oxford, Oxford, England.
authors.forename: Michael V
authors.initials: MV
authors.lastname: Holmes
authors.affiliation: Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England2Medical Research Council Population Health Research Unit, University of Oxford, Oxford, England.
authors.forename: Andri
authors.initials: A
authors.lastname: Iona
authors.affiliation: Chinese Academy of Medical Sciences, Beijing, China.
authors.forename: Yu
authors.initials: Y
authors.lastname: Guo
authors.affiliation: Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England2Medical Research Council Population Health Research Unit, University of Oxford, Oxford, England.
authors.forename: Huaidong
authors.initials: H
authors.lastname: Du
authors.affiliation: Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England2Medical Research Council Population Health Research Unit, University of Oxford, Oxford, England.
authors.forename: Yiping
authors.initials: Y
authors.lastname: Chen
authors.affiliation: Chinese Academy of Medical Sciences, Beijing, China.
authors.forename: Zheng
authors.initials: Z
authors.lastname: Bian
authors.affiliation: Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England2Medical Research Council Population Health Research Unit, University of Oxford, Oxford, England.
authors.forename: Ling
authors.initials: L
authors.lastname: Yang
authors.affiliation: Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England.
authors.forename: William
authors.initials: W
authors.lastname: Herrington
authors.affiliation: Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England.
authors.forename: Derrick
authors.initials: D
authors.lastname: Bennett
authors.affiliation: Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England.
authors.forename: Iain
authors.initials: I
authors.lastname: Turnbull
authors.affiliation: Qingdao Center for Disease Control and Prevention, Qingdao, China.
authors.forename: Yongmei
authors.initials: Y
authors.lastname: Liu
authors.affiliation: Henan Provincial Center for Disease Control and Prevention, Henan, China.
authors.forename: Shixian
authors.initials: S
authors.lastname: Feng
authors.affiliation: National Center for Food Safety Risk Assessment, Beijing, China.
authors.forename: Junshi
authors.initials: J
authors.lastname: Chen
authors.affiliation: Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England.
authors.forename: Robert
authors.initials: R
authors.lastname: Clarke
authors.affiliation: Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England.
authors.forename: Rory
authors.initials: R
authors.lastname: Collins
authors.affiliation: Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England.
authors.forename: Richard
authors.initials: R
authors.lastname: Peto
authors.affiliation: Chinese Academy of Medical Sciences, Beijing, China7School of Public Health, Peking University, Beijing, China.
authors.forename: Liming
authors.initials: L
authors.lastname: Li
authors.affiliation: Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England.
authors.forename: Zhengming
authors.initials: Z
authors.lastname: Chen
mesh_terms: D000328:Adult; D017677:Age Distribution; D000368:Aged; D001943:Breast Neoplasms / Q000401:mortality; D002423:Cause of Death; D002681:China / Q000453:epidemiology; D003920:Diabetes Mellitus / Q000401:mortality*; D005260:Female; D005833:Genital Neoplasms, Female / Q000401:mortality; D006801:Humans; D007239:Infections / Q000401:mortality; D008107:Liver Diseases / Q000401:mortality; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000401:mortality; D010182:Pancreatic Diseases / Q000401:mortality; D011446:Prospective Studies; D019057:Quality-Adjusted Life Years; D051436:Renal Insufficiency, Chronic / Q000401:mortality; D012424:Rural Population / Q000706:statistics & numerical data*; D017678:Sex Distribution; D020521:Stroke / Q000401:mortality; D014505:Urban Population / Q000706:statistics & numerical data*