Population Health Research Institute, McMaster University, Hamilton Health Sciences, ON, Canada.
Medical Research and Biometrics Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Beijing, China; National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
Lancet. 2024 Aug 10;404(10452):554-569. doi: 10.1016/S0140-6736(24)01050-X. Epub 2024 Jul 25.
The focus of most epidemiological studies has been mortality or clinical events, with less information on activity limitations related to basic daily functions and their consequences. Standardised data from multiple countries at different economic levels in different regions of the world on activity limitations and their associations with clinical outcomes are sparse. We aimed to quantify the prevalence of activity limitations and use of assistive devices and the association of limitations with adverse outcomes in 25 countries grouped by different economic levels.
In this analysis, we obtained data from individuals in 25 high-income, middle-income, and low-income countries from the Prospective Urban Rural Epidemiological (PURE) study (175 660 participants). In the PURE study, individuals aged 35-70 years who intended to continue living in their current home for a further 4 years were invited to complete a questionnaire on activity limitations. Participant follow-up was planned once every 3 years either by telephone or in person. The activity limitation screen consisted of questions on self-reported difficulty with walking, grasping, bending, seeing close, seeing far, speaking, hearing, and use of assistive devices (gait, vision, and hearing aids). We estimated crude prevalence of self-reported activity limitations and use of assistive devices, and prevalence standardised by age and sex. We used logistic regression to additionally adjust prevalence for education and socioeconomic factors and to estimate the probability of activity limitations and assistive devices by age, sex, and country income. We used Cox frailty models to evaluate the association between each activity limitation with mortality and clinical events (cardiovascular disease, heart failure, pneumonia, falls, and cancer). The PURE study is registered with ClinicalTrials.gov, NCT03225586.
Between Jan 12, 2001, and May 6, 2019, 175 584 individuals completed at least one question on the activity limitation questionnaire (mean age 50·6 years [SD 9·8]; 103 625 [59%] women). Of the individuals who completed all questions, mean follow-up was 10·7 years (SD 4·4). The most common self-reported activity limitations were difficulty with bending (23 921 [13·6%] of 175 515 participants), seeing close (22 532 [13·4%] of 167 801 participants), and walking (22 805 [13·0%] of 175 554 participants); prevalence of limitations was higher with older age and among women. The prevalence of all limitations standardised by age and sex, with the exception of hearing, was highest in low-income countries and middle-income countries, and this remained consistent after adjustment for socioeconomic factors. The use of gait, visual, and hearing aids was lowest in low-income countries and middle-income countries, particularly among women. The prevalence of seeing close limitation was four times higher (6257 [16·5%] of 37 926 participants vs 717 [4·0%] of 18 039 participants) and the prevalence of seeing far limitation was five times higher (4003 [10·6%] of 37 923 participants vs 391 [2·2%] of 18 038 participants) in low-income countries than in high-income countries, but the prevalence of glasses use in low-income countries was half that in high-income countries. Walking limitation was most strongly associated with mortality (adjusted hazard ratio 1·32 [95% CI 1·25-1·39]) and most consistently associated with other clinical events, with other notable associations observed between seeing far limitation and mortality, grasping limitation and cardiovascular disease, bending limitation and falls, and between speaking limitation and stroke.
The global prevalence of activity limitations is substantially higher in women than men and in low-income countries and middle-income countries compared with high-income countries, coupled with a much lower use of gait, visual, and hearing aids. Strategies are needed to prevent and mitigate activity limitations globally, with particular emphasis on low-income countries and women.
Funding sources are listed at the end of the Article.
大多数流行病学研究的重点是死亡率或临床事件，而对与基本日常功能相关的活动受限及其后果的了解较少。来自全球不同经济水平和不同地区的多个国家的标准化数据，关于活动受限及其与临床结果的关联，十分有限。我们旨在量化活动受限的流行程度以及在 25 个国家/地区使用辅助设备的情况，并评估限制与不良结果之间的关联，这些国家/地区是根据不同的经济水平分组的。
在这项分析中，我们从 Prospective Urban Rural Epidemiological（PURE）研究的 25 个高收入、中等收入和低收入国家/地区的参与者（175660 人）中获取了数据。在 PURE 研究中，年龄在 35-70 岁之间且打算在未来 4 年内继续居住在当前住所的参与者，被邀请完成一份关于活动受限的问卷。参与者的随访计划每 3 年进行一次，通过电话或面对面的方式进行。活动受限筛查包括自我报告的行走、抓握、弯曲、看近、看远、说话、听力以及使用辅助设备（步行、视力和听力辅助设备）困难的问题。我们估计了自我报告的活动受限和使用辅助设备的粗患病率，以及按年龄和性别标准化的患病率。我们使用逻辑回归来进一步调整教育和社会经济因素的患病率，并估计年龄、性别和国家收入对活动受限和辅助设备的概率。我们使用 Cox 脆性模型来评估每个活动受限与死亡率和临床事件（心血管疾病、心力衰竭、肺炎、跌倒和癌症）之间的关联。PURE 研究在 ClinicalTrials.gov 上注册，编号为 NCT03225586。
在 2001 年 1 月 12 日至 2019 年 5 月 6 日期间，有 175584 人完成了活动受限问卷中的至少一个问题（平均年龄 50.6 岁[标准差 9.8]；103625[59%]为女性）。在完成所有问题的参与者中，平均随访时间为 10.7 年（标准差 4.4）。最常见的自我报告活动受限是弯腰困难（175515 名参与者中有 23921 人[13.6%]）、看近困难（167801 名参与者中有 22532 人[13.4%]）和行走困难（175554 名参与者中有 22805 人[13.0%]）；年龄较大和女性的受限患病率更高。除听力外，所有按年龄和性别标准化的限制患病率在低收入国家和中等收入国家最高，这一结果在调整社会经济因素后仍然一致。在低收入国家和中等收入国家，步行、视力和听力辅助设备的使用率最低，尤其是女性。在低收入国家，看近受限的患病率高四倍（37926 名参与者中有 6257 人[16.5%]），看远受限的患病率高五倍（37923 名参与者中有 4003 人[10.6%]），而在高收入国家，看远受限的患病率高五倍（37923 名参与者中有 391 人[2.2%]），但在低收入国家，戴眼镜的比例是高收入国家的一半。行走受限与死亡率的关联最强（调整后的危险比 1.32[95%CI 1.25-1.39]），与其他临床事件的关联最为一致，在其他方面，也观察到看远受限与死亡率、抓握受限与心血管疾病、弯腰受限与跌倒以及说话受限与中风之间存在显著关联。
在女性中，活动受限的流行程度明显高于男性，在低收入国家和中等收入国家中，活动受限的流行程度明显高于高收入国家，而这些国家/地区使用步行、视力和听力辅助设备的比例较低。需要制定全球策略来预防和减轻活动受限，特别是在低收入国家和女性中。
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