Large-scale observational studies in diverse populations
Lead Research Organisation:
University of Oxford
Abstract
Experience in Western countries has shown that large population-based prospective studies are a valuable way of investigating many slow-acting causes of common chronic diseases. The PHRU is collaborating with researchers in low and middle income countries to generate reliable evidence about the importance of common risk factors for premature death (such as smoking, alcohol, obesity and hypertension).
Our previous research has demonstrated the hazards of prolonged smoking and the benefits of stopping smoking in high-income countries; and ongoing studies, involving 1.4 million participants, are currently assessing the risks of smoking in Mexico, Cuba and India. In 2009 and 2014 we reported that excessive alcohol consumption (chiefly vodka) was responsible for most premature deaths in Russia and this immediately prompted new public health strategies to limit heavy alcohol consumption. Our study in Mexico (where one-third of men and one-half of women are obese) has shown that uncontrolled diabetes causes at least one third of all deaths between 35 and 74 years of age.
Our previous research has demonstrated the hazards of prolonged smoking and the benefits of stopping smoking in high-income countries; and ongoing studies, involving 1.4 million participants, are currently assessing the risks of smoking in Mexico, Cuba and India. In 2009 and 2014 we reported that excessive alcohol consumption (chiefly vodka) was responsible for most premature deaths in Russia and this immediately prompted new public health strategies to limit heavy alcohol consumption. Our study in Mexico (where one-third of men and one-half of women are obese) has shown that uncontrolled diabetes causes at least one third of all deaths between 35 and 74 years of age.
Technical Summary
Over a period of decades, large population-based observational studies have helped identify several major 'classic causes' of premature death from non-communicable disease (NCD), including smoking, hypertension, obesity (adiposity), harmful alcohol use, dyslipidaemia, diabetes, poor diet and physical inactivity. However, the effects of such factors vary greatly from one population to another. There is still substantial uncertainty as to how important these factors are in different settings, and how their importance is changing with time. Direct evidence from low-and middle-income countries (LMICs) is important as it may in the long run improve local and regional NCD control strategies and actions. However, such evidence is lacking. Indeed, at present, global estimates of the importance of classic causes depend mainly on mathematical extrapolation from findings in high-income countries. LMIC findings may change global estimates significantly, thus strengthening our understanding of the NCD burden and the local relevance of causes.
During the 1990s/2000s, therefore, PHRU in collaboration with local investigators set up large prospective studies in Chennai (500,000 adults), Kerala (400,000), Russia (200,000 adults), Cuba (150,000) and Mexico City (150,000 with blood). Recruitment finished in Cuba in 2000, Chennai in 2001, Kerala in 2002, Mexico in 2004 and Russia in 2008. Follow-up involves fieldwork together, where possible, with electronic linkage to national mortality records. Resurveys among subsets of survivors have been conducted or are planned in each cohort. Some 53,000 deaths have already been recorded in Chennai, 33,000 in Kerala, 12,000 in Cuba and 20,000 in Mexico. In Mexico, further linkage to non-fatal health records is being conducted and validated, while the availability of blood samples collected at baseline in nearly all participants will allow (funding permitting) for the measurement of a large range of biochemical and genetic markers. These cohorts have already demonstrated the value of studying classic causes of premature death in different settings, for example by demonstrating the risks from hazardous drinking in Russia (which, together with smoking, may well account for 3/4 of all male deaths before age 75) and the risks from diabetes in Mexico (where diabetes was found to be a cause of at least one third of all deaths between 35 and 74 years of age, twice previous indirect estimates based on evidence from other populations).
The prospective studies PHRU has set up will help monitor the evolution of the worldwide epidemics of premature death from classic causes, while the availability of blood samples in the Mexico study affords the further opportunity for discovery of novel genetic and metabolic pathways and their relevance for premature death. The studies have been set up, follow-up has accumulated, collaboration is assured and PHRU will, during the next 5 years, continue to collaborate closely with the national PIs to generate reliable analyses and publications. These reports will reach the highest levels of the governments concerned as well as reaching the wider population.
During the 1990s/2000s, therefore, PHRU in collaboration with local investigators set up large prospective studies in Chennai (500,000 adults), Kerala (400,000), Russia (200,000 adults), Cuba (150,000) and Mexico City (150,000 with blood). Recruitment finished in Cuba in 2000, Chennai in 2001, Kerala in 2002, Mexico in 2004 and Russia in 2008. Follow-up involves fieldwork together, where possible, with electronic linkage to national mortality records. Resurveys among subsets of survivors have been conducted or are planned in each cohort. Some 53,000 deaths have already been recorded in Chennai, 33,000 in Kerala, 12,000 in Cuba and 20,000 in Mexico. In Mexico, further linkage to non-fatal health records is being conducted and validated, while the availability of blood samples collected at baseline in nearly all participants will allow (funding permitting) for the measurement of a large range of biochemical and genetic markers. These cohorts have already demonstrated the value of studying classic causes of premature death in different settings, for example by demonstrating the risks from hazardous drinking in Russia (which, together with smoking, may well account for 3/4 of all male deaths before age 75) and the risks from diabetes in Mexico (where diabetes was found to be a cause of at least one third of all deaths between 35 and 74 years of age, twice previous indirect estimates based on evidence from other populations).
The prospective studies PHRU has set up will help monitor the evolution of the worldwide epidemics of premature death from classic causes, while the availability of blood samples in the Mexico study affords the further opportunity for discovery of novel genetic and metabolic pathways and their relevance for premature death. The studies have been set up, follow-up has accumulated, collaboration is assured and PHRU will, during the next 5 years, continue to collaborate closely with the national PIs to generate reliable analyses and publications. These reports will reach the highest levels of the governments concerned as well as reaching the wider population.
Organisations
- University of Oxford, United Kingdom (Collaboration, Lead Research Organisation)
- Tata Memorial Hospital (Collaboration)
- National Institute for Health Research, United Kingdom (Collaboration)
- UK Biobank, United Kingdom (Collaboration)
- Center for Disease Control Foundation (Collaboration)
- New York University Abu Dhabi, United Arab Emirates (Collaboration)
- CDC Foundation (Collaboration)
- Resolve to Save Lives (Collaboration)
- University Kebangsaan Malaysia Medical Centre (Collaboration)
- Oxford University Hospitals NHS Foundation Trust, Headington (Collaboration)
- Yonsei University, Korea, Republic of (Collaboration)
Publications

Alegre-Díaz J
(2016)
OC04_04 Extreme Cardiac and Renal Mortality From Diabetes: 12-Year Blood-Based Prospective Study of 150,000 Mexican Adults
in Global Heart

Alegre-Díaz J
(2016)
Diabetes and Cause-Specific Mortality in Mexico City.
in The New England journal of medicine

Armas Rojas N
(2019)
Cohort Profile: the Cuba Prospective Study.
in International journal of epidemiology

Armas Rojas N
(2019)
Burden of hypertension and associated risks for cardiovascular mortality in Cuba: a prospective cohort study
in The Lancet Public Health


Carter JL
(2019)
The roles of non-cognitive and cognitive skills in the life course development of adult health inequalities.
in Social science & medicine (1982)

Carter JL
(2020)
Sex-Specific Associations of Vascular Risk Factors With Abdominal Aortic Aneurysm: Findings From 1.5 Million Women and 0.8 Million Men in the United States and United Kingdom.
in Journal of the American Heart Association

Carter JL
(2019)
Reproducibility of dietary intakes of macronutrients, specific food groups, and dietary patterns in 211 050 adults in the UK Biobank study.
in Journal of nutritional science

Chen Z
(2018)
Adiposity and risk of ischaemic and haemorrhagic stroke in 0·5 million Chinese men and women: a prospective cohort study
in The Lancet Global Health

Di Angelantonio E
(2017)
Body-mass index and all-cause mortality - Authors' reply
in The Lancet
Description | WHO Global Hearts Initiative |
Geographic Reach | Multiple continents/international |
Policy Influence Type | Gave evidence to a government review |
Impact | Our work has informed the World Health Organisation Global Hearts Initiative to address cardiovascular disease in low and middle income countries. Government policy on non-communicable disease control in Cuba, Russia and India |
Description | BHF Oxford Centre of Research Excellence Intermediate Transition Fellowship Award |
Amount | £210,000 (GBP) |
Organisation | British Heart Foundation (BHF) |
Sector | Charity/Non Profit |
Country | United Kingdom |
Start |
Description | BHF Oxford Centre of Research Excellence Intermediate Transition Fellowship Award extension |
Amount | £105,000 (GBP) |
Organisation | British Heart Foundation (BHF) |
Sector | Charity/Non Profit |
Country | United Kingdom |
Start |
Description | Global Hearts Initiative: Expanding the evidence base for cardiovascular disease risk factors |
Amount | $1,250,000 (USD) |
Organisation | CDC Foundation |
Sector | Public |
Country | United States |
Start |
Description | MRC UK-Malaysia Health Research Partnership |
Amount | £176,000 (GBP) |
Organisation | Medical Research Council (MRC) |
Sector | Public |
Country | United Kingdom |
Start |
Description | NIHR Biomedical Research Centre - research theme: Obesity, diet and lifestyle |
Amount | £4,200,000 (GBP) |
Organisation | National Institute for Health Research |
Sector | Public |
Country | United Kingdom |
Start |
Description | BHF Centre for Research Excellence |
Organisation | University of Oxford |
Department | BHF Centre of Research Excellence |
Country | United Kingdom |
Sector | Academic/University |
PI Contribution | n/a |
Collaborator Contribution | funding |
Impact | Support for Dr Ben Lacey to work on routinely-collected electronic health records in preparation for fellowship |
Start Year | 2018 |
Description | BRC Obesity Theme |
Organisation | University of Oxford |
Department | Nuffield Department of Primary Care Health Sciences |
Country | United Kingdom |
Sector | Academic/University |
PI Contribution | BRC Obesity theme Networking Event oral presentations: 29/03/2019: 'Body composition and Blood Pressure in 10 000 UK Adults: Recent findings from the UK Biobank and Oxford Biobank' 30/01/2020: 'Observational and genetic associations of adiposity measures with CHD risk in the UK Biobank: A prospective cohort study of 500 000 adults' |
Collaborator Contribution | n/a |
Impact | Malden, Deborah, Ben Lacey, Jonathan Emberson, Fredrik Karpe, Naomi Allen, Derrick Bennett, and Sarah Lewington. "Body Fat Distribution and Systolic Blood Pressure in 10,000 Adults with Whole-Body Imaging: UK Biobank and Oxford BioBank." Obesity 27.7 (2019): 1200-206 |
Start Year | 2018 |
Description | CDC Foundation |
Organisation | CDC Foundation |
Country | United States |
Sector | Public |
PI Contribution | Co-principal Investigator |
Collaborator Contribution | The CDC Foundation and Amgen are partnering on a new global cardiovascular health initiative to support independent epidemiological research by the University of Oxford and technological and evaluation research by the Centers for Disease Control and Prevention (CDC). |
Impact | none yet |
Start Year | 2018 |
Description | CDC Foundation |
Organisation | Center for Disease Control Foundation |
Country | United States |
Sector | Charity/Non Profit |
PI Contribution | academic partnership |
Collaborator Contribution | academic partnership |
Impact | n/a |
Start Year | 2016 |
Description | CDC Non-Communicable Disease Branch |
Organisation | Center for Disease Control Foundation |
Country | United States |
Sector | Charity/Non Profit |
PI Contribution | Collaboration with Global Non-Communicable Disease Branch of the US Center of Disease Control. Funding from CDC-Foundation. Title 'Global Hearts Initiative: Expanding the Evidence Base for Cardiovascular Disease Risk Factors'. |
Collaborator Contribution | academic partnership |
Impact | Ongoing |
Start Year | 2019 |
Description | Ethnic differences in the association between smoking and lung cancer: a comparison between Korea and the UK |
Organisation | Yonsei University |
Country | Korea, Republic of |
Sector | Academic/University |
PI Contribution | Statistical and epidemiological expertise |
Collaborator Contribution | Epidemiological expertise and data |
Impact | Peer-reviewed publciations |
Start Year | 2017 |
Description | Imaging study of the participants for the Barsi Prospective Cohort Study |
Organisation | Tata Memorial Hospital |
Country | India |
Sector | Hospitals |
PI Contribution | Conducting an imaging study of participants of the Barsi Prospective Cohort Study |
Collaborator Contribution | Academic collaboration |
Impact | n/a |
Start Year | 2019 |
Description | MRC UK_Malaysia Health Research Partnership |
Organisation | University Kebangsaan Malaysia Medical Centre |
Country | Malaysia |
Sector | Hospitals |
PI Contribution | Collaboration with Universiti Kebangsaan Malaysia. Funding from MRC UK-Malaysia Health Research Partnership. Title: Obesity and non-communicable disease in Malaysia: an imaging study of 6000 adults in the Malaysian Cohort Study. The collaboration will facilitate an imaging sub-study of 6000 participants of the Malaysian Cohort Study. |
Collaborator Contribution | academic partnership |
Impact | ongoing |
Start Year | 2019 |
Description | Middle-East Cohort Studies Collaboration |
Organisation | New York University Abu Dhabi |
Country | United Arab Emirates |
Sector | Academic/University |
PI Contribution | Statistical and epidemiological expertise |
Collaborator Contribution | Sharing of results from individual studies for preparation of manuscripts for publication |
Impact | n/a |
Start Year | 2017 |
Description | NIHR Health Informatics Collaborative |
Organisation | National Institute for Health Research |
Country | United Kingdom |
Sector | Public |
PI Contribution | The Group is a collaboration of clinicians and data scientists from five NHS Trusts focused on cardiovascular research |
Collaborator Contribution | academic collaboration |
Impact | n/a |
Start Year | 2019 |
Description | NIHR Oxford BRC |
Organisation | Oxford University Hospitals NHS Foundation Trust |
Department | NIHR Oxford Biomedical Research Centre |
Country | United Kingdom |
Sector | Academic/University |
PI Contribution | Personal award |
Collaborator Contribution | funding |
Impact | Support for Dr Ben Lacey to work on large-scale observation studies |
Start Year | 2017 |
Description | Resolve to Save Lives |
Organisation | Resolve to Save Lives |
Country | United States |
Sector | Charity/Non Profit |
PI Contribution | This is a global public health initiative to address elevated blood pressure in low and middle income countries. We have advised on the conduct and analysis of blood pressure surveys. |
Collaborator Contribution | academic partnership |
Impact | n/a |
Start Year | 2019 |
Description | Richard Doll Consortium |
Organisation | University of Oxford |
Department | Nuffield Department of Population Health |
Country | United Kingdom |
Sector | Academic/University |
PI Contribution | This is a consortium of all prospective studies with over 100,000 participants (with or without blood collected for long-term storage). The Collaboration was established by NDPH. The current focus of our work on re-evaluating the global evidence on air pollution, second-hand smoke and several dietary factors. |
Collaborator Contribution | academic collaboration |
Impact | The work of the Consortium has led to a re-evaluation of the global evidence on air pollution, second-hand smoke and diet. |
Description | UK Biobank Renal Outcomes Group |
Organisation | UK Biobank |
Country | United Kingdom |
Sector | Charity/Non Profit |
PI Contribution | Member of working group |
Collaborator Contribution | They run it |
Impact | N/A |
Start Year | 2016 |
Description | Cyber Security in the UAE |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Undergraduate students |
Results and Impact | science communicator on the UAE 'CyberQuest' project. This is a national competition for University/ high school students run by the Secret Intelligence Agency across the UAE. The Edinburgh International Science Festival was hired by the UAE government to design and teach one week of cybersecurity modules in order to prepare the kids for the competition. Prizes include things like full scholarships to study Cyber security at some of the top institutions in the world, and MacBook pro's etc. I was designated a class of 25 students aged 18+ and I taught them the following modules: - Linux basics - Port Scanning - Firewalls - Phishing Basic - Phishing advanced - Information gathering - Web hacking basics - Using wire-shark - Web hacking advanced - Securing web Apps Each module would consist of about 2 hours of teaching time (using simulated online environments created by the EISF team) and then a timed, online assessment at the end. The test scores are combined for the whole 'training camp' and used to decide which children are through to the final competition. In April 2017, I was based in Abu Dhabi (8th-12th of April), but this January (6th-10th of January, 2018) I was based in Fujairah - a more conservative region in the North of the country. |
Year(s) Of Engagement Activity | 2017 |
Description | Edinburgh International Science Festival |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Public/other audiences |
Results and Impact | However, for the past few years EISF has been running the same events in the UAE at the Abu Dhabi Science Festival (more info: https://www.adsftickets.com ). I first went out to the UAE for two weeks in November 2014. I usually run an event called 'ER Surgery' which involves teaching children aged 8-12 years about medicine using a simulated surgical environment - e.g. removing pretend 'gallstones' from a manikin using laparoscopy. In Edinburgh, I worked as a Science Communicator, whereas in Abu Dhabi (2014) I worked as a Team Leader, which involved teaching science communicators to run the workshops themselves. These science communicators were all National UAE citizens studying science and engineering at University, and working as a science communicator at the ADSF was a mandatory part of their University degree. |
Year(s) Of Engagement Activity | 2016,2017 |
Description | IF Science Oxford |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | Regional |
Primary Audience | Public/other audiences |
Results and Impact | Took part in the IF Oxford Science Festival at the Westgate Centre - Julie Burrett |
Year(s) Of Engagement Activity | 2019 |
Description | Maths Festival |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | Regional |
Primary Audience | Public/other audiences |
Results and Impact | Maths Festival at Temple Cowley Shopping Centre |
Year(s) Of Engagement Activity | 2020 |
Description | Science Week - Freeland Primary School |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Schools |
Results and Impact | Assisted with the delivery of the data game at Freeland Primary School during Oxford Science Week - Julie Burrett |
Year(s) Of Engagement Activity | 2019 |
Description | Women in Sciences |
Form Of Engagement Activity | Participation in an open day or visit at my research institution |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Schools |
Results and Impact | Trinity, Jesus and Wadham Colleges hosted Women in Sciences outreach event for female Year 12 students interested in studying a science at university. This year we are running it as a residential over three days to enable us to include students from far away state schools in the NE and Wales. Deborah Malden presented at this event. |
Year(s) Of Engagement Activity | 2020 |