Population attributable fractions for risk factors for dementia in low-income and middle-income countries: an analysis using cross-sectional survey data

Background Nine potentially modifiable risk factors (less childhood education, midlife hearing loss, hypertension, and obesity, and later-life smoking, depression, physical inactivity, social isolation, and diabetes) account for 35% of worldwide dementia, but most data to calculate these risk factors come from high-income countries only. We aimed to calculate population attributable fractions (PAFs) for dementia in selected low-income and middle-income countries (LMICs) to identify potential dementia prevention targets in these countries. Methods The study was an analysis of cross-sectional data obtained from the 10/66 Dementia Research surveys of representative populations in India, China, and six Latin America countries (Cuba, Dominican Republic, Mexico, Peru, Puerto Rico, and Venezuela), which used identical risk factor ascertainment methods in each country. Between 2004 and 2006 (and between 2007 and 2010 for Puerto Rico), all residents aged 65 years and older in predefined catchment areas were invited to participate in the survey. We used risk factor prevalence estimates from this 10/66 survey data, and relative risk estimates from previous meta-analyses, to calculate PAFs for each risk factor. To account for individuals having overlapping risk factors, we adjusted PAF for communality between risk factors, and used these values to calculate overall weighted PAFs for India, China, and the Latin American sample. Findings The overall weighted PAF for potentially modifiable risk factors for dementia was 39.5% (95% CI 37.5-41.6) in China (n=2162 participants), 41.2% (39.1-43.4) in India (n=2004), and 55.8% (54.9-56.7) in our Latin American sample (n=12865). Five dementia risk factors were more prevalent in these LMICs than worldwide estimates, leading to higher PAFs for dementia: less childhood education (weighted PAF of 10.8% in China, 13.6% in India, and 10.9% in Latin America vs 7.5% worldwide), smoking (14.7%, 6.4%, and 5.7%, respectively, vs 5.5% worldwide), hypertension (6.4%, 4.0%, and 9.3%, vs 2.0%), obesity (5.6%, 2.9%, and 7.9%, vs 0.8%), and diabetes (1.6%, 1.7%, and 3.2%, vs 1.2%). Interpretation The dementia prevention potential in India, China, and this sample of Latin American countries is large, and greater than in high-income countries. Less education in early life, hypertension, hearing loss, obesity, and physical inactivity have particularly high PAFs and could be initial targets for dementia prevention strategies. Copyright (C) 2019 The Author(s). Published by Elsevier Ltd.