Publications by authors named "Bruce B Duncan"

135 Publications

Deep neural network-estimated electrocardiographic age as a mortality predictor.

Nat Commun 2021 08 25;12(1):5117. Epub 2021 Aug 25.

Telehealth Center, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.

The electrocardiogram (ECG) is the most commonly used exam for the evaluation of cardiovascular diseases. Here we propose that the age predicted by artificial intelligence (AI) from the raw ECG (ECG-age) can be a measure of cardiovascular health. A deep neural network is trained to predict a patient's age from the 12-lead ECG in the CODE study cohort (n = 1,558,415 patients). On a 15% hold-out split, patients with ECG-age more than 8 years greater than the chronological age have a higher mortality rate (hazard ratio (HR) 1.79, p < 0.001), whereas those with ECG-age more than 8 years smaller, have a lower mortality rate (HR 0.78, p < 0.001). Similar results are obtained in the external cohorts ELSA-Brasil (n = 14,236) and SaMi-Trop (n = 1,631). Moreover, even for apparent normal ECGs, the predicted ECG-age gap from the chronological age remains a statistically significant risk predictor. These results show that the AI-enabled analysis of the ECG can add prognostic information.
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http://dx.doi.org/10.1038/s41467-021-25351-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8387361PMC
August 2021

Reference values for the triglyceride to high-density lipoprotein ratio and its association with cardiometabolic diseases in a mixed adult population: The ELSA-Brasil study.

J Clin Lipidol 2021 Jul 29. Epub 2021 Jul 29.

Department of Pathophysiology, Montes Claros State University (UNIMONTES), Montes Claros, MG, Brazil. Electronic address:

Background: Among several lipid ratios available, the triglyceride/HDL-cholesterol (TG/HDL-C) may detect individuals at risk of cardiometabolic diseases. However, its reference values for different ethnicities are not well established.

Objective: To define sex- and ethnicity-specific reference values for TG/HDL-C ratio in a large sample of healthy multiethnic adults and test its association with cardiometabolic conditions.

Methods: An apparently healthy sample (n = 2,472), aged 35-74, free of major cardiovascular risk factors, was used to generate the reference values for the TG/HDL-C. Exclusion criteria were diabetes, elevated blood pressure, obesity, hypercholesterolemia, severe hypertriglyceridemia, and smoking history. Cut-offs based on the reference values were tested in the whole ELSA Brasil study (n = 13,245), stratified by sex and ethnicity, to identify cardiometabolic conditions.

Results: TG/HDL-C ratio was higher in men than women, and did not change significantly with age, regardless of sex and ethnicity. Also, black individuals showed lower levels of TG/HDL-C as compared to other ethnic groups. ROC curve showed that the cut-off based on the 75th percentile displayed better sensitivities and specificities for men and women, regardless of ethnicity. Also, the sex- and ethnicity-specific cut-offs based on the 75th percentile were significantly associated with all tested cardiometabolic conditions (hypertension, diabetes, obesity, metabolic syndrome, and insulin resistance). Also, we observed that the use of a single sex-specific cut-off (men: 2.6; women: 1.7) could be used for the different ethnicities with good reliability.

Conclusion: The defined TG/HDL-C cut-offs (men: 2.6; women: 1.7) are reliable and showed good clinical applicability to detect cardiometabolic conditions in a multiethnic population.
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http://dx.doi.org/10.1016/j.jacl.2021.07.005DOI Listing
July 2021

Control of Glucose, Blood Pressure, and Cholesterol among Adults with Diabetes: The Brazilian National Health Survey.

J Clin Med 2021 Jul 31;10(15). Epub 2021 Jul 31.

Postgraduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul, Porto Alegre 90035-003, RS, Brazil.

ABC (glucose, blood pressure and LDL-cholesterol) goals are basic standards of diabetes care. We aimed to assess ABC control and related factors in a representative sample of Brazilian adults with diabetes. We analyzed 465 adults with known diabetes in the Brazilian National Health Survey. The targets used were <7% for glycated hemoglobin (A1C); <140/90 mmHg for blood pressure; and <100 mg/dL for LDL-C, with stricter targets for the latter two for those with high cardiovascular (CVD) risk. Individual goals were attained by 46% (95% CI, 40.3-51.6%) for A1C, 51.4% (95% CI, 45.7-57.1%) for blood pressure, and 40% (95% CI, 34.5-45.6%) for LDL-C. The achievement of all three goals was attained by 12.5% (95% CI, 8.9-16.2%). Those with high CVD risk attained blood pressure and LDL-C goals less frequently. A1C control improved with increasing age and worsened with greater duration of diabetes. Achievement of at least two ABC goals decreased with increasing BMI and greater duration of diabetes. In sum, about half of those with known diabetes achieved each ABC goal and only a small fraction achieved all three goals. Better access and adherence to treatment and strategies to personalize goals according to specific priorities are of the essence.
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http://dx.doi.org/10.3390/jcm10153428DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8347573PMC
July 2021

Lifetime risk of developing diabetes and years of life lost among those with diabetes in Brazil.

J Glob Health 2021 3;11:04041. Epub 2021 Jul 3.

Postgraduate Program in Epidemiology, School of Medicine and Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.

Background: Given the paucity of studies for low- or middle-income countries, we aim to provide the first ever estimations of lifetime risk of diabetes, years of life spent and lost among those with diabetes for Brazilians. Estimates of Brazil´s diabetes burden consist essentially of reports of diabetes prevalence from national surveys and mortality data. However, these additional metrics are at times more meaningful ways to characterize this burden.

Methods: We joined data on incidence of physician-diagnosed diabetes from the Brazilian risk factor surveillance system, all-cause mortality from national statistics, and diabetes mortality rate ratios from ELSA-Brasil, an ongoing cohort study. To calculate lifetime risk of developing diabetes, we applied an illness-death state model. To calculate years of life lost for those with diabetes and years lived with the disease, we additionally calculated the mortality rates for those with diabetes.

Results: A 35-year-old white adult had a 23.4% (95% CI = 22.5%-25.5%) lifetime risk of developing diabetes by age 80 while a same-aged black/brown adult had a 30.8% risk (95% confidence interval (CI) = 29.6%-33.2%). Men diagnosed with diabetes at age 35 would live 32.9 (95% CI = 32.4-33.2) years with diabetes and lose 5.5 (95% CI = 5.1-6.1) years of life. Similarly-aged women would live 38.8 (95% CI = 38.3-38.9) years with diabetes and lose 2.1 (95% CI = 1.9-2.6) years of life.

Conclusions: Assuming maintenance of current rates, one-quarter of young Brazilians will develop diabetes over their lifetimes, with this number reaching almost one-third among young, black/brown women. Those developing diabetes will suffer a decrease in life expectancy and will generate a considerable cost in terms of medical care.
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http://dx.doi.org/10.7189/jgh.11.04041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8284547PMC
August 2021

Social Distancing, Mask Use, and Transmission of Severe Acute Respiratory Syndrome Coronavirus 2, Brazil, April-June 2020.

Emerg Infect Dis 2021 Aug 4;27(8):2135-2143. Epub 2021 Jun 4.

We assessed the associations of social distancing and mask use with symptomatic, laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection in Porto Alegre, Brazil. We conducted a population-based case-control study during April-June 2020. Municipal authorities furnished case-patients, and controls were taken from representative household surveys. In adjusted logistic regression analyses of 271 case-patients and 1,396 controls, those reporting moderate to greatest adherence to social distancing had 59% (odds ratio [OR] 0.41, 95% CI 0.24-0.70) to 75% (OR 0.25, 95% CI 0.15-0.42) lower odds of infection. Lesser out-of-household exposure (vs. going out every day all day) reduced odds from 52% (OR 0.48, 95% CI 0.29-0.77) to 75% (OR 0.25, 95% CI 0.18-0.36). Mask use reduced odds of infection by 87% (OR 0.13, 95% CI 0.04-0.36). In conclusion, social distancing and mask use while outside the house provided major protection against symptomatic infection.
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http://dx.doi.org/10.3201/eid2708.204757DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8314805PMC
August 2021

Heterogeneity of Associations between Total and Types of Fish Intake and the Incidence of Type 2 Diabetes: Federated Meta-Analysis of 28 Prospective Studies Including 956,122 Participants.

Nutrients 2021 Apr 7;13(4). Epub 2021 Apr 7.

Postgraduate Program in Epidemiology Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre 90040-060, Brazil.

The association between fish consumption and new-onset type 2 diabetes is inconsistent and differs according to geographical location. We examined the association between the total and types of fish consumption and type 2 diabetes using individual participant data from 28 prospective cohort studies from the Americas (6), Europe (15), the Western Pacific (6), and the Eastern Mediterranean (1) comprising 956,122 participants and 48,084 cases of incident type 2 diabetes. Incidence rate ratios (IRRs) for associations of total fish, shellfish, fatty, lean, fried, freshwater, and saltwater fish intake and type 2 diabetes were derived for each study, adjusting for a consistent set of confounders and combined across studies using random-effects meta-analysis. We stratified all analyses by sex due to observed interaction ( = 0.002) on the association between fish and type 2 diabetes. In women, for each 100 g/week higher intake the IRRs (95% CIs) of type 2 diabetes were 1.02 (1.01-1.03, = 61%) for total fish, 1.04 (1.01-1.07, = 46%) for fatty fish, and 1.02 (1.00-1.04, = 33%) for lean fish. In men, all associations were null. In women, we observed variation by geographical location: IRRs for total fish were 1.03 (1.02-1.04, = 0%) in the Americas and null in other regions. In conclusion, we found evidence of a neutral association between total fish intake and type 2 diabetes in men, but there was a modest positive association among women with heterogeneity across studies, which was partly explained by geographical location and types of fish intake. Future research should investigate the role of cooking methods, accompanying foods and environmental pollutants, but meanwhile, existing dietary regional, national, or international guidelines should continue to guide fish consumption within overall healthy dietary patterns.
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http://dx.doi.org/10.3390/nu13041223DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8068031PMC
April 2021

Incidence of excess body weight and annual weight gain in women and men: Results from the ELSA-Brasil cohort.

Am J Hum Biol 2021 Apr 28:e23606. Epub 2021 Apr 28.

Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Brazil.

Objective: To estimate annual weight gain and the incidence of overweight and obesity, stratified according to gender and socioeconomic factors.

Methods: From the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), we included 13 625 women and men aged 35-74 (2008-2010) who attended a follow-up visit after a mean 3.8-years. Standardized questionnaires were used to record sociodemographic data, and height and weight were measured on all participants during in-person visits at research centers. The incidence rate to overweight was calculated among those not having excess weight at baseline, and incident obesity among those not having this condition at baseline. We evaluated the incidence of overweight and obesity in men and women, adjusted by age, through Poisson regression with robust variance. Large annual weight gain by gender was being defined as ≥90th percentile in the cohort.

Results: A global incidence of 7.7% for overweight and 10.6% for obesity was observed, with higher levels seen among black woman (28.5%), young men (21.1%) and woman with low educational level (35.0%). The proportions of overweight and obesity increased with age at both time points, more commonly among those with the lowest levels of per capita income and fewer years of schooling. Large annual weight gain was greater among participants with an intermediate level of education and those who self-identified as black.

Conclusions: A high overall risk of becoming overweight/obese was found, especially among women. The roles of race and education level are fundamental to understanding the effects produced by social inequalities in rates of excess weight.
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http://dx.doi.org/10.1002/ajhb.23606DOI Listing
April 2021

Incidence of thyroid diseases: Results from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

Arch Endocrinol Metab 2021 Apr 12. Epub 2021 Apr 12.

Centro de Pesquisa Clínica e Epidemiológica, Universidade de São Paulo, São Paulo, SP, Brasil.

Objective: To evaluate incidence of subclinical and overt hyperthyroidism and hypothyroidism.

Methods: The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) is a prospective cohort study of 15,105 civil servants, examined at baseline and over a 4-year follow-up. This analysis included 9,705 participants with normal thyroid function at baseline, follow-up information about thyroid function and with no report of using drugs that may interfere in the thyroid function. Thyroid function was defined by TSH/FT4 levels or routine use of thyroid hormones/anti-thyroid medications. Annual and cumulative (over 4-year) incidence rates were presented as percentages (95% Confidence Intervals).

Results: The incidence of all overt and subclinical thyroid disease was 6.7% (1.73%/year): 0.19% for overt hyperthyroidism (0.048%/year), 0.54% for subclinical hyperthyroidism (0.14%/year), 1.98% for overt hypothyroidism (0.51%/year), and 3.99% for subclinical hypothyroidism (1.03%/year). The incidence of all thyroid diseases was higher in women, when compared to men, with a low women:men ratio (1.36). For Blacks the highest incidence was for overt hyperthyroidism, while for Whites, the highest incidence was for overt hypothyroidism. However, the highest incidence of overt hyperthyroidism was detected in Asian descendants. The presence of antithyroperoxidase antibodies at baseline was associated with higher incidence of overt thyroid diseases.

Conclusion: These results showed a high incidence of hypothyroidism, which is compatible with a country with a more-than-adequate iodine intake. The low women:men ratio of the incidence of thyroid dysfunction highlights the importance of the diagnosis of thyroid diseases among men in Brazil.
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http://dx.doi.org/10.20945/2359-3997000000348DOI Listing
April 2021

Association between control of diabetes mellitus and polypharmacy at the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

Pharmacoepidemiol Drug Saf 2021 06 3;30(6):749-757. Epub 2021 Apr 3.

Brazilian Longitudinal Study of Adult Health, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.

Purpose: To determine whether desirable diabetes control is associated with polypharmacy and to evaluate potential drug interactions (DI) in participants with diabetes mellitus in the Brazilian Longitudinal Study on Adult Health (ELSA-Brasil).

Methods: This cross-sectional study included 1418 participants with medical diagnosis of diabetes at study baseline (2008-2010). Polypharmacy was defined as the use of ≥5 drugs. We described the frequency of the most common pharmacological groups used by patients and the potential DI.The association between desirable diabetes control (normal A1c, blood pressure and lipid levels) and polypharmacy was investigated using logistic regression.

Results: Most participants were men (52.5%), mean age 57.6 (SD 8.4) years, educated to the university level (39.4%), and self-reported as white (42.9%). In this study, 7.1% (n = 101) of participants had desirable control of diabetes, while 40.4% (n = 573) used polypharmacy, and this use was not significantly associated with better diabetes control (adjusted odds ratio (OR = 1.35 [95%CI 0.86-2.13] P = .19).The pharmacological groups most frequently used were oral antidiabetics followed by acetylsalicylic acid, angiotensin-converting enzyme inhibitors (ACE inhibitors) and statins.The prevalence of potentially mild, moderate and severe DI were, respectively, 2.5%, 14.7% and 0.9%; however, in the desirable control of DM group, these potential DI were related to comorbidity control.

Conclusion: Faced with the importance of achieving optimal control of diabetes and minimizing risks of potential DI, these results, which are in keeping with previous findings described in the literature, might indicate that guidelines for the patient-centered management of control of diabetes must be revised.
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http://dx.doi.org/10.1002/pds.5236DOI Listing
June 2021

Associations of Total Legume, Pulse, and Soy Consumption with Incident Type 2 Diabetes: Federated Meta-Analysis of 27 Studies from Diverse World Regions.

J Nutr 2021 05;151(5):1231-1240

School of Public Health, Physiotherapy & Sports Science, University College Dublin, Dublin, Ireland.

Background: The consumption of legumes is promoted as part of a healthy diet in many countries but associations of total and types of legume consumption with type 2 diabetes (T2D) are not well established. Analyses across diverse populations are lacking despite the availability of unpublished legume consumption data in prospective cohort studies.

Objective: To examine the prospective associations of total and types of legume intake with the risk of incident T2D.

Methods: Meta-analyses of associations between total legume, pulse, and soy consumption and T2D were conducted using a federated approach without physical data-pooling. Prospective cohorts were included if legume exposure and T2D outcome data were available and the cohort investigators agreed to participate. We estimated incidence rate ratios (IRRs) and CIs of associations using individual participant data including ≤42,473 incident cases among 807,785 adults without diabetes in 27 cohorts across the Americas, Eastern Mediterranean, Europe, and Western Pacific. Random-effects meta-analysis was used to combine effect estimates and estimate heterogeneity.

Results: Median total legume intake ranged from 0-140 g/d across cohorts. We observed a weak positive association between total legume consumption and T2D (IRR = 1.02, 95% CI: 1.01 to 1.04) per 20 g/d higher intake, with moderately high heterogeneity (I2 = 74%). Analysis by region showed no evidence of associations in the Americas, Eastern Mediterranean, and Western Pacific. The positive association in Europe (IRR = 1.05, 95% CI: 1.01 to 1.10, I2 = 82%) was mainly driven by studies from Germany, UK, and Sweden. No evidence of associations was observed for the consumption of pulses or soy.

Conclusions: These findings suggest no evidence of an association of legume intakes with T2D in several world regions. The positive association observed in some European studies warrants further investigation relating to overall dietary contexts in which legumes are consumed, including accompanying foods which may be positively associated with T2D.
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http://dx.doi.org/10.1093/jn/nxaa447DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8112771PMC
May 2021

The COVID-19 Pandemic in Brazil: Institute for Health Metrics and Evaluation projections and observed evolution, May-August, 2020.

Epidemiol Serv Saude 2021 5;30(1):e2020680. Epub 2021 Feb 5.

Universidade Federal do Rio Grande do Sul, Programa de Pós-Graduação em Epidemiologia, Porto Alegre, RS, Brasil.

Objective: To describe the Institute for Health Metrics and Evaluation (IHME) projections for the COVID-19 pandemic in Brazil and the Brazilian states, present their accuracy and discuss their implications.

Methods: The IHME projections from May to August 2020 for Brazil and selected states were compared with the ensuing reported number of cumulative deaths.

Results: The pandemic was projected to cause 182,809 deaths by December 1, 2020 in Brazil. An increase in mask use could reduce the projected death toll by ~17,000. The mean error in the cumulative number of deaths at 2, 4 and 6 weeks after the projections were made was 13%, 18% and 22%, respectively.

Conclusion: Short and medium-term projections provide important and sufficiently accurate data to inform health managers, elected officials, and society at large. After following an arduous course up until August, the pandemic is projected to decline steadily although slowly, with ~400 deaths/day still occurring in early December.
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http://dx.doi.org/10.1590/S1679-49742021000100017DOI Listing
February 2021

Regression to the Mean Contributes to the Apparent Improvement in Glycemia 3.8 Years After Screening: The ELSA-Brasil Study.

Diabetes Care 2021 01 10;44(1):81-88. Epub 2020 Nov 10.

Postgraduate Program in Epidemiology, School of Medicine and Hospital de Clínicas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.

Objective: Glycemic regression is common in real-world settings, but the contribution of regression to the mean (RTM) has been little investigated. We aimed to estimate glycemic regression before and after adjusting for RTM in a free-living cohort of adults with newly ascertained diabetes and intermediate hyperglycemia (IH).

Research Design And Methods: The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) is a cohort study of 15,105 adults screened between 2008 and 2010 with standardized oral glucose tolerance test and HbA, repeated after 3.84 ± 0.42 years. After excluding those receiving medical treatment for diabetes, we calculated partial or complete regression before and after adjusting baseline values for RTM.

Results: Regarding newly ascertained diabetes, partial or complete regression was seen in 49.4% (95% CI 45.2-53.7); after adjustment for RTM, in 20.2% (95% CI 12.1-28.3). Regarding IH, regression to normal levels was seen in 39.5% (95% CI 37.9-41.3) or in 23.7% (95% CI 22.6-24.3), depending on use of the World Health Organization (WHO) or the American Diabetes Association (ADA) definition, respectively; after adjustment, corresponding frequencies were 26.1% (95% CI 22.4-28.1) and 19.4% (95% CI 18.4-20.5). Adjustment for RTM reduced the number of cases detected at screening: 526 to 94 cases of diabetes, 3,118 to 1,986 cases of WHO-defined IH, and 6,182 to 5,711 cases of ADA-defined IH. Weight loss ≥2.6% was associated with greater regression from diabetes (relative risk 1.52, 95% CI 1.26-1.84) and IH (relative risk 1.30, 95% CI 1.17-1.45).

Conclusions: In this quasi-real-world setting, regression from diabetes at ∼4 years was common, less so for IH. Regression was frequently explained by RTM but, in part, also related to improved weight loss and homeostasis over the follow-up.
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http://dx.doi.org/10.2337/dc20-2030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783938PMC
January 2021

Increased particle size of triacylglycerol-enriched remnant lipoproteins, but not their plasma concentration or lipid content, augments risk prediction of incident type 2 diabetes.

Diabetologia 2021 02 7;64(2):385-396. Epub 2020 Nov 7.

Cardiology Division, Faculty of Medical Sciences, State University of Campinas (Unicamp), Campinas, SP, Brazil.

Aims/hypothesis: Type 2 diabetes prevention requires the accurate identification of those at high risk. Beyond the association of fasting serum triacylglycerols with diabetes, triacylglycerol-enriched remnant lipoproteins (TRLs) more accurately reflect pathophysiological changes that underlie progression to diabetes, such as hepatic insulin resistance, pancreatic steatosis and systemic inflammation. We hypothesised that TRL-related factors could improve risk prediction for incident diabetes.

Methods: We included individuals from the Brazilian Longitudinal Study of Adult Health cohort. We trained a logistic regression model for the risk of incident diabetes in 80% of the cohort using tenfold cross-validation, and tested the model in the remaining 20% of the cohort (test set). Variables included medical history and traits of the metabolic syndrome, followed by TRL-related measurements (plasma concentration, TRL particle diameter, cholesterol and triacylglycerol content). TRL features were measured using NMR spectroscopy. Discrimination was assessed using the area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC).

Results: Among 4463 at-risk individuals, there were 366 new cases of diabetes after a mean (±SD) of 3.7 (±0.63) years of follow-up. We derived an 18-variable model with a global AUROC of 0.846 (95% CI: 0.829, 0.869). Overall TRL-related markers were not associated with diabetes. However, TRL particle diameter increased the AUROC, particularly in individuals with HbA <39 mmol/mol (5.7%) (hold-out test set [n = 659]; training-validation set [n = 2638]), but not in individuals with baseline HbA 39-46 mmol/mol (5.7-6.4%) (hold-out test set [n = 233]; training-validation set [n = 933]). In the subgroup with baseline HbA <39 mmol/mol (5.7%), AUROC in the test set increased from 0.717 (95% CI 0.603, 0.818) to 0.794 (95% CI 0.731, 0.862), and AUPRC in the test set rose from 0.582 to 0.701 when using the baseline model and the baseline model plus TRL particle diameter, respectively. TRL particle diameter was highly correlated with obesity, insulin resistance and inflammation in those with impaired fasting glucose at baseline, but less so in those with HbA <39 mmol/mol (5.7%).

Conclusions/interpretation: TRL particle diameter improves the prediction of diabetes, but only in individuals with HbA <39 mmol/mol (5.7%) at baseline. These data support TRL particle diameter as a risk factor that is changed early in the course of the pathophysiological processes that lead to the development of type 2 diabetes, even before glucose abnormalities are established. Graphical abstract.
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http://dx.doi.org/10.1007/s00125-020-05322-1DOI Listing
February 2021

Markers of adiposity, insulin resistance, prediabetes and cognitive function at baseline of the Brazilian Longitudinal Study of Adult Health (ELSA - Brasil).

Diabetes Res Clin Pract 2020 Dec 15;170:108499. Epub 2020 Oct 15.

Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil. Electronic address:

Aim: The aim of the study is to investigate whether adiposity markers, insulin resistance and prediabetes are associated with cognitive performance in middle-aged men and women without diabetes.

Methods: Cross-sectional study with 11,115 adults without diabetes (34-64 years old). Cognitive performance was tested by word-list learning, word-list delayed recall, word recognition tests, semantic and phonemic verbal fluency tests and trail making test B. Linear regression models and generalized linear regression with logarithmic links between the cognitive tests and anthropometric indicators (body mass index [BMI]), insulin resistance (Homeostasis Model Assessment for Insulin Resistance [HOMA-IR]), and prediabetes (impaired glucose tolerance) were stratified by sex. The results were adjusted for age, education, comorbidities, health-related behaviors, waist circumference, and lipids.

Results: Among women, higher BMI was associated with poorer performance on phonemic verbal fluency test (β-0.02 [-0.04; -0.01]) and memory tests (β-0.05 [-0.07; -0.02]). Higher HOMA-IR was associated with poorer cognitive performance in memory (β-0.11 [-0.19; -0.01]) and phonemic verbal fluency tests (β-0.12 [-0.20; -0.04]). In men, HOMA-IR (β-0.15 [-0.25; -0.04]) and prediabetes (β-0.35 [-0.69; -0.03]) were associated with poorer performance on memory tests.

Conclusions: We found a significant association of BMI and HOMA-IR with cognitive performance in young and middle-aged adult women without diabetes. In men, we found an association between HOMA-IR and prediabetes and poorer performance on memory tests.
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http://dx.doi.org/10.1016/j.diabres.2020.108499DOI Listing
December 2020

Aryl-hydrocarbon receptor binding and the incidence of type 2 diabetes: the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

Environ Health 2020 10 12;19(1):105. Epub 2020 Oct 12.

Department of Neuroscience, Medical Research Center for Bioreaction to Reactive Oxygen Species and Biomedical Science Institute, School of Medicine, Graduate School, Kyung Hee University, Seoul, South Korea.

Background: Persistent organic pollutants (POPs) may cause diabetes, in part through aryl hydrocarbon receptor (AhR) binding. Ensuing mitochondrial dysfunction is postulated to mediate this effect. We aim to investigate the association of POPs with incident diabetes indirectly by bio-assaying AhR ligand bioactivity and intracellular ATP level induced by participant serum samples.

Methods: In incident case-cohort analyses of one ELSA-Brasil center, 1605 eligible subjects without diabetes at baseline had incident diabetes ascertained by self-report, medication use, OGTT or HbA1c at follow-up 4 years later. We assayed AhR ligand bioactivity (AhRL) and intracellular ATP content, the latter reflecting the presence of mitochondria-inhibiting substances (MIS), following incubation of recombinant mouse Hepa1c1c7 cells with participant sera for 71 incident diabetes cases and 472 randomly selected controls.

Results: In multiply-adjusted proportional hazards regression analyses, those with above-median AhRL and below-median MIS-ATP had 69 and 226% greater risk of developing diabetes (HR = 1.69; 95%CI 1.01-2.83 and 3.26; 1.84-5.78), respectively. A strong interaction was seen between the two exposures (HR = 8.15; 2.86-23.2).

Conclusion: The markedly increased incidence of diabetes seen in those with both higher AhR ligand bioactivity and increased mitochondrial inhibition supports the hypothesis that widespread POPs exposure contributes to the diabetes epidemic.
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http://dx.doi.org/10.1186/s12940-020-00658-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7549209PMC
October 2020

Changes in the quality of cause-of-death statistics in Brazil: garbage codes among registered deaths in 1996-2016.

Popul Health Metr 2020 09 30;18(Suppl 1):20. Epub 2020 Sep 30.

Institute for Health Metrics and Evaluation, 2301 5th Avenue, Suite 600 Box 358210, Seattle, WA, 98121, USA.

Background: Registered causes in vital statistics classified as garbage codes (GC) are considered indicators of quality of cause-of-death data. Our aim was to describe temporal changes in this quality in Brazil, and the leading GCs according to levels assembled for the Global Burden of Disease (GBD) study. We also assessed socioeconomic differences in the burden of different levels of GCs at a regional level.

Methods: We extracted data from the Brazilian Mortality Information System from 1996 to 2016. All three- and four-digit ICD-10 codes considered GC were selected and classified into four categories, according to the GBD study proposal. GC levels 1 and 2 are the most damaging unusable codes, or major GCs. Proportionate distribution of deaths by GC levels according selected variables were performed. Age-standardized mortality rates after correction of underreporting of deaths were calculated to investigate temporal relationships as was the linear association adjusted for completeness between GC rates in states and the Sociodemographic Index (SDI) from the GBD study, for 1996-2005 and 2006-2016. We classified Brazilian states into three classes of development by applying tertiles cutoffs in the SDI state-level estimates.

Results: Age-standardized mortality rates due to GCs in Brazil decreased from 1996 to 2016, particularly level 1 GCs. The most important GC groups were ill-defined causes (level 1) in 1996, and pneumonia unspecified (level 4) in 2016. At state level, there was a significant inverse association between SDI and the rate of level 1-2 GCs in 1996-2005, but both SDI and completeness had a non-expected significant direct association with levels 3-4. In 2006-2016, states with higher SDIs tended to have lower rates of all types of GCs. Mortality rates due to major GCs decreased in all three SDI classes in 1996-2016, but GC levels 3-4 decreased only in the high SDI category. States classified in the low or medium SDI groups were responsible for the most important decline of major GCs.

Conclusion: Occurrence of major GCs are associated with socioeconomic determinants over time in Brazil. Their reduction with decreasing disparity in rates between socioeconomic groups indicates progress in reducing inequalities and strengthening cause-of-death statistics in the country.
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http://dx.doi.org/10.1186/s12963-020-00221-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526091PMC
September 2020

The burden of low back pain in Brazil: estimates from the Global Burden of Disease 2017 Study.

Popul Health Metr 2020 09 30;18(Suppl 1):12. Epub 2020 Sep 30.

Postgraduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600 Sala 414, Bairro Santa Cecilia, Porto Alegre, 90035-003, Brazil.

Background: The prevalence and burden of musculoskeletal (MSK) conditions are growing around the world, and low back pain (LBP) is the most significant of the five defined MSK disorders in the Global Burden of Disease (GBD) study. LBP has been the leading cause of non-fatal health loss for the last three decades. The objective of this study is to describe the current status and trends of the burden due to LBP in Brazil based on information drawn from the GBD 2017 study.

Methods: We estimated prevalence and years lived with disability (YLDs) for LBP by Brazilian federative units, sex, age group, and age-standardized between 1990 and 2017 and conducted a decomposition analysis of changes in age- and sex-specific YLD rates attributable to total population growth and population ageing for the purpose of understanding the drivers of changes in LBP YLDs rates in Brazil. Furthermore, we analyzed the changes in disability-adjusted life years (DALYs) rankings for this disease over the period.

Results: The results show high prevalence and burden of LBP in Brazil. LBP prevalence increased 26.83% (95% UI 23.08 to 30.41) from 1990 to 2017. This MSK condition represents the most important cause of YLDs in Brazil, where the increase in burden is mainly related to increase in population size and ageing. The LBP age-standardized YLDs rate are similar among Brazilian federative units. LBP ranks in the top three causes of DALYs in Brazil, even though it does not contribute to mortality.

Conclusions: Findings from this study show LBP to be the most important cause of YLDs and the 3rd leading cause of DALYs in Brazil. The Brazilian population is ageing, and the country has been experiencing a rapid epidemiological transition, which generates an increasing number of people who need chronic care. In this scenario, more attention should be paid to the burden of non-fatal health conditions.
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http://dx.doi.org/10.1186/s12963-020-00205-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526352PMC
September 2020

Homeostasis model assessment of insulin resistance (HOMA-IR) and metabolic syndrome at baseline of a multicentric Brazilian cohort: ELSA-Brasil study.

Cad Saude Publica 2020 09 2;36(8):e00072120. Epub 2020 Sep 2.

Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brasil.

Homeostasis model assessment of insulin resistance (HOMA-IR) is a method to measure insulin resistance. HOMA-IR cut-offs for identifying metabolic syndrome might vary across populations and body mass index (BMI) levels. We aimed to investigate HOMA-insulin resistance cut-offs that best discriminate individuals with insulin resistance and with metabolic syndrome for each BMI category in a large sample of adults without diabetes in the baseline of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Among the 12,313 participants with mean age of 51.2 (SD 8.9) years, the prevalence of metabolic syndrome was 34.6%, and 60.1% had overweight or obesity. The prevalence of metabolic syndrome among normal weight, overweight and obesity categories were, respectively, 13%, 43.2% and 60.7%. The point of maximum combined sensitivity and specificity of HOMA-IR to discriminate the metabolic syndrome was 2.35 in the whole sample, with increasing values at higher BMI categories. This investigation contributes to better understanding HOMA-IR values associated with insulin resistance and metabolic syndrome in a large Brazilian adult sample, and that use of cut-off points according to ROC curve may be the better strategy. It also suggests that different values might be appropriate across BMI categories.
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http://dx.doi.org/10.1590/0102-311X00072120DOI Listing
September 2020

Predictors of coronary artery calcium incidence and progression: The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

Atherosclerosis 2020 09 29;309:8-15. Epub 2020 Jul 29.

Center for Clinical and Epidemiological Research, University Hospital, University of Sao Paulo, Sao Paulo, Brazil. Electronic address:

Background And Aims: There are limited data on serial coronary artery calcium (CAC) assessments outside North American and European populations. We sought to investigate risk factors for CAC incidence and progression in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

Methods: We included individuals with no prior cardiovascular disease and two CAC measurements in ELSA-Brasil. Incident CAC was defined as a baseline CAC of 0 followed by CAC >0 on the second study. CAC progression was defined according to multiple published criteria. We performed logistic and linear regression to identify risk factors for CAC incidence and progression. We also examined risk factor effect modification by baseline CAC (0 vs. >0).

Results: A total of 2707 individuals were included (57% women, age 48.6 ± 7.7 years). Participants self-identified as white (55%), brown (24%), black (16%), Asian (4%) and Indigenous (1%). The mean period between CAC assessments was 5.1 ± 0.9 years. CAC incidence occurred in 282 (13.3%) of 2127 individuals with baseline CAC of 0. CAC progression occurred in 319 (55%) of 580 participants with baseline CAC >0. Risk factors for CAC incidence included older age, male sex, white race, hypertension, diabetes, higher BMI, smoking, lower HDL-C, higher LDL-C and triglycerides, and metabolic syndrome. Older age and elevated LDL-C were associated with CAC incidence, but not progression. Risk factors consistently associated with CAC progression were hypertension, diabetes, hypertriglyceridemia, and metabolic syndrome. On interaction testing, these four risk factors were more strongly associated with CAC progression as compared to CAC incidence.

Conclusions: CAC incidence was associated with multiple traditional risk factors, whereas the only risk factors associated with progression of CAC were hypertension, diabetes, hypertriglyceridemia, and metabolic syndrome.
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http://dx.doi.org/10.1016/j.atherosclerosis.2020.07.003DOI Listing
September 2020

Sleep problems and their association with weight and waist gain - The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

Sleep Med 2020 09 21;73:196-201. Epub 2020 Jun 21.

Postgraduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul, Brazil.

Objective: To evaluate the association of sleep problems with weight and waist size gain during four years of follow-up.

Methods: We investigated 13,030 participants (35-74 years) of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), a multicentric cohort conducted with civil servants from six academic institutions recruited between 2008 and 2010. Sleep problems were assessed at baseline by the Clinical Interview Schedule - Revised (CIS-R), designed to detect common mental disorders based on somatic, depressive and anxiety symptoms. Weight and waist size were measured at baseline and at follow-up (2012-2014). Large weight and waist size gain were defined as ≥ 90th percentile (≥1.65 kg/year and ≥2.41 cm/year, respectively).

Results: Sleep problems were associated with higher risk of a large weight gain (RR = 1.11; 95% CI 1.01-1.24) and large waist size gain (RR = 1.19; 95% CI 1.07-1.32), adjusted for age, sex, ethnicity, income, educational level, investigation center, smoking, alcohol intake, dietary energy intake, leisure-time physical activity and body mass index (BMI) or waist circumference at baseline. After additional adjustment for common mental disorders the associations became non-significant (RR = 0.99; 95% CI 0.88-1.12; RR = 1.08; 95% CI 0.97-1.22, respectively).

Conclusion: Sleep problems are associated with increased risk of developing large weight and waist size gain, but are not independently associated with common mental disorders.
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http://dx.doi.org/10.1016/j.sleep.2020.06.017DOI Listing
September 2020

Diabetes and subclinical hypothyroidism on heart rate variability.

Eur J Clin Invest 2020 Dec 31;50(12):e13349. Epub 2020 Jul 31.

Center for Clinical and Epidemiological Research of University Hospital, University of Sao Paulo, Sao Paulo, Brazil.

Background: We aimed to analyse if the effects of coexistent diabetes and subclinical hypothyroidism extend to the cardio autonomic nervous system, using heart rate variability baseline data from the Brazilian Longitudinal Study of Adult Health.

Materials And Methods: Heart rate variability analyses were performed by linear time and frequency domains in 5-minute time series collected in the supine position. The associations of diabetes and subclinical hypothyroidism with the lowest quartile group for heart rate and the highest quartile group for each heart rate variability parameter were analysed using additive and multiplicative terms in logistic models. For the first approach, the subsample was categorized into four groups: subjects without diabetes and normal thyroid function (controls); subjects without diabetes and subclinical hypothyroidism; patients with diabetes and normal thyroid function; and patients with diabetes and subclinical hypothyroidism. For the interaction alnalysis, diabetes and subclinical hypothyroidism diagnoses were included in separate, along with a multiplicative interaction term between them.

Results: Point odds ratio estimates for the 4th quartiles of heart rate, and 1st quartiles of all heart rate variability measurements were higher for subjects with combined diabetes and subclinical hypothyroidism than for diabetes only, independently of main sociodemographic and clinical variables (HR: 8.33 vs 2.63; SDNN: 2.59 vs 1.61; RMSSD: 2.37 vs 1.42; LF: 2.83 vs 1.71; HF: 3.06 vs 1.39), but not independently of HbA1c and TSH. Only the interaction term for the association with heart rate, adjusted for sociodemographic and clinical variables, had borderline statistical significance.

Conclusion: Diabetes and subclinical hypothyroidism exert a potential joint impact on cardiac autonomic control, showed by additive effects between diabetes and subclinical hypothyroidism, as well as a significant interaction term for the association with heart rate.
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http://dx.doi.org/10.1111/eci.13349DOI Listing
December 2020

Clinical practice guidelines in Brazil - developing a national programme.

Health Res Policy Syst 2020 Jun 17;18(1):69. Epub 2020 Jun 17.

Department of Health Research Methods, Evidence and Impact and of Medicine, McMaster GRADE Centre, McMaster University Health Sciences Centre, Hamilton, Canada.

In Brazil, governmental and non-governmental organisations develop practice guidelines (PGs) in order to optimise patient care. Although important improvements have been made over the past years, many of these documents still lack transparency and methodological rigour. In order to conduct a critical analysis and define future steps in PG development in Brazil, we carried out a structured assessment of strengths, weaknesses, opportunities and threats (SWOT analysis) for the development of a national guideline programme. Participants consisted of academia, methodologists, medical societies and healthcare system representatives. In summary, the PG development process has improved in Brazil and current investments in methodological research and capacity-building are ongoing. Despite the centralised processes for public PGs, standardised procedures for their development are not well established and human resources are insufficient in number and capacity to develop the amount of trustworthy documents needed. Brazil's capacity could be strengthened and initial efforts have been made such as the adoption of standards proposed by world-renowned institutions in PG development and enhancement of the involvement of key stakeholders. Further steps involve the alignment between health technology assessment and PG processes for synergy and the development of a national network to promote the interaction between groups involved in the development of PGs. The lessons learned from this paper could be used to foster debate on guideline development, especially for countries facing similar threats on this topic.
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http://dx.doi.org/10.1186/s12961-020-00582-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7302389PMC
June 2020

A nationwide analysis of the excess death attributable to diabetes in Brazil.

J Glob Health 2020 Jun;10(1):010401

Postgraduate Program in Epidemiology, School of Medicine and Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.

Background: Data on mortality burden and excess deaths attributable to diabetes are sparse and frequently unreliable, particularly in low and middle-income countries. Estimates in Brazil to date have relied on death certificate data, which do not consider the multicausal nature of deaths. Our aim was to combine cohort data with national prevalence and mortality statistics to estimate the absolute number of deaths that could have been prevented if the mortality rates of people with diabetes were the same as for those without. In addition, we aimed to estimate the increase in burden when considering undiagnosed diabetes.

Methods: We estimated self-reported diabetes prevalence from the National Health Survey (PNS) and overall mortality from the national mortality information system (SIM). We estimated the diabetes mortality rate ratio (rates of those with vs without diabetes) from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), an ongoing cohort study. Joining estimates from these three sources, we calculated for the population the absolute number and the fraction of deaths attributable to diabetes. We repeated our analyses considering both self-reported and unknown diabetes, the latter estimated based on single point-in-time glycemic determinations in ELSA-Brasil. Finally, we compared results with diabetes-related mortality information from death certificates.

Results: In 2013, 65 581 deaths, 9.1% of all deaths between the ages of 35-80, were attributable to known diabetes. If cases of unknown diabetes were considered, this figure would rise to 14.3%. In contrast, based on death certificates only, 5.3% of all death had diabetes as the underlying cause and 10.4% as any mentioned cause.

Conclusions: In this first report of diabetes mortality burden in Brazil using cohort data to estimate diabetes mortality rate ratios and the prevalence of unknown diabetes, we showed marked underestimation of the current burden, especially when unknown cases of diabetes are also considered.
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http://dx.doi.org/10.7189/jogh.10.010401DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7101024PMC
June 2020

Association between diabetes and cognitive function at baseline in the Brazilian Longitudinal Study of Adult Health (ELSA- Brasil).

Sci Rep 2020 01 31;10(1):1596. Epub 2020 Jan 31.

Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.

Diabetes has been associated with cognitive changes and an increased risk of vascular dementia and Alzheimer's disease, but it is unclear whether there are associations between diabetes and early alterations in cognitive performance. The present study consisted of a cross-section analysis of 14,444 participants aged 35-74 years and from a developing country at baseline in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil); these participants were recruited between 2008 and 2010. We investigated whether there was an association between diabetes and early changes in the cognitive performance of this Brazilian population. To assess cognitive domains, we used the word-list learning, word-list delayed recall and word recognition tests along. Phonemic verbal fluency tests included semantic phonemic test (animals) and a phonemic test (words beginning with the letter F). Executive functions associated with attention, concentration and psychomotor speed were evaluated using the Trail Making Test B. The exposure variable in the study was defined as diabetes. Multiple linear regression was used to estimate the association between diabetes and cognitive performance. The results were adjusted for age, sex, education, hypertension, coronary disease, depression, physical activity, smoking, alcohol consumption, and the cholesterol/HDL-C ratio. We found a significant association between diabetes and decreased memory, language and executive function (attention, concentration and psychomotor speed) performance in this population from a country with a distinct epidemiological profile, even after adjusting for the main intervening variables.
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http://dx.doi.org/10.1038/s41598-020-58332-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6994611PMC
January 2020

Four-year adiposity change and remission of hypertension: an observational evaluation from the Longitudinal Study of Adult Health (ELSA-Brasil).

J Hum Hypertens 2020 01 18;34(1):68-75. Epub 2019 Nov 18.

Department of Epidemiology and Quantitative Methods, National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil.

The degree to which weight reduction leads to the remission of hypertension in population studies is not clear. We investigated whether the changes in adiposity measures predicted the remission of hypertension in a racially admixed population over a mean 4-year follow-up. All 4847 hypertensive individuals at baseline (2008-2010) from the multicenter Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) were included. Changes in weight, waist circumference (WC), or body mass index (BMI) (reduction or increase ≥5% from baseline values, vs stability) and remission of hypertension (SBP < 140 and DBP < 90 mmHg and no use of antihypertensive medication at follow-up visit, in 2012-2014) were investigated using mixed effects logistic regression models. Proportional attributable benefit was additionally calculated. Analyses were stratified by sex and antihypertensive medication use at baseline. Remission of hypertension was 11.3% (n = 546). Among men, after adjustments, the reduction of weight (OR = 1.52 95% CI 1.10-2.10), WC (OR = 1.56 95% CI 1.04-2.35) or BMI (OR = 1.60 95% CI 1.13-2.27) was associated with the remission of hypertension. Among those not taking antihypertensive medication at baseline, after adjustments, the reduction of weight (OR = 1.64 95% CI 1.18-2.27), WC (OR = 1.76 95% CI 1.18-2.61) or BMI (OR = 1.57 95% CI 1.10-2.25) was associated with the remission of hypertension. Proportional attributable benefit among those with adiposity reduction was about 30%, indicating its potential for prevention. In conclusion, our study reinforces the role of adiposity-reducing strategies (e.g., healthy diet and regular physical activity) for the treatment and prevention of hypertension, which might have potential applications for clinical practice.
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http://dx.doi.org/10.1038/s41371-019-0289-5DOI Listing
January 2020

Impact of improved low-density lipoprotein cholesterol assessment on guideline classification in the modern treatment era-Results from a racially diverse Brazilian cross-sectional study.

J Clin Lipidol 2019 Sep - Oct;13(5):804-811.e2. Epub 2019 Jul 9.

Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. Electronic address:

Background: The Martin/Hopkins low-density lipoprotein cholesterol equation (LDL-C) was previously demonstrated as more accurate than Friedewald LDL-C estimation (LDL-C) in a North American database not able to take race into account.

Objectives: We hypothesized that LDL-C would be more accurate than LDL-C and correlate better with LDL particle number (LDL-P) in a racially diverse Brazilian cohort.

Methods: We performed a cross-sectional analysis of 4897 participants in the Brazilian Longitudinal Study of Adult Health, assessing LDL-C and LDL-C accuracy via overlap with ultracentrifugation-based measurement among clinical guideline LDL-C categories as well as mg/dL and percent error differences. We analyzed by triglyceride categories and correlated LDL-C estimation with LDL-P.

Results: LDL-C demonstrated improved accuracy at 70 to <100 and <70 mg/dL (P < .001), with large errors ≥20 mg/dL about 9 times more frequent in LDL-C at LDL-C <70 mg/dL, mainly due to underestimation. Among individuals with LDL-C <70 mg/dL and triglycerides ≥150 mg/dL, 65% vs 100% of ultracentrifugation-based low-density lipoprotein cholesterol calculation fell within appropriate categories of estimated LDL-C and LDL-C, respectively (P < .001). Similar results were observed when analyzed for age, sex, and race. Participants at LDL-C <70 and 70 to <100 mg/dL with discordantly elevated LDL-C vs LDL-C had a 58.5% and 41.5% higher LDL-P than those with concordance (P < .0001), respectively.

Conclusions: In a diverse Brazilian cohort, LDL-C was more accurate than LDL-C at low LDL-C and high triglycerides. LDL-C may avoid underestimation of LDL-C and better reflect atherogenic lipid burden in low particle size, high particle count states.
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http://dx.doi.org/10.1016/j.jacl.2019.07.002DOI Listing
July 2020

Insulin resistance underlying type 2 diabetes - Authors' reply.

Lancet Diabetes Endocrinol 2019 06;7(6):424-425

Postgraduate Studies Program in Epidemiology, School of Medicine and Hospital de Clínicas, Universidade Federal do Rio Grande do Sul, 90035-003 Porto Alegre, Rio Grande do Sul, Brazil.

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http://dx.doi.org/10.1016/S2213-8587(19)30148-2DOI Listing
June 2019

Context-dependence of race self-classification: Results from a highly mixed and unequal middle-income country.

PLoS One 2019 16;14(5):e0216653. Epub 2019 May 16.

Center for Clinical and Epidemiological Research, University Hospital, University of São Paulo, São Paulo, SP Brazil.

Ethnic-racial classification criteria are widely recognized to vary according to historical, cultural and political contexts. In Brazil, the strong influence of individual socio-economic factors on race/colour self-classification is well known. With the expansion of genomic technologies, the use of genomic ancestry has been suggested as a substitute for classification procedures such as self-declaring race, as if they represented the same concept. We investigated the association between genomic ancestry, the racial composition of census tracts and individual socioeconomic factors and self-declared race/colour in a cohort of 15,105 Brazilians. Results show that the probability of self-declaring as black or brown increases according to the proportion of African ancestry and varies widely among cities. In Porto Alegre, where most of the population is white, with every 10% increase in the proportion of African ancestry, the odds of self-declaring as black increased 14 times (95%CI 6.08-32.81). In Salvador, where most of the population is black or brown, that increase was of 3.98 times (95%CI 2.96-5.35). The racial composition of the area of residence was also associated with the probability of self-declaring as black or brown. Every 10% increase in the proportion of black and brown inhabitants in the residential census tract increased the odds of self-declaring as black by 1.33 times (95%CI 1.24-1.42). Ancestry alone does not explain self-declared race/colour. An emphasis on multiple situational contexts (both individual and collective) provides a more comprehensive framework for the study of the predictors of self-declared race/colour, a highly relevant construct in many different scenarios, such as public policy, sociology and medicine.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0216653PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6522012PMC
January 2020

Decreased heart rate variability as a predictor for diabetes-A prospective study of the Brazilian longitudinal study of adult health.

Diabetes Metab Res Rev 2019 10 10;35(7):e3175. Epub 2019 Jun 10.

Center for Clinical and Epidemiological Research of University Hospital, University of Sao Paulo, Sao Paulo, SP, Brazil.

Aim: To investigate whether heart rate variability (HRV) is a predictor for the incidence of diabetes in a 4-year follow-up.

Materials And Methods: The HRV of 9192 participants free of diabetes was analysed in time and frequency domains and stratified based on the reference values presented in the literature. The participants were then allocated to one of three groups, according to age-specific value distributions for each HRV domain: lower than the 25 percentile, between the 25 and 75 percentiles, and higher than the 75 percentile. The association between HRV and diabetes incidence at 4-year follow-up was analysed using Poisson regression models with robust estimator.

Results: Six hundred thirty-four participants (6.90%) developed diabetes within 4 years and five out of six HRV analysed indices showed increased relative risk of developing diabetes associated with low HRV: SDNN (RR = 1.29; 95% CI, 1.09-1.52; .003), pNN50 (RR = 1.33; 95% CI, 1.11-1.58; .001), RMSSD (RR = 1.29; 95% CI, 1.09-1.53; .004), LF (RR = 1.25; 95% CI, 1.05-1.48; .012), and HF (RR = 1.39; 95% CI, 1.16-1.63; .001).

Conclusions: This study suggests that both overall variability and changes in parasympathetic modulation precede the incidence of diabetes. For four HRV indices below the 25 percentile, the risk for incident diabetes was 68% higher than for those participants who presented none. We concluded that HRV is an independent risk predictor of diabetes in a 4-year period.
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http://dx.doi.org/10.1002/dmrr.3175DOI Listing
October 2019

Physical inactivity as risk factor for mortality by diabetes mellitus in Brazil in 1990, 2006, and 2016.

Diabetol Metab Syndr 2019 28;11:23. Epub 2019 Feb 28.

5Department of Maternal and Child Nursing and Public Health, School of Nursing, Universidade Federal de Minas Gerais, Belo Horizonte, MG Brazil.

Background: The aims of this study were to estimate the mortality due to diabetes mellitus attributed to physical inactivity in Brazil, to analyze these estimate in three points in time (1990, 2006 and, 2016), and to analyze these estimates according to the socioeconomic status of Brazilian states.

Methods: All deaths and diseases recorded in Brazil during this period were analyzed. Surveys of the general adult population using random sampling procedures evaluating self-reported physical activity in all life domains in Brazil were included. The total number and the age-standardized rates of deaths, and population-attributable fraction (PAF) for diabetes mellitus attributed to physical inactivity in the years 1990, 2006, and 2016 were estimated. Socioeconomic Development Index (SDI) was used as an indicator of socioeconomic status of Brazilian states.

Results: In relation to mortality due to diabetes mellitus attributed to physical inactivity, 736 deaths were estimated in 1990, 1337 deaths were estimated in 2006, and 1897 in 2016, which represented, in 1990, an age-standardized mortality rate (per 100,000 inhabitants) of 1.2, 2.1 in 2006, and 1.1 in 2016. Approximately 3.0% (PAF) of deaths due to diabetes mellitus could be avoided if the Brazilian population were physically active. In 2006 and 2016, Brazilian states with worst socioeconomic indicators had higher age-standardized mortality rate by diabetes mellitus due to physical inactivity.

Conclusion: These findings are the first to estimate the burden of diabetes mellitus due to physical inactivity in Brazil and support the promotion of physical activity in the Brazilian population to prevent and manage diabetes mellitus.
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http://dx.doi.org/10.1186/s13098-019-0419-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6396532PMC
February 2019
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