Publications by authors named "Paulo A Lotufo"

278 Publications

Urinary iodine and sodium concentration and thyroid status in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

J Trace Elem Med Biol 2021 Jun 10;68:126805. Epub 2021 Jun 10.

Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil. Electronic address:

Objectives: To evaluate urinary iodine concentration (UIC) in civil servants aged 35-74 years of the Brazilian Study of Adults Health (ELSA-Brasil) to analyze its relationship with sociodemographic, clinical risk factors, lifestyle, urinary Na and thyroid status.

Design: Cross-sectional study in six Brazilian cities.

Methods: This analysis included 792 participants with information about urinary iodine concentration (UIC). Thyroid status was defined by serum levels of TSH/FT4 and the current use of antithyroid drugs for treatment of overt hyperthyroidism or levothyroxine to treat overt hypothyroidism. The determination of UIC was carried out with an inductively coupled plasma mass spectrometer (ICP-MS) and was expressed as median with Interquartile Range (IQR).

Results: In 792 participants, thereof 52% women, mean age was 51.9 (9.0) years. The median UIC was 219 (IQR, 166-291) for all persons studied, thereof 211 (IQR, 157-276) for women and 231 (IQR, 178-304) for men. According to the WHO classification, for all persons studied, 60% had more than adequate iodine-supply (UIC ≥200 μg/L), 37% were adequately supplied (UIC 100-199 μg/L) and <3% had a deficient iodine status (<100 μg/L). In the 35-44-year age strata, which includes women of childbearing age, 23.2% of women presented less than 150 μg/L of UIC. No differences in UIC were detected according to thyroid status. (P = 0.39) The correlation between Ur-Na and UIC showed a Spearman coefficient of 0.52 (P < 0.0001) and it was also found an association of Ur-Na with UIC: Beta of 1.76 (95% Confidence Interval (95% CI): 1.01 to 2.51. The urinary Na concentration showed a synergy with the UIC, that means medians of 57, 72, 107 and 141 mmol Na/L urine (P < 0.001) in the groups with the four UIC classes according to the WHO grading mentioned above. The very low Na content in the persons exhibiting <100 μg/L UIC seems to reflect also a higher urine volume due to the frequent use of diuretics. The strong relationship between the urinary Na concentration and the UIC points to a dependence of the UIC on the individual consumption of iodized salt, which should be more considered in future studies. The strong relationship between the urinary Na concentration and the UIC points to a dependence of the UIC on the individual consumption of iodized salt, which should be more considered in future studies.

Conclusions: Euthyroid persons were dominating by more than four fifths and no significant association was found between UIC and thyroid status. Although most of the persons studied present more than adequate iodine intake it was observed that nearly a quarter of women in childbearing age are iodine deficient.
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http://dx.doi.org/10.1016/j.jtemb.2021.126805DOI Listing
June 2021

Cross-sectional associations of leisure and transport related physical activity with depression and anxiety.

J Psychiatr Res 2021 Jun 4;140:228-234. Epub 2021 Jun 4.

Departmento de Clínica Médica, Faculdade de Medicina da USP & Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil; Laboratory of Neurosciences (LIM-27), Institute of Psychiatry, Hospital das Clínicas da Faculdade de Medicina da USP, Brazil.

Background: Previous evidence supports the notion that the physical activity (PA) domain (leisure-time or transport), and the amount of time spent in PA, influence the association of PA with depressive and anxiety symptoms. However, no study evaluated the associations of different volumes of leisure-time PA (LTPA) and transport PA (TPA) with prevalent depression, anxiety, and co-occurring depression and anxiety (D&A) disorders.

Aim: To investigate the associations between different volumes of LTPA and TPA with prevalent depression, anxiety, and D&A.

Methods: Cross-sectional study using baseline data of the ELSA-Brasil cohort. The International Physical Activity Questionnaire (IPAQ) long-form was used to assess PA levels in each domain. The Clinical Interview Scheduled Revised (CIS-R) was used to diagnose prevalent depressive, anxiety, and D&A disorders. Logistic regressions, adjusting for confounding factors, were employed. Results are expressed as adjusted odds ratios (aOR) and 95% confidence intervals (CI).

Results: A total of 14,381 adults (54.5% female, 67.5% aged 45-64 years) were assessed. T60-89min/week >300min/week p < 0.001). High volumes of LTPA were associated with a lower prevalence 270-299min/week; >300 minutes60-89min/week volumes of TPA were associated with lower prevalence of depression.

Limitations: Cross-sectional design and self-reported PA. Lack of assessment of sedentary behaviour or occupational PA.

Conclusions: The present study highlights the importance of contextual factors in the association between PA and mental health, particularly at higher levels.
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http://dx.doi.org/10.1016/j.jpsychires.2021.05.053DOI Listing
June 2021

Generation of 6 lines of human pluripotent stem cells from hypertensive patients and 3 lines of human pluripotent stem cell from normotensive patients.

Stem Cell Res 2021 05 6;53:102384. Epub 2021 May 6.

National Laboratory for Embryonic Stem Cells (LaNCE), Department of Genetics and Evolutionary Biology, Institute of Biosciences, University of São Paulo, SP 05508-090, Brazil. Electronic address:

Hypertension is a complex multifactorial disease characterized by a chronic increase of arterial pressure. Ninety percent of the cases are idiopathic and thus classified as essential hypertension. Uncontrolled arterial pressure has devasting consequences including cardiac insufficiency, stroke, dementia, chronic renal disease, ischemic heart disease and death. The hiPSC lines described here from six hypertensive patients and three controls were characterized according to established criteria and were shown to maintain pluripotency, differentiation into the three germ layers and genomic integrity. These cell lines can contribute to the understanding of the molecular mechanisms involved in hypertension in different cell types.
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http://dx.doi.org/10.1016/j.scr.2021.102384DOI Listing
May 2021

Phytosterol consumption and markers of subclinical atherosclerosis: Cross-sectional results from ELSA-Brasil.

Nutr Metab Cardiovasc Dis 2021 06 20;31(6):1756-1766. Epub 2021 Mar 20.

Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, Brazil. Electronic address:

Background And Aims: Phytosterol (PS) consumption is associated with lower total and LDL-cholesterol (LDL-c) concentrations, but its impact on cardiovascular risk is unclear. This study assessed the effect of usual intake of PS on markers of subclinical atherosclerosis in the Longitudinal Study of Adult Health (ELSA-Brasil).

Methods And Results: This cross-sectional study included 2560 participants of ELSA-Brasil, aged 48 (43-54) years, with available food frequency questionnaires (FFQ), coronary artery calcium (CAC) scores, carotid intima media thickness (cIMT), and carotid-femoral pulse wave velocity (cf-PWV), at baseline. Several logistic and linear regression models were used, and significance level was set at a P < 0.05. Mean values (SD) for PS consumption were 256 (198) mg/day, CAC 22.78 (110.54) Agatston Units, cf-PWV 9.07 (1.60) m/s and cIMT 0.57 (0.12) mm. PS consumption in Q4 was associated with lower total- and LDL-c levels, and with higher percentiles of cf-PWV (P < 0.001). Proportion of subjects in Q4 of PS consumption was 1.5 times higher among individuals in cf-PWV Q4, than in Q1 (P = 0.002, for comparisons among quartiles). There was a trend (P = 0.003) for higher cf-PWV with higher PS intake. In crude logistic and linear regressions, PS intake was associated with cf-PWV. In the adjusted models, these associations disappeared. No associations were found between PS and cIMT or CAC.

Conclusions: In this large and apparently healthy cross-sectional sample from ELSA-Brasil, usual PS consumption was associated with lower total- and LDL-cholesterol, but not with markers of subclinical atherosclerosis.
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http://dx.doi.org/10.1016/j.numecd.2021.02.031DOI Listing
June 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

Hearing loss, tinnitus, and hypertension: analysis of the baseline data from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

Clinics (Sao Paulo) 2021 26;76:e2370. Epub 2021 Mar 26.

Centro de Pesquisa Clinica e Epidemiologica, Hospital Universitario, Universidade de Sao Paulo, Sao Paulo, SP, BR.

Objectives: To investigate the association among hypertension, tinnitus, and sensorineural hearing loss and evaluate the influence of other covariates on this association.

Methods: Baseline data (2008-2010) from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) were analyzed. Altogether, 900 participants were evaluated. The baseline assessment consisted of a 7-hour examination to obtain clinical and laboratory variables. Hearing was measured using pure-tone audiometry.

Results: Overall, 33.3% of the participants had hypertension. Participants with hypertension were more likely to be older, male, and diabetic compared to those without hypertension. The prevalence of tinnitus was higher among hypertensive participants and the odds ratio for tinnitus was higher in participants with hypertension than in those without hypertension. However, the difference was not significant after adjusting for age. Audiometric results at 250-8,000 Hz were worse in participants with hypertension than in those without hypertension in the crude analysis; however, the differences were not significant after adjustment for age, sex, diagnosis of diabetes, and exposure to noise. No significant difference was observed in hearing thresholds among participants having hypertension for <6 years, those having hypertension for ≥6 years, and individuals without hypertension.

Conclusion: Hearing thresholds were worse in participants with hypertension. However, after adjusting for age, sex, diagnosis of diabetes, and exposure to noise, no significant differences were observed between participants with and without hypertension. A higher prevalence of tinnitus was observed in participants with hypertension compared to those without hypertension, but without significance after adjusting for age.
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http://dx.doi.org/10.6061/clinics/2021/e2370DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7978663PMC
April 2021

Branched-chain amino acids predict incident diabetes in the Brazilian Longitudinal Study of Adult Health - ELSA-Brasil.

Diabetes Res Clin Pract 2021 Apr 10;174:108747. Epub 2021 Mar 10.

Departamento de Clínica Médica, Faculdade de Medicina, Universidade de São Paulo, Av. Lineu Prestes 2565 - 4° floor, CEP: 05508-000 São Paulo, SP, Brazil; Centro de Pesquisa do Hospital Universitário, Universidade de São Paulo, Av. Lineu Prestes 2565, 3rd floor, CEP 05508-000 São Paulo, SP, Brazil. Electronic address:

Aims: To evaluate the role of branch chain amino acid (BCAA) concentrations as a predictor for incident type 2 diabetes (DM).

Methods: Participants from ELSA-Brasil without diabetes at baseline and followed for 3.9 ± 0.6 years were included in the analysis. The determinations of BCAA (valine, leucine, isoleucine) were performed by proton nuclear magnetic resonance spectroscopy. Cardiometabolic profile and incidence of DM were evaluated according to quartiles of BCAA at baseline, stratified by sex.

Results: From 3,828 participants (56% female, 50.5 ± 8.7 years) 299 (8.5%) were diagnosed with DM. For both sexes, a worsening of cardiometabolic profile was observed across increasing BCAA quartiles. In survival analysis, incidence rates of DM for the entire period were highest in participants in the third and fourth quartile of BCAA (log Rank analysis < 0.001 for both sexes). In Cox regression analysis, for men, the HR (95%CI) for risk of DM was 2.24 (1.24-4.03) for those from the fourth quartile of BCAA, while in women it was 1.94 (1.07-3.50), comparing to first quartile of BCAA after adjustments for age, BMI, physical activity, family history of DM, pre-diabetes, blood pressure, total cholesterol and HOMA-IR.

Conclusions: Higher levels of BCAA were independently predictors of DM.
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http://dx.doi.org/10.1016/j.diabres.2021.108747DOI Listing
April 2021

Association of Carotid Plaques and Common Carotid Intima-media Thickness with Modifiable Cardiovascular Risk Factors.

J Stroke Cerebrovasc Dis 2021 May 23;30(5):105671. Epub 2021 Feb 23.

Hospital Universitário da Universidade de São Paulo, São Paulo, Brazil; Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. Electronic address:

Objective: To assess the association of carotid plaques and common carotid artery intima-media thickness with traditional modifiable cardiovascular risk factors.

Methods: We examined 4,266 participants aged 35-74years in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline. The presence of plaques at all carotid arteries sites was evaluated. The mean far wall common carotid artery intima-media thickness was measured. To evaluate the association of cardiovascular risk factors with plaques and plaque burden, we applied logistic regression models presented as crude, adjusted by sociodemographic variables, along with multivariate further adjustment for hypertension, diabetes, hypercholesterolemia, and smoking. For the association of cardiovascular risk factors and common carotid artery intima-media thickness, linear regression models were used with the same adjustments.

Results: Median age was 51 years (interquartile range: 45-58 years; 54.5% of females). Plaque prevalence in at least one segment of the carotid arteries was 35.9%. Mean common carotid artery intima-media thickness of the far walls was 0.609 ± 0.133 mm. In the multivariate model for plaque presence, the odds ratios were:1.39 (1.19-1.63) for hypertension;1.58 (1.36-1.82) for hypercholesterolemia; 2.00 (1.65-2.43),1.19 (1.02-1.40) for current and past smoking, and 1.13 (0.95-1.35) for diabetes. In the multivariate linear regression models, common carotid artery intima-media thickness beta-coefficients were: 0.035 mm (0.027-0.043) for hypertension; 0.020 mm (0.013-0.027) for hypercholesterolemia; 0.020 mm (0.010-0.029), 0.012 mm (0.004-0.020) for current and past smoking, and 0.024 mm (0.015-0.033) for diabetes.

Conclusion: Cardiovascular risk factors were independently associated with increasing common carotid artery intima-media thickness, plaque prevalence, and plaque scores. Diabetes did not show an independent association with plaques in the multivariate model.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.105671DOI Listing
May 2021

Obstructive sleep apnea is associated with lower adiponectin and higher cholesterol levels independently of traditional factors and other sleep disorders in middle-aged adults: the ELSA-Brasil cohort.

Sleep Breath 2021 Feb 15. Epub 2021 Feb 15.

Center of Clinical and Epidemiologic Research (CPCE), University of Sao Paulo, Av. Prof. Lineu Prestes, 2565-4 andar, Cidade Universitária, São Paulo, SP, 05508-000, Brazil.

Purpose: Obstructive sleep apnea (OSA) may contribute to metabolic and inflammatory deregulation but previous studies failed to consider sleep duration, sleep fragmentation, insomnia, and daytime sleepiness as potential confounders.

Methods: Consecutive non-diabetic middle-aged participants from the ELSA-Brasil cohort were invited to perform a clinical evaluation, home sleep study for 1 night, and wrist actigraphy for 7 days. OSA was defined by an apnea-hypopnea index ≥ 15 events/h. Participants were stratified according to the presence of OSA measuring the following markers: fasting glucose, glucose tolerance test, homeostatic model assessment of insulin resistance (HOMA-IR) index, fasting insulin, insulin after 2 h of glucose load, glycated hemoglobin, total cholesterol and their fractions, triglycerides, C-reactive protein, TNF-alpha, interleukin-6, interleukin-10, leptin, adiponectin, E-selectin, ADMA, MCP-1, TGF, apolipoprotein B, fibrinogen, and lipoprotein(a). Differences between groups were identified by chi-square test and ANOVA.

Results: We studied 708 participants (mean age: 46 ± 5 years, men: 44%, BMI 26.1 ± 4.1 kg/m). Compared to no OSA, participants with OSA presented higher levels while fasting and after 2 h glucose load of insulin, HOMA-IR, cholesterol, triglycerides, and C-reactive protein (all p < 0.001). After linear regression analysis adjusting for traditional risk factors plus sleep duration, fragmentation, insomnia, and daytime sleepiness, OSA was negatively associated with adiponectin (β = - 0.271 CI 95% - 0.456 - 0.085) and positively associated with cholesterol (β = 9.707 CI 95% 2.737 16.678). Sex-stratification revealed that these associations were significant for men but not women.

Conclusions: In non-diabetic middle-age adults, men with OSA presented with lower adiponectin and higher cholesterol levels independently of sleep duration, sleep fragmentation, insomnia, and daytime sleepiness.
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http://dx.doi.org/10.1007/s11325-021-02290-7DOI Listing
February 2021

Profiling plasma-extracellular vesicle proteins and microRNAs in diabetes onset in middle-aged male participants in the ELSA-Brasil study.

Physiol Rep 2021 02;9(3):e14731

Interdisciplinary Post-graduate Program in Health Sciences, Cruzeiro do Sul University, Sao Paulo, Brazil.

We measured plasma-derived extracellular vesicle (EV) proteins and their microRNA (miRNA) cargos in normoglycemic (NG), glucose intolerant (GI), and newly diagnosed diabetes mellitus (DM) in middle-aged male participants of the Brazilian Longitudinal Study of Adult Health (ELSA-Brazil). Mass spectrometry revealed decreased IGHG-1 and increased ITIH2 protein levels in the GI group compared with that in the NG group and higher serotransferrin in EVs in the DM group than in those in the NG and GI groups. The GI group also showed increased serum ferritin levels, as evaluated by biochemical analysis, compared with those in both groups. Seventeen miRNAs were differentially expressed (DEMiRs) in the plasma EVs of the three groups. DM patients showed upregulation of miR-141-3p and downregulation of miR-324-5p and -376c-3p compared with the NG and GI groups. The DM and GI groups showed increased miR-26b-5p expression compared with that in the NG group. The DM group showed decreased miR-374b-5p levels compared with those in the GI group and higher concentrations than those in the NG group. Thus, three EV proteins and five DEMiR cargos have potential prognostic importance for diabetic complications mainly associated with the immune function and iron status of GI and DM patients.
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http://dx.doi.org/10.14814/phy2.14731DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7883809PMC
February 2021

Obstructive Sleep Apnea, Sleep Duration, and Associated Mediators With Carotid Intima-Media Thickness: The ELSA-Brasil Study.

Arterioscler Thromb Vasc Biol 2021 04 11;41(4):1549-1557. Epub 2021 Feb 11.

Center of Clinical and Epidemiologic Research (CPCE) (S.P.S., R.B.S., I.S.S., B.K.P., S.G., A.N.A., L.F.C., W.A.S., P.A.L., I.M.B., L.F.D.), University of Sao Paulo, Brazil.

[Figure: see text].
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http://dx.doi.org/10.1161/ATVBAHA.120.315644DOI Listing
April 2021

The impact of atrial fibrillation and long-term oral anticoagulant use on all-cause and cardiovascular mortality: A 12-year evaluation of the prospective Brazilian Study of Stroke Mortality and Morbidity.

Int J Stroke 2021 Feb 25:1747493021995592. Epub 2021 Feb 25.

Center for Clinical and Epidemiological Research, Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil.

Background: Atrial fibrillation is a predictor of poor prognosis after stroke.

Aims: To evaluate atrial fibrillation and all-cause and cardiovascular mortality in a stroke cohort with low socioeconomic status, taking into consideration oral anticoagulant use during 12-year follow-up.

Methods: All-cause mortality was analyzed by Kaplan-Meier survival curve and Cox regression models to estimate hazard ratios and 95% confidence intervals (95% CI). For specific mortality causes, cumulative incidence functions were computed. A logit link function was used to calculate odds ratios (OR) with 95% CIs. Full models were adjusted by age, sex, oral anticoagulant use (as a time-dependent variable) and cardiovascular risk factors.

Results: Of 1121 ischemic stroke participants, 17.8% had atrial fibrillation. Overall, 654 deaths (58.3%) were observed. Survival rate was lower (median days, interquartile range-IQR) among those with atrial fibrillation (531, IQR: 46-2039) . non-atrial fibrillation (1808, IQR: 334-3301), -log rank < 0.0001). Over 12-year follow-up, previous atrial fibrillation was associated with increased mortality: all-cause (multivariable hazard ratios, 1.82; 95% CI: 1.43-2.31) and cardiovascular mortality (multivariable OR, 2.07; 95% CI: 1.36-3.14), but not stroke mortality. In the same multivariable models, oral anticoagulant use was inversely associated with all-cause mortality (oral anticoagulant time-dependent effect: multivariable hazard ratios, 0.47; 95% CI: 0.30-0.50,  = 0.002) and stroke mortality (oral anticoagulant time-dependent effect ≥ 6 months: multivariable OR, 0.09; 95% CI: 0.01-0.65, -value = 0.02), but not cardiovascular mortality.

Conclusions: Among individuals with low socioeconomic status, atrial fibrillation was an independent predictor of poor survival, increasing all-cause and cardiovascular mortality risk. Long-term oral anticoagulant use was associated with a markedly reduced risk of all-cause and stroke mortality.
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http://dx.doi.org/10.1177/1747493021995592DOI Listing
February 2021

Reduced heart-rate variability and increased risk of hypertension-a prospective study of the ELSA-Brasil.

J Hum Hypertens 2021 Jan 18. Epub 2021 Jan 18.

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

Although autonomic disturbances are known to precede hypertension onset, the risks underlying different ranges of blood pressure and impaired cardiac autonomic modulation are still unknown. This study aimed to identify the risk of hypertension incidence related to low heart-rate variability profile in normotensive blood pressure subcategories: normal (<120/80 mmHg) and prehypertension (120/80-139/89 mmHg) in a 4-year follow-up. 7665 participants free of hypertension at baseline were examined. They were allocated into one of two groups (
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http://dx.doi.org/10.1038/s41371-020-00460-wDOI Listing
January 2021

Association Between GlycA and Cognitive Function: Cross-Sectional Results From the ELSA-Brasil Study.

Alzheimer Dis Assoc Disord 2021 Apr-Jun 01;35(2):128-134

Center for Clinical and Epidemiologic Research, Hospital Universitario, University of São Paulo.

Inflammation is associated with poor cognitive performance. GlycA is a novel marker of systemic inflammation, but information on GlycA and cognition is scarce. We aimed to evaluate the association between GlycA and cognitive performance in a large sample from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). In this cross-sectional study, participants with GlycA measured at baseline were included. Cognitive function was evaluated using the word list test, the trail-making test, and the semantic and phonemic verbal fluency tests. The association of GlycA with cognitive performance was investigated using linear regression models adjusted for sociodemographic and clinical variables. A total of 4327 participants were analyzed (mean age=51.5±9.0 y old, 54% were female, 60% white). The mean GlycA was 414.9±69.8 µmol/L. Higher GlycA levels were associated with lower global cognitive performance, even after adjustments for confounders and C-reactive protein. Higher GlycA levels were associated with lower performance in language and executive function domains (language: β=-0.005, 95% confidence interval CI=-0.010, -0.001, P=0.01; and executive function: β=-0.005, 95% confidence interval=0.009, -0.001, P=0.02]. GlycA was associated with worse cognitive performance in the ELSA-Brasil study, independent of C-reactive protein levels. GlycA may be a potential biomarker for cognitive impairment.
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http://dx.doi.org/10.1097/WAD.0000000000000431DOI Listing
June 2020

Thyroid-stimulating hormone levels and incident depression: Results from the ELSA-Brasil study.

Clin Endocrinol (Oxf) 2021 May 14;94(5):858-865. Epub 2021 Feb 14.

Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil.

Objective: This study aimed to prospectively evaluate whether TSH levels at baseline were associated with incident depression after four years of follow-up in a cohort of middle-aged adults, the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

Methods: TSH and free-thyroxine (FT4) levels were evaluated at baseline. Depression diagnoses were performed using the Clinical Interview Schedule-Revised (CIS-R) at baseline and after a 4-year follow-up. Poisson regression models (95% Confidence Intervals) were built to evaluate the association between TSH quintiles at baseline and incident depression. All analyses were stratified by sex. Models were presented crude, adjusted for age and sex; and further adjusted for race, education, BMI, smoking, alcohol consumption, use of antidepressants/benzodiazepines, kidney function and comorbidities.

Results: Mean age was 51.5 years, and 51.2% were women. Overall, low TSH levels (1 quintile) were associated with incident depression (adjusted RR = 1.36, 95% CI 1.02-1.81), remaining significant for women (adjusted RR = 1.64, 95% CI 1.15-2.33), but not for men. The same results were found when restricting analysis to euthyroid participants (adjusted RR = 1.46, 95% CI 1.08-1.99), also significant for women only (adjusted RR = 1.63, 95% CI 1.12-2.38).

Conclusions: Our results showed that low TSH levels were positively associated with incident depression, particularly among women. Similar results were found when restricting the analysis to euthyroid participants. In contrast, high TSH levels were inversely associated with incident depression, also among women.
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http://dx.doi.org/10.1111/cen.14407DOI Listing
May 2021

Atrial fibrillation in low- and middle-income countries: a narrative review.

Eur Heart J Suppl 2020 Dec 22;22(Suppl O):O61-O77. Epub 2020 Dec 22.

Center for Clinical and Epidemiological Research, Hospital Universitário, Universidade de São Paulo, Av. Lineu Prestes 2565, Cidade Universitária, São Paulo 05508-000, Brazil.

Preventing premature non-communicable disease mortality necessitates a thorough review of one of the most important risk factors for stroke, which is atrial fibrillation (AF). The latter and AF-related stroke are still considered to be problems of high-income countries and are frequently overlooked in low- and middle-income countries (LMICs). In this narrative review, we provide an overview of studies that evaluated at least one of the following determinants of AF burden in LMICs: current epidemiology and trends, stroke prevention, health outcomes, and economic burden. Studies focusing on samples close to the general population (including community- and primary care-based samples) indicate sex-specific prevalence rates up to 7.4% in LMICs. Although AF prevalence is still higher in high-income countries than LMICs, the gap in AF burden between these two groups has been reducing in the past three decades. Oral anticoagulant (OAC) therapy for stroke prevention is underused in LMICs, and there are little data on OAC therapy in relation to stroke risk scores, such as CHADS-VASc. Available data also points to higher morbidity and mortality for patient with AF in LMICs than their counterparts in high-income countries. Data on the consequent economic burden in LMICs is scarce, but it is reasonable to consider it will follow the same trend as that observed for health outcomes. Raising the visibility of AF as a public health problem in LMICs is necessary as a first step to providing adequate care for patients with this condition.
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http://dx.doi.org/10.1093/eurheartj/suaa181DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7753884PMC
December 2020

Prognostic value of electrocardiographic abnormalities in adults from the Brazilian longitudinal study of adults' health.

Heart 2020 Dec 23. Epub 2020 Dec 23.

Internal Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil

Objective: Cardiovascular diseases (CVDs) are highly preventable non-communicable diseases. ECG is a potential tool for risk stratification with respect to CVD. Our aim was to evaluate ECG's role in all-cause and cardiovascular mortality prediction.

Methods: Participants from the Brazilian Longitudinal Study of Adult Health, free of known CVD at baseline were included. A 12-lead ECG was obtained at baseline (2008-2010). Participants were followed up to 2018 by annual interviews. Deaths were independently reviewed. Cox as well as Fine and Grey multivariable regression models were applied to evaluate if the presence of any major electrocardiographic abnormality (MEA), defined according to the Minnesota Code system, would predict total and cardiovascular deaths. We also evaluated the Net Reclassification Index of adding MEA to the Systematic Coronary Risk Evaluation (SCORE).

Results: The 13 428 participants (median age 51 years, 45% men) were followed up for 8±1 years. All-cause and cardiovascular mortality occurred in 2.8% and 1.2% of the population, respectively. Prevalent MEA was an independent predictor of overall (HR=2.3, 95% CI 1.7 to 2.9) and cardiovascular mortality (HR=4.6, 95% CI 3.0 to 7.0) after adjustments for age, race, education and traditional cardiovascular risk factors. Adding MEA to the SCORE resulted in 9% mis-reclassification in the non-event subgroup and 33% correct reclassification in those with a fatal cardiovascular event.

Conclusion: Presence of MEA was an independent predictor of overall and cardiovascular mortality. ECG may have a role in risk prediction of cardiovascular mortality in primary care.
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http://dx.doi.org/10.1136/heartjnl-2020-318097DOI Listing
December 2020

Frequency and Reasons for Non-Administration and Suspension of Drugs During an Acute Coronary Syndrome Event. The ERICO Study.

Arq Bras Cardiol 2020 11;115(5):830-839

Universidade de São Paulo - Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário da USP, São Paulo, SP - Brasil.

Background: Few studies have discussed the reasons for pharmacological undertreatment of Acute Coronary Syndrome (ACS).

Objectives: To determine the frequency and reasons for the non-administration and suspension of medications during in-hospital treatments of ACS in the Strategy of Registry of Acute Coronary Syndrome (ERICO) study.

Methods: The present study analyzed the medical charts of the 563 participants in the ERICO study to evaluate the frequency and reasons for the non-administration and/or suspension of medications. Logistic regression models were built to analyze if sex, age ≥65 years of age, educational level, or ACS subtype were associated with (a) the non-administration of ≥1 medications; and (b) the non-administration or suspension of ≥1 medications. The significance level was set at 5%.

Results: This study's sample included 58.1% males, with a median of 62 years of age. In 183 (32.5%) participants, ≥1 medications were not administered, while in 288 (51.2%), ≥1 medications were not administered or were suspended. The most common reasons were the risk of bleeding (aspirin, clopidogrel, and heparin), heart failure (beta blockers), and hypotension (angiotensin-converting enzyme inhibitors and angiotensin receptor blockers). Individuals aged ≥65 (odds ratio [OR]:1.51; 95% confidence interval [95% CI]:1.05-2.19) and those with unstable angina (OR:1.72; 95% CI:1.07-2.75) showed a higher probability for the non-administration of ≥1 medication. Considering only patients with myocardial infarction, being ≥65 years of age was associated with both the non-administration and the non-administration or suspension of ≥1 medication.

Conclusions: Non-administration or suspension of ≥1 medication proved to be common in this ERICO study. Individuals of ≥65 years of age or with unstable angina showed a higher probability of the non-administration of ≥1 medication and may be undertreated in this scenario. (Arq Bras Cardiol. 2020; 115(5):830-839).
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http://dx.doi.org/10.36660/abc.20190317DOI Listing
November 2020

Metabolic status is not associated with job stress in individuals with obesity: the ELSA-Brasil baseline.

Int Arch Occup Environ Health 2021 May 27;94(4):639-646. Epub 2020 Nov 27.

Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.

Purpose: Job stress has proven to be a relevant cause of stress for adults, but its effect on the development of metabolic alterations in individuals with obesity is still poorly explored. We aimed to investigate the association between job stress and metabolically unhealthy obesity (MUO) phenotype in participants with obesity at the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline assessment.

Methods: This study analyzed data collected at the baseline examination between 2008 and 2010. A total of 2371 individuals with obesity were included. Two metabolic phenotypes were characterized based on the US National Health and Nutrition Examination Survey criteria. The job stress scale was based on the Brazilian version of the Swedish Demand-Control-Support Questionnaire. The association between job stress domains and MUO phenotype was assessed by binary logistic models.

Results: In our sample, 1297 (54.7%) participants were women, mean age was 49.6 ± 7.1 years and 1696 (71.5%) had MUO. Low skill discretion was associated with MUO after adjustment for age, sex and race. However, in fully-adjusted models, the MUO phenotype was not associated with high job demand (odds ratio [OR] = 1.05; 95% confidence interval [95%CI] 0.82-1.35), low skill discretion (OR = 1.26; 95%CI 0.95-1.68), low decision authority (OR = 0.94; 95%CI 0.70-1.25) nor low social support (OR = 0.93; 95%CI 0.71-1.20).

Conclusion: We found a significant association between low skill discretion and an adverse metabolic profile in models adjusted for age, sex and race. No associations were significant between job stress domains and the metabolic profile of individuals with obesity in full models.
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http://dx.doi.org/10.1007/s00420-020-01613-7DOI Listing
May 2021

Unfavorable Triglyceride-rich Particle Profile in Subclinical Thyroid Disease: A Cross-sectional Analysis of ELSA-Brasil.

Endocrinology 2021 02;162(2)

Center for Clinical and Epidemiological Research, Hospital Universitário, Universidade de Sao Paulo, São Paulo, São Paulo, Brazil.

Subclinical thyroid disorders have been associated with atherosclerosis and increased cardiovascular risk. As triglyceride-rich lipoprotein particles (TRLPs) have recently emerged as a casual factor for atherogenesis, the aim of this study was to evaluate the relationship between subclinical hypo- and hyperthyroidism and TRLP subfractions. We selected 5066 participants from the ELSA-Brasil cohort with available data of thyroid function and lipid profile measured by nuclear magnetic resonance (NMR) spectroscopy. Individuals were divided into 3 groups by baseline thyroid function (subclinical hypothyroidism, euthyroidism, and subclinical hyperthyroidism). Triglyceride-rich lipoprotein particle subfractions were analyzed through NMR spectroscopy. To examine the association between TRLP subfractions and thyroid function, we conducted univariate and multivariate linear regression models adjusted for demographic characteristics, body mass index, diabetes, smoking status, and alcohol use. Of 3304 individuals, 54% were women, with a mean age of 50.6 ± 8.7 years, 51% white, and 53% with at least a college education. Of these individuals, 92% were euthyroid, whereas 6.8% had subclinical hypothyroidism and 1.2% had subclinical hyperthyroidism. The univariate linear regression showed that very small TRLPs (P = 0.026) and very large TRLPs (P = 0.008) were statistically increased in subclinical hypothyroidism when compared with euthyroidism. In subclinical hyperthyroidism, there was a reduction in total TRLPs (P = 0.003), seemingly driven by reduced very small TRLPs (P = 0.067). The findings were confirmed when adjusted for demographic characteristics, as well as comorbidities. This study suggests that subclinical hypothyroidism is associated with very small and very large TRLPs, which are related to an unfavorable atherogenic profile. Subclinical hyperthyroidism is associated to lower very small TRLPs.
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http://dx.doi.org/10.1210/endocr/bqaa205DOI Listing
February 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 Feb 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

Association of Sodium with Obstructive Sleep Apnea. The ELSA-Brasil Study.

Ann Am Thorac Soc 2021 03;18(3):502-510

Estudo Longitudinal de Saúde do Adulto-ELSA Brasil.

Excessive sodium may have a role in the pathogenesis of obstructive sleep apnea (OSA) for patients with hypervolemic conditions, but it is unclear whether this is valid for all patients with OSA, including those with no significant comorbidities. To test the association of urinary sodium and OSA in a large sample of participants from the ELSA-Brasil (Estudo Longitudinal de Saúde do Adulto-Brasil) Study. In addition, we stratified the analysis participants according to the presence of hypertension. In this cross-sectional study, OSA was defined by an apnea-hypopnea index ≥15 events/h. A validated 12-hour urine collection as representative of the 24-hour period was obtained from all participants to measure sodium excretion. We performed a logistic regression analysis to test the association of urinary sodium excretion with OSA (dependent variable) adjusting for age, sex, race and income, glomerular filtration rate, diabetes, physical activity, and antihypertensive classes related to sodium excretion. To address potential residual factors that may influence sodium excretion, we performed additional analysis replacing sodium excretion for salt intake (food frequency questionnaire) using the same models. We studied 1,946 participants (age 49 ± 8 yr; 43.4% men). A third of them had OSA. Compared with those with no OSA, participants with OSA presented with higher sodium excretion (1.66 [1.19-2.29] vs. 1.99 [1.44-2.69] g/12 h;  < 0.001). After adjustments for confounding factors, we found no overall significant associations of sodium excretion with OSA (odds ratio [OR], 1.09; 95% confidence interval [CI], 0.97-1.23;  = 0.150). Regardless of the OSA status, the sodium excretion was higher in hypertensive than in normotensive participants (1.93 [1.35-2.64] vs. 1.71 [1.22-2.37] g/12 h). An independent association of sodium excretion with OSA was observed in patients with hypertension only (OR, 1.326; 95% CI, 1.067-1.648;  = 0.011), but the interaction of urinary sodium with hypertension was not significant ( = 0.37). The analysis of salt intake revealed consistent findings. The potential role of sodium in the pathogenesis of OSA seems to be modest and limited for those with higher salt intake and, consequently, higher fluid retention such as observed in patients with hypertension.
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http://dx.doi.org/10.1513/AnnalsATS.202005-498OCDOI Listing
March 2021

Glaucoma, but not cataracts, predicts lower verbal fluency performance: 3.8-year follow-up from the ELSA-Brasil study.

Neuropsychol Dev Cogn B Aging Neuropsychol Cogn 2020 Oct 19:1-13. Epub 2020 Oct 19.

Department of Internal Medicine, Faculdade De Medicina Da Universidade De São Paulo, São Paulo, Brazil.

Glaucoma, cataracts, and cognitive decline are most common in older ages. Although cross-sectional studies showed that these disorders are associated, follow-up studies are lacking. To investigate this issue, baseline and follow-up data from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) were employed. We evaluated participants ≥ 55 years-old at follow-up without diagnosis of dementia, stroke, and other eye conditions except for glaucoma and cataracts. Cognition was evaluated using delayed word recall, verbal fluency, and trail making (version B) tests. Regression models were employed to investigate associations between glaucoma and cognition, adjusted by several confounders. Out of 3,867 participants, 379 and 118 presented cataracts and glaucoma, respectively. Only glaucoma was apredictor of lower verbal fluency (B = -0.23, 95% CI -035 to -012, p< 0.001). Other associations were not significant (ps>0.57). Our results suggest that glaucoma may be related to declining cognition.
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http://dx.doi.org/10.1080/13825585.2020.1837723DOI Listing
October 2020

Normative Data for the ELSA-Brasil Neuropsychological Assessment and Operationalized Criterion for Cognitive Impairment for Middle-Aged and Older Adults.

J Int Neuropsychol Soc 2021 03 14;27(3):293-303. Epub 2020 Oct 14.

Division of Geriatrics, University of Sao Paulo Medical School, Av. Dr. Arnaldo, 455 - Cerqueira César, São Paulo, SP01246-903, Brazil E-mail:

Objectives: Normative data should consider sociodemographic diversity for the accurate diagnosis of cognitive impairment. This study aims to provide normative data for a brief neuropsychological battery and present diagnostic criteria for cognitive impairment that could be used in primary care settings.

Methods: We selected 9618 Brazilian middle-aged and older adults after detailed exclusion criteria to avoid subtle cognitive impairment. We analyzed age, sex, and education influence on cognitive performance. To verify the evidence of criterion validity, we compared the cognitive performance of subjects with and without a depressive episode. Additionally, we verified the percentage of spurious scores under three different cutoffs.

Results: Age and education had the greatest impact on cognition. Normative scores were provided according to age and education groups. Participants with a depressive episode performed poorer than control subjects. The clinical cutoff of at least two scores below the 7th percentile revealed the adequate percentage of spurious and possible clinical performance.

Conclusions: The Longitudinal Study on Adult Health (ELSA-Brasil) provided normative data based on a unique selected set of cognitively normal subjects. Normative groups were selected based on age and education, and the battery was sensitive to the presence of a depressive episode. We suggested clinical cutoffs for the tests in this battery that could be used in primary care settings to improve the accurate diagnosis of cognitive impairment.
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http://dx.doi.org/10.1017/S1355617720000880DOI Listing
March 2021

Effects of tDCS on neuroplasticity and inflammatory biomarkers in bipolar depression: Results from a sham-controlled study.

Prog Neuropsychopharmacol Biol Psychiatry 2021 03 4;105:110119. Epub 2020 Oct 4.

Laboratory of Neurosciences (LIM-27), Instituto Nacional de Biomarcadores em Neuropsiquiatria (INBioN), Department and Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Department of Internal Medicine, Faculdade de Medicina da Universidade de São Paulo & Hospital Universitário, Universidade de São Paulo, Av. Prof Lineu Prestes 2565, 05508-000 São Paulo, Brazil. Electronic address:

Objectives: We investigated the role of peripheral biomarkers associated with neuroplasticity and immune-inflammatory processes on the effects of transcranial direct current stimulation (tDCS), a safe, affordable, and portable non-invasive neuromodulatory treatment, in bipolar depression.

Methods: This is an exploratory analysis using a dataset from the sham-controlled study the Bipolar Depression Electrical Treatment Trial (BETTER)(clinicaltrials.govNCT02152878). Participants were 52 adults with type I or II bipolar disorder in a moderate-to-severe depressive episode, randomized to 12 bifrontal active or sham tDCS sessions over a 6-week treatment course. Plasma levels of brain derived neurotrophic factor (BDNF), glial cell derived neurotrophic factor (GDNF), interleukins (IL) 2, 4, 6, 8, 10, 18, 33, 1β, 12p70, 17a, interferon gamma (IFN), tumor necrosis factor alpha (TNF) and its soluble receptors 1 and 2, ST2, and KLOTHO were investigated at baseline and endpoint. We performed analyses unadjusted for multiple testing to evaluate whether baseline biomarkers were predictive for depression improvement and changed during treatment using linear regression models.

Results: A time x group interaction (Cohen's d: -1.16, 95% CI = -1.96 to -0.3, p = .005) was found for IL-8, with greater reductions after active tDCS. Higher baseline IL-6 plasma levels was associated with symptomatic improvement after tDCS (F = 5.43; p = .025). Other associations were not significant.

Conclusions: Our exploratory findings suggested that IL-6 is a potential predictor of tDCS response and IL-8 might decrease after tDCS; although confirmatory studies are warranted due to the multiplicity of comparisons.
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http://dx.doi.org/10.1016/j.pnpbp.2020.110119DOI Listing
March 2021

Longitudinal measurement invariance of neuropsychological tests in a diverse sample from the ELSA-Brasil study.

Braz J Psychiatry 2021 May-Jun;43(3):254-261

Divisão de Geriatria, Faculdade de Medicina, USP, São Paulo, SP, Brazil.

Objective: Longitudinal measurement invariance analyses are an important way to assess a test's ability to estimate the underlying construct over time, ensuring that cognitive scores across visits represent a similar underlying construct, and that changes in test performance are attributable to individual change in cognitive abilities. We aimed to evaluate longitudinal measurement invariance in a large, social and culturally diverse sample over time.

Methods: A total of 5,949 participants from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) were included, whose cognition was reassessed after four years. Longitudinal measurement invariance analysis was performed by comparing a nested series of multiple-group confirmatory factor analysis models (for memory and executive function factors).

Results: Configural, metric, scalar and strict invariance were tested and supported over time.

Conclusion: Cognitive temporal changes in this sample are more likely to be due to normal and/or pathological aging. Testing longitudinal measurement invariance is essential for diverse samples at high risk of dementia, such as in low- and middle-income countries.
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http://dx.doi.org/10.1590/1516-4446-2020-0978DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8136397PMC
June 2021

Differences in HDL particle size in the presence of subclinical thyroid dysfunctions: The ELSA-Brasil study.

Atherosclerosis 2020 11 11;312:60-65. Epub 2020 Sep 11.

Center for Clinical and Epidemiological Research, Hospital Universitário, Universidade de Sao Paulo, Sao Paulo, SP, Brazil; Department of Internal Medicine, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil. Electronic address:

Background And Aims: Thyroid dysfunction is related to several lipid abnormalities. There is no consensus about concentration of high-density lipoprotein (HDL) in different studies. The aim of this report is to evaluate HDL particle (HDL-P) subfractions across a spectrum of thyroid functions in a Brazilian population.

Methods: Individuals were divided into three groups by baseline thyroid function (subclinical hypothyroidism, euthyroidism, and subclinical hyperthyroidism). HDL-P subfractions were analyzed by Nuclear Magnetic Resonance (NMR) spectroscopy. To examine the association between HDL-P subfractions and thyroid function, we used univariate and multivariate linear regression models adjusted for demographic characteristics, comorbidities, lifestyle factors, and traditional lipid measurement (HDL-C, LDL-C and triglycerides).

Results: Of 3304 participants, 54.1% were women, 51.2% white, with mean age 50.6 ± 8.7 years. HDL-C and triglycerides levels (p = 0.032 and p = 0.016, respectively) were higher in the SC hypothyroid group. There were no statistically significant differences in total cholesterol levels and LDL-C levels. In univariate analysis, small HDL-P subfractions were significantly lower in subclinical hypothyroidism (p = 0.026) whereas intermediate HDL-P were higher in subclinical hyperthyroidism (p = 0.049), compared to euthyroidism. After adjustment for demographic data, SC hypothyroidism was still statistically associated with lower levels of small HDL-P. After adjusting for comorbidities, lifestyle factors, and traditional lipid measurements, SC hypothyroidism had an established association with lower levels of small HDL-P while SC hyperthyroidism was associated with lower levels of large HDL-P.

Conclusions: In this large cohort from a Brazilian population, subclinical hypothyroidism was associated with lower small HDL-P subfractions, and subclinical hyperthyroidism with lower large HDL-P subfractions and higher intermediate HDL-P subfractions.
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http://dx.doi.org/10.1016/j.atherosclerosis.2020.08.021DOI Listing
November 2020

Vehicular traffic density and cognitive performance in the ELSA-Brasil study.

Environ Res 2020 12 14;191:110208. Epub 2020 Sep 14.

Department of Preventive Medicine, University of São Paulo Medical School, São Paulo, SP, Brazil. Electronic address:

Background: Despite the knowledge about the deleterious effects of air pollutants and their influence on mortality and morbidity due to respiratory and cardiovascular diseases, little is known about the relationship between atmospheric pollutants and neurological diseases. Recently, studies from high-income countries have suggested an association between exposures to air pollutants with cognitive impairment. Thus, we investigated the association of air pollution with cognitive performance in the participants of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

Methods: Cognitive function was evaluated using the word list, the verbal fluency, and the trail making tests (TMT). Pollutant exposure was evaluated indirectly using the distance-weighted traffic density (DWTD) of participants' residence and workplace. We investigated the cross-sectional association between DWTD and cognitive test scores using adjusted linear regression models for sociodemographic and clinical variables.

Results: 3050 were included (mean age = 52.1 ± 9.2 years old, 56.5% women, and 63.6% white). In the simple linear regression models, participants in the higher tertile of combined DWTD (residence and workplace) presented better cognitive performance in all tests when compared to participants in the lower tertile. The DWTD was not associated with cognitive performance in adjusted linear models especially when adjusted for socioeconomic variables (age, sex, education, and race). We found similar results when we investigated the association of cognitive performance with DTWD near participants' workplace and residence separately.

Conclusion: Air pollutants were not associated with worse cognitive performance in a large sample of middle-aged and older adults.
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http://dx.doi.org/10.1016/j.envres.2020.110208DOI Listing
December 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