Association between cognitive performance and self-reported glaucoma in middle-aged and older adults: a cross-sectional analysis of ELSA-Brasil.

Recent evidence suggests that glaucoma and Alzheimer's disease are neurodegenerative diseases sharing common pathophysiological and etiological features, although findings are inconclusive. We sought to investigate whether self-reported glaucoma patients without dementia present poorer cognitive performance, an issue that has been less investigated. We employed cross-sectional data from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) and included participants ≥50 years of age without a known diagnosis of dementia and a self-reported glaucoma diagnosis. We excluded those with previous stroke, other eye conditions, and using drugs that could impair cognition. We evaluated cognition using delayed word recall, phonemic verbal fluency, and trail making (version B) tests. We used multinomial linear regression models to investigate associations between self-reported glaucoma with cognition, adjusted by several sociodemographic and clinical variables. Out of 4,331 participants, 139 reported glaucoma. Fully-adjusted models showed that self-reported glaucoma patients presented poorer performance in the verbal fluency test (ß=-0.39, 95%CI=-0.64 to -0.14, P=0.002), but not in the other cognitive assessments. Thus, our results support the hypothesis that self-reported glaucoma is associated with poor cognitive performance; however, longitudinal data are necessary to corroborate our findings.

Neck and waist circumference values according to sex, age, and body-mass index: Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

Body fat distribution predicts cardiovascular events better than body-mass index (BMI). Waist circumference (WC) and neck circumference (NC) are inexpensive anthropometric measurements. We aimed to present the conditional distribution of WC and NC values according to BMI, stratified by age and sex, from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline data. We analyzed 15,085 ELSA-Brasil participants with complete data. We used spline quantile regression models, stratified by sex and age, to estimate the NC and WC quantiles according to BMI. To test a putative association between age and median NC or WC values, we built sex-specific median regression models using both BMI and age as explanatory variables. We present estimated 25th, 50th, 75th, and 90th percentiles for NC and WC values, according to BMI, age, and sex. Predicted interquartile intervals for NC values varied from 1.6 to 3.8 cm and, for WC values, from 5.1 to 10.3 cm. Median NC was not associated with age in men (P=0.11) nor in women (P=0.79). However, median WC increased with advancing age in both sexes (P<0.001 for both). There was significant dispersion in WC and NC values for a given BMI and age strata for both men and women. WC, but not NC values, were associated with increasing age. The smaller influence of advancing age on the relationship between BMI and NC (compared to WC) values may be useful in longitudinal studies.

Neck and waist circumference values according to sex, age, and body-mass index: Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

Body fat distribution predicts cardiovascular events better than body-mass index (BMI). Waist circumference (WC) and neck circumference (NC) are inexpensive anthropometric measurements. We aimed to present the conditional distribution of WC and NC values according to BMI, stratified by age and sex, from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline data. We analyzed 15,085 ELSA-Brasil participants with complete data. We used spline quantile regression models, stratified by sex and age, to estimate the NC and WC quantiles according to BMI. To test a putative association between age and median NC or WC values, we built sex-specific median regression models using both BMI and age as explanatory variables. We present estimated 25th, 50th, 75th, and 90th percentiles for NC and WC values, according to BMI, age, and sex. Predicted interquartile intervals for NC values varied from 1.6 to 3.8 cm and, for WC values, from 5.1 to 10.3 cm. Median NC was not associated with age in men (P=0.11) nor in women (P=0.79). However, median WC increased with advancing age in both sexes (P<0.001 for both). There was significant dispersion in WC and NC values for a given BMI and age strata for both men and women. WC, but not NC values, were associated with increasing age. The smaller influence of advancing age on the relationship between BMI and NC (compared to WC) values may be useful in longitudinal studies.

Association between cognitive performance and self-reported glaucoma in middle-aged and older adults: a cross-sectional analysis of ELSA-Brasil

Recent evidence suggests that glaucoma and Alzheimer's disease are neurodegenerative diseases sharing common pathophysiological and etiological features, although findings are inconclusive. We sought to investigate whether self-reported glaucoma patients without dementia present poorer cognitive performance, an issue that has been less investigated. We employed cross-sectional data from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) and included participants ≥50 years of age without a known diagnosis of dementia and a self-reported glaucoma diagnosis. We excluded those with previous stroke, other eye conditions, and using drugs that could impair cognition. We evaluated cognition using delayed word recall, phonemic verbal fluency, and trail making (version B) tests. We used multinomial linear regression models to investigate associations between self-reported glaucoma with cognition, adjusted by several sociodemographic and clinical variables. Out of 4,331 participants, 139 reported glaucoma. Fully-adjusted models showed that self-reported glaucoma patients presented poorer performance in the verbal fluency test (β=-0.39, 95%CI=-0.64 to -0.14, P=0.002), but not in the other cognitive assessments. Thus, our results support the hypothesis that self-reported glaucoma is associated with poor cognitive performance; however, longitudinal data are necessary to corroborate our findings.

Variability in baseline laboratory measurements of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

Multi-center epidemiological studies must ascertain that their measurements are accurate and reliable. For laboratory measurements, reliability can be assessed through investigation of reproducibility of measurements in the same individual. In this paper, we present results from the quality control analysis of the baseline laboratory measurements from the ELSA-Brasil study. The study enrolled 15,105 civil servants at 6 research centers in 3 regions of Brazil between 2008-2010, with multiple biochemical analytes being measured at a central laboratory. Quality control was ascertained through standard laboratory evaluation of intra- and inter-assay variability and test-retest analysis in a subset of randomly chosen participants. An additional sample of urine or blood was collected from these participants, and these samples were handled in the same manner as the original ones, locally and at the central laboratory. Reliability was assessed with the intraclass correlation coefficient (ICC), estimated through a random effects model. Coefficients of variation (CV) and Bland-Altman plots were additionally used to assess measurement variability. Laboratory intra and inter-assay CVs varied from 0.86% to 7.77%. From test-retest analyses, the ICCs were high for the majority of the analytes. Notably lower ICCs were observed for serum sodium (ICC=0.50; 95%CI=0.31-0.65) and serum potassium (ICC=0.73; 95%CI=0.60-0.83), due to the small biological range of these analytes. The CVs ranged from 1 to 14%. The Bland-Altman plots confirmed these results. The quality control analyses showed that the collection, processing and measurement protocols utilized in the ELSA-Brasil produced reliable biochemical measurements.

Sex-specific associations of birth weight with measures of adiposity in mid-to-late adulthood: the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

BACKGROUND/OBJECTIVES: To investigate sex-specific associations of birth weight with body mass index (BMI), waist circumference (WC) and waist-to-hip ratio (WHR) in mid-to-late adulthood. SUBJECTS/METHODS: ELSA-Brasil is a multicenter cohort study of adults aged 35-74 years affiliated with universities or research institutions of six capital cities in Brazil. After exclusions, we investigated 11 636 participants. Socio-demographic factors and birth weight were obtained by interview. All anthropometry was directly measured at baseline. We categorized birth weight as low (⩽2.5 kg); normal (2.5-4 kg) and high (⩾4 kg). We performed analysis of covariance (ANCOVA) for continuous outcomes and ordinal logistic regression for categorical adiposity outcomes. We examined interaction on the multiplicative scale by sex and by race. RESULTS: High birth weight uniformly predicted greater overall and central obesity in men and women. However, low (vs normal) birth weight, in ANCOVA models adjusted for participant age, family income, race, education, maternal education, and maternal and paternal history of diabetes, was associated with lower BMI, WC and WHR means for men, but not for women (Pinteraction=0.01, <0.0001 and <0.0001, respectively). In similarly adjusted ordinal logistic regression models, odds of obesity (odds ratio (OR)=0.65, 0.46-0.90) and of being in the high (vs low) tertile of WC (OR=0.66, 0.50-0.87) and of WHR (OR=0.79, 0.60-1.03) were lower for low (vs normal) birth weight men, but trended higher (BMI: OR=1.18, 0.92-1.51; WC: OR=1.21, 0.97-1.53; WHR: OR=1.44, 1.15-1.82) for low (vs normal) birth weight women. CONCLUSIONS: In this Brazilian sample of middle-aged and elderly adults who have lived through a rapid nutritional transition, low birth weight was associated with adult adiposity in a sex-specific manner. In men, low birth weight was associated with lower overall and central adult adiposity, while in women low birth weight was generally associated with greater central adiposity.

Carboxymethyl lysine, an advanced glycation end product, and incident diabetes: a case-cohort analysis of the ARIC Study.

AIMS: To verify whether elevated fasting levels of circulating carboxymethyl lysine (CML), an advanced glycation end product, predict the development of diabetes in middle-age adults. METHODS: Using a stratified case-cohort design, we followed 543 middle-aged individuals who developed diabetes and 514 who did not over a median 9 years in the Atherosclerosis Risk in Communities Study. Weighted Cox proportional hazards analyses were used to account for the design. RESULTS: In weighted analyses, correlation between CML levels and anthropometric, inflammatory or metabolic variables was minimal (Pearson correlations usually < 0.10). CML, when modelled as a continuous variable and after adjustment for age, sex, race, centre, parental history of diabetes, BMI, waist-to-hip ratio, non-esterified fatty acids, oxidized LDL-cholesterol, GFR, smoking, an inflammation score, adiponectin, leptin, insulin and glucose levels, was associated with an increased risk of diabetes [Hazard ratio (HR) = 1.35; 95% confidence interval (CI) 1.09-1.67, for each 100 ng/ml CML increment]. Baseline glucose level and race each modified the association (P < 0.05 for interaction), which was present only among those with impaired fasting glucose (≥ 5.6 mmol/l, HR = 1.61, 95% CI 1.26-2.05) and among white participants (HR = 1.50, 95% CI 1.13-1.99). CONCLUSIONS: Elevated fasting CML, after adjustment for multiple risk factors for diabetes, predicts the development of incident diabetes, the association being present among those with impaired fasting glucose and in white participants. These prospective findings suggest that advanced glycation end products might play a role in the development of diabetes.

Variability in baseline laboratory measurements of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

Multi-center epidemiological studies must ascertain that their measurements are accurate and reliable. For laboratory measurements, reliability can be assessed through investigation of reproducibility of measurements in the same individual. In this paper, we present results from the quality control analysis of the baseline laboratory measurements from the ELSA-Brasil study. The study enrolled 15,105 civil servants at 6 research centers in 3 regions of Brazil between 2008–2010, with multiple biochemical analytes being measured at a central laboratory. Quality control was ascertained through standard laboratory evaluation of intra- and inter-assay variability and test-retest analysis in a subset of randomly chosen participants. An additional sample of urine or blood was collected from these participants, and these samples were handled in the same manner as the original ones, locally and at the central laboratory. Reliability was assessed with the intraclass correlation coefficient (ICC), estimated through a random effects model. Coefficients of variation (CV) and Bland-Altman plots were additionally used to assess measurement variability. Laboratory intra and inter-assay CVs varied from 0.86% to 7.77%. From test-retest analyses, the ICCs were high for the majority of the analytes. Notably lower ICCs were observed for serum sodium (ICC=0.50; 95%CI=0.31–0.65) and serum potassium (ICC=0.73; 95%CI=0.60–0.83), due to the small biological range of these analytes. The CVs ranged from 1 to 14%. The Bland-Altman plots confirmed these results. The quality control analyses showed that the collection, processing and measurement protocols utilized in the ELSA-Brasil produced reliable biochemical measurements.

Fasting plasma glucose to avoid a full OGTT in the diagnosis of gestational diabetes.

AIMS: To evaluate the performance of fasting plasma glucose (FPG) in determining the need for a full oral glucose tolerance test (OGTT) to diagnose gestational diabetes (GDM) by the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria. METHODS: A multicenter cohort study of 4926 pregnant women 20 years or older consecutively enrolled in prenatal care clinics of the Brazilian National Health Service from 1991 to 1995. All women underwent a single 2 h 75 g OGTT by weeks 24-28 of pregnancy and were followed to detect adverse pregnancy outcomes. RESULTS: A FPG cut-off value of 80 mg/dl indicated that only 38.7% of all women needed to undergo a complete OGTT, while detecting 96.9% of all GDM cases. When the 85 mg/dl cut-off was used, the corresponding percentages were 18.7% and 92.5%, respectively. The fraction of women labeled with GDM who had adverse pregnancy outcomes was nearly identical when using FPG strategies and universal full testing. CONCLUSIONS: Using a FPG cut-off to diagnose GDM and to determine the need for post-load OGTT measurements is a valid strategy to diagnose GDM by IADPSG criteria. This approach may improve feasibility of applying IADPSG diagnostic criteria by reducing costs and increasing convenience.

Visions for the 20th International Epidemiological Association's World Congress of Epidemiology (WCE 2014).

During August 17th-21st, 2014, the University of Alaska Anchorage, along with other local, state, and federal agencies throughout Alaska, will host the 20(th) International Epidemiological Association's (IEA) World Congress of Epidemiology (WCE 2014). The theme for this Congress is "Global Epidemiology in a Changing Environment: The Circumpolar Perspective." The changing environment includes the full range of environments that shape population health and health inequities from the physical to the social and economic. Our circumpolar perspective on these environments includes views on how political systems, work, immigration, Indigenous status, and gender relations and sexuality affect the global world and the health of its people. Suggestions and insights from the 3(rd) North American Congress of Epidemiology (2011) and the first-ever joint regional workshop co-organized by the IEA North American Region and the IEA Latin American and Caribbean Region held at the 19(th) IEA World Congress of Epidemiology (2011) have helped direct the focus for WCE 2014. Since the Arctic regions are feeling the effects of climate change first, we believe focusing on the emerging data on the health impacts of climate change throughout the world will be an important topic for this Congress. This will include a broad range of more traditional epidemiology areas such as infectious disease epidemiology, environmental epidemiology, health disparities, and surveillance and emergency preparedness. Addressing health inequities and promoting health equity is likewise a key concern of the Congress. This Congress will also host presentations on injury epidemiology, occupational health, infectious diseases, chronic diseases, maternal and child health, surveillance and field epidemiology, mental health, violence (from self-directed, e.g., suicide, to interpersonal to structural), psychoactive substance use (including tobacco), and measures of subjective health. Attention will be given to epidemiology's theoretical frameworks and emphasizing knowledge translation, from epidemiology to health systems, to policy, and to the broader public. We also plan to offer many hands-on workshops including practical uses of epidemiology to improve health systems and reduce health inequities within and between countries; the manner in which epidemiology can inform public health practice; the understanding and use of the Dictionary of Epidemiology; and many others.

Evaluation of a 1-h 75-g oral glucose tolerance test in the diagnosis of gestational diabetes.

In order to evaluate the performance of a 1-h 75-g oral glucose tolerance test (OGTT) for the diagnosis of gestational diabetes mellitus (GDM), a cohort of 4998 women, 20 years or older, without previous diabetes being treated in prenatal care clinics in Brazil answered a questionnaire and performed a 75-g OGTT including fasting, 1-h and 2-h glucose measurements between their 24th and 28th gestational weeks. Pregnancy outcomes were transcribed from medical registries. GDM was defined according to WHO criteria (fasting: >/=126 mg/dL; 2-h value: >/=140 mg/dL) and macrosomia as a birth weight equal to or higher than 4000 g. Areas under the receiver operator characteristic curve (AUC) were compared and diagnostic properties of various cut-off points were evaluated. The AUCs for the prediction of macrosomia were 0.606 (0.572-0.637) for the 1-h and 0.589 (0.557-0.622) for the 2-h plasma glucose test. Similar predictability was demonstrable regarding combined adverse outcomes: 0.582 (0.559-0.604) for the 1-h test and 0.572 (0.549-0.595) for the 2-h test. When the 1-h glucose test was evaluated against a diagnosis of GDM defined by the 2-h glucose test, the AUC was 0.903 (0.886-0.919). The cut-off point that maximized sensitivity (83%) and specificity (83%) was 141 mg/dL, identifying 21% of the women as positive. A cut-off point of 160 mg/dL, with lower sensitivity (62%), had higher specificity (94%), labeling 8.6% as positive. Detection of GDM can be done with a 1-h 75-g OGTT: the value of 160 mg/dL has the same diagnostic performance as the conventional 2-h value (140 mg/dL). The simplification of the test may improve coverage and timing of the diagnosis of GDM.

Evaluation of a 1-h 75-g oral glucose tolerance test in the diagnosis of gestational diabetes

In order to evaluate the performance of a 1-h 75-g oral glucose tolerance test (OGTT) for the diagnosis of gestational diabetes mellitus (GDM), a cohort of 4998 women, 20 years or older, without previous diabetes being treated in prenatal care clinics in Brazil answered a questionnaire and performed a 75-g OGTT including fasting, 1-h and 2-h glucose measurements between their 24th and 28th gestational weeks. Pregnancy outcomes were transcribed from medical registries. GDM was defined according to WHO criteria (fasting: greater than or equal to 126 mg/dL; 2-h value: greater than or equal to 140 mg/dL) and macrosomia as a birth weight equal to or higher than 4000 g. Areas under the receiver operator characteristic curve (AUC) were compared and diagnostic properties of various cut-off points were evaluated. The AUCs for the prediction of macrosomia were 0.606 (0.572-0.637) for the 1-h and 0.589 (0.557-0.622) for the 2-h plasma glucose test. Similar predictability was demonstrable regarding combined adverse outcomes: 0.582 (0.559-0.604) for the 1-h test and 0.572 (0.549-0.595) for the 2-h test. When the 1-h glucose test was evaluated against a diagnosis of GDM defined by the 2-h glucose test, the AUC was 0.903 (0.886-0.919). The cut-off point that maximized sensitivity (83%) and specificity (83%) was 141 mg/dL, identifying 21% of the women as positive. A cut-off point of 160 mg/dL, with lower sensitivity (62%), had higher specificity (94%), labeling 8.6% as positive. Detection of GDM can be done with a 1-h 75-g OGTT: the value of 160 mg/dL has the same diagnostic performance as the conventional 2-h value (140 mg/dL). The simplification of the test may improve coverage and timing of the diagnosis of GDM.

Metabolic syndrome risk for cardiovascular disease and diabetes in the ARIC study.

OBJECTIVE: The metabolic syndrome is associated with increased risk for cardiovascular disease and diabetes. Several analyses from the Atherosclerosis Risk in Communities (ARIC) study have been performed to examine the role of the metabolic syndrome and its components in predicting risk for cardiovascular disease and diabetes. DESIGN AND SUBJECTS: The large, biracial, population-based ARIC study enrolled 15792 middle-aged Americans in four communities in the United States and has followed them for the development of cardiovascular disease and diabetes. MEASUREMENTS: Outcome parameters included prevalence of the metabolic syndrome and its individual components, carotid intima-media thickness, incident coronary heart disease, incident ischemic stroke and incident diabetes. RESULTS AND CONCLUSION: Several analyses from the ARIC study have shown that the metabolic syndrome, as well as individual metabolic syndrome components, is predictive of the prevalence and incidence of coronary heart disease, ischemic stroke, carotid artery disease and diabetes.

Glutamic acid decarboxylase antibodies are indicators of the course, but not of the onset, of diabetes in middle-aged adults: the Atherosclerosis Risk in Communities Study.

To efficiently examine the association of glutamic acid decarboxylase antibody (GADA) positivity with the onset and progression of diabetes in middle-aged adults, we performed a case-cohort study representing the ~9-year experience of 10,275 Atherosclerosis Risk in Communities Study participants, initially aged 45-64 years. Antibodies to glutamic acid decarboxylase (GAD65) were measured by radioimmunoassay in 580 incident diabetes cases and 544 non-cases. The overall weighted prevalence of GADA positivity (>or=1 U/mL) was 7.3%. Baseline risk factors, with the exception of smoking and interleukin-6 (P or=2.38 U/mL) of positivity. GADA-positive and GADA-negative non-diabetic individuals had similar risk profiles for diabetes, with central obesity and elevated inflammation markers, aside from glucose, being the main predictors. Among diabetes cases at study's end, progression to insulin treatment increased monotonically as a function of baseline GADA level. Overall, being GADA positive increased risk of progression to insulin use almost 10 times (HR = 9.9; 95%CI = 3.4, 28.5). In conclusion, in initially non-diabetic middle-aged adults, GADA positivity did not increase diabetes risk, and the overall baseline profile of risk factors was similar for positive and negative individuals. Among middle-aged adults, with the possible exception of those with the highest GADA levels, autoimmune pathophysiology reflected by GADA may become clinically relevant only after diabetes onset.

Glutamic acid decarboxylase antibodies are indicators of the course, but not of the onset, of diabetes in middle-aged adults: the Atherosclerosis Risk in Communities Study

To efficiently examine the association of glutamic acid decarboxylase antibody (GADA) positivity with the onset and progression of diabetes in middle-aged adults, we performed a case-cohort study representing the ~9-year experience of 10,275 Atherosclerosis Risk in Communities Study participants, initially aged 45-64 years. Antibodies to glutamic acid decarboxylase (GAD65) were measured by radioimmunoassay in 580 incident diabetes cases and 544 non-cases. The overall weighted prevalence of GADA positivity (³1 U/mL) was 7.3 percent. Baseline risk factors, with the exception of smoking and interleukin-6 (P ú 0.02), were generally similar between GADA-positive and -negative individuals. GADA positivity did not predict incident diabetes in multiply adjusted (HR = 1.04; 95 percentCI = 0.55, 1.96) proportional hazard analyses. However, a small non-significant adjusted risk (HR = 1.29; 95 percentCI = 0.58, 2.88) was seen for those in the highest tertile (³2.38 U/mL) of positivity. GADA-positive and GADA-negative non-diabetic individuals had similar risk profiles for diabetes, with central obesity and elevated inflammation markers, aside from glucose, being the main predictors. Among diabetes cases at study's end, progression to insulin treatment increased monotonically as a function of baseline GADA level. Overall, being GADA positive increased risk of progression to insulin use almost 10 times (HR = 9.9; 95 percentCI = 3.4, 28.5). In conclusion, in initially non-diabetic middle-aged adults, GADA positivity did not increase diabetes risk, and the overall baseline profile of risk factors was similar for positive and negative individuals. Among middle-aged adults, with the possible exception of those with the highest GADA levels, autoimmune pathophysiology reflected by GADA may become clinically relevant only after diabetes onset.

Leptin and incident type 2 diabetes: risk or protection?

AIMS/HYPOTHESIS: The aim of this study was to investigate the association of leptin levels with incident diabetes in middle-aged adults, taking into account factors purportedly related to leptin resistance. SUBJECTS AND METHODS: We conducted a case-cohort study (570 incident diabetes cases and 530 non-cases) representing the 9-year experience of 10,275 participants of the Atherosclerosis Risk in Communities Study. Plasma leptin was measured by direct sandwich ELISA. RESULTS: In proportional hazards models adjusting for age, study centre, ethnicity and sex, high leptin levels (defined by sex-specific cut-off points) predicted an increased risk of diabetes, with a hazard ratio (HR) comparing the upper with the lower quartile of 3.9 (95% CI 2.6-5.6). However, after further adjusting additionally for obesity indices, fasting insulin, inflammation score, hypertension, triglycerides and adiponectin, high leptin predicted a lower diabetes risk (HR=0.40, 95% CI 0.23-0.67). Additional inclusion of fasting glucose attenuated this protective association (HR=0.59, 95% CI 0.32-1.08, p<0.03 for linear trend across quartiles). In similar models, protective associations were generally seen across subgroups of sex, race, nutritional status and smoking, though not among those with lower inflammation scores or impaired fasting glucose (interaction p=0.03 for both). CONCLUSIONS/INTERPRETATION: High leptin levels, probably reflecting leptin resistance, predict an increased risk of diabetes. Adjusting for factors purportedly related to leptin resistance unveils a protective association, independent of adiponectin and consistent with some of leptin's described protective effects against diabetes.

[Drug use by pregnant women in six Brazilian cities]. / Uso de medicamentos por gestantes em seis cidades brasileiras.

OBJECTIVE: To describe drugs used during pregnancy by women attending prenatal clinics of the national public health system (SUS) in Brazilian cities. METHODS: Using a structured questionnaire, 5,564 pregnant women between the week 21 to 28 who attended prenatal visits of the SUS in six Brazilian cities were interviewed. The interview questions were grouped in "guided use" to cover pain, cramps, nausea, cough, and others, and "guided medicine" to cover vitamins, iron, and fluoride. The Food and Drug Administration gestational risk classification (1991-1995) was applied. RESULTS: Of a total of 5,564 women, 4,614 (83.8%) used at least one drug during pregnancy, with a total of 9,556 drugs used. The drugs most frequently used were vitamins associated with anti-anemics (33.5%), gastrointestinal drugs (31.3%), analgesics and anti-inflammatory drugs (22.2%), anti-anemics (19.8%), and antibiotics (11.1%). Regarding gestational risk, 3,243 drugs used (34%) belonged to category A risk, 1,923 (22.6%) to category B, 3,798 (39.7%) to category C, 289 (3.0%) to category D, and 55 (0.6%) to category X. CONCLUSIONS: A large variation in drug use across the cities was observed, especially for anti-anemics and vitamins associated with anti-anemics, revealing the lack of a national consensus regarding the use of these drugs during pregnancy. There was no literature data about safety during pregnancy for 12.9% of the drugs used. This percentage, plus the 26.9% of category C drugs, shows that 40% of the drugs used during pregnancy do not belong to the approved safety categories. However, only 3% of the 9,956 drugs used were clearly contraindicated during pregnancy.

Gestational diabetes mellitus diagnosed with a 2-h 75-g oral glucose tolerance test and adverse pregnancy outcomes.

OBJECTIVE: To evaluate American Diabetes Association (ADA) and World Health Organization (WHO) diagnostic criteria for gestational diabetes mellitus (GDM) against pregnancy outcomes. RESEARCH DESIGN AND METHODS: This cohort study consecutively enrolled Brazilian adult women attending general prenatal clinics. All women were requested to undertake a standardized 2-h 75-g oral glucose tolerance test (OGTT) between their estimated 24th and 28th gestational weeks and were then followed to delivery. New ADA criteria for GDM require two plasma glucose values > or = 5.3 mmol/l (fasting), > or = 10 mmol/l (1 h), and > or = 8.6 mmol/l (2 h). WHO criteria require a plasma glucose > or = 7.0 mmol/l (fasting) or > or = 7.8 mmol/l (2 h). Individuals with hyperglycemia indicative of diabetes outside of pregnancy were excluded. RESULTS: Among the 4,977 women studied, 2.4% (95% CI 2.0-2.9) presented with GDM by ADA criteria and 7.2% (6.5-7.9) by WHO criteria. After adjustment for the effects of age, obesity, and other risk factors, GDM by ADA criteria predicted an increased risk of macrosomia (RR 1.29, 95% CI 0.73-2.18), preeclampsia (2.28, 1.22-4.16), and perinatal death (3.10, 1.42-6.47). Similarly, GDM by WHO criteria predicted increased risk for macrosomia (1.45, 1.06-1.95), preeclampsia (1.94, 1.22-3.03), and perinatal death (1.59, 0.86-2.90). Of women positive by WHO criteria, 260 (73%) were negative by ADA criteria. Conversely, 22 (18%) women positive by ADA criteria were negative by WHO criteria. CONCLUSIONS: GDM based on a 2-h 75-g OGTT defined by either WHO or ADA criteria predicts adverse pregnancy outcomes.

Chronic activation of the innate immune system may underlie the metabolic syndrome.

CONTEXT: The metabolic syndrome is characterized by a clustering, in free-living populations, of cardiovascular and diabetes risk factors generally linked to insulin resistance, obesity and central obesity. Consonant with the well-established inflammatory pathogenesis of atherosclerotic disease, the metabolic syndrome is now being investigated in relation to its inflammatory nature. OBJECTIVE: We present cross-sectional findings demonstrating that markers of inflammation correlate with components of the metabolic syndrome, and prospective findings of the ARIC Study indicating that markers of inflammation and endothelial dysfunction predict the development of diabetes mellitus and weight gain in adults. We present biological evidence to suggest that chronic activation of the innate immune system may underlie the metabolic syndrome, characterizing the common soil for the causality of type 2 diabetes mellitus and cardiovascular disease. CONCLUSIONS: Better understanding of the role of the innate immune system in these diseases may lead to important advances in the prediction and management of diabetes and cardiovascular disease.