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

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.

Homeostasis model assessment of insulin resistance (HOMA-IR) and metabolic syndrome at baseline of a multicentric Brazilian cohort: ELSA-Brasil study / Modelo de avaliação da homeostase de resistência à insulina (HOMA-IR) e síndrome metabólica na linha de base de uma coorte brasileira multicêntrica: estudo ELSA-Brasil / Modelo homeostático para evaluar la resistencia a la insulina (HOMA-IR) y síndrome metabólico en la línea de base de una cohorte brasileña multicéntrica: estudio ELSA-Brasil

Abstract: 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.

Resumo: O modelo de avaliação da homeostase da resistência à insulina (HOMA-IR) é um método para medir a resistência à insulina. Os pontos de corte do HOMA-IR para identificar a síndrome metabólica podem variar entre as populações e os níveis de índice de massa corporal (IMC). Nosso objetivo foi investigar os pontos de corte do HOMA-IR que melhor discriminam indivíduos com resistência à insulina e com síndrome metabólica para cada categoria de IMC em uma grande amostra de adultos sem diabetes na linha de base do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil). Entre os 12.313 participantes com média de idade de 51,2 (DP 8,9) anos, a prevalência de síndrome metabólica foi de 34,6%, e 60,1% apresentavam sobrepeso ou obesidade. As prevalências de síndrome metabólica nas categorias de peso normal, sobrepeso e obesidade foram, respectivamente, 13%, 43,2% e 60,7%. O ponto de máxima sensibilidade e especificidade combinadas do HOMA-IR para discriminar a síndrome metabólica foi de 2,35 em toda a amostra, com valores crescentes nas categorias de IMC mais elevadas. Esta investigação contribui para o melhor entendimento dos valores de HOMA-IR associados à resistência à insulina e síndrome metabólica em uma grande amostra de adultos brasileiros, e que o uso de pontos de corte de acordo com a curva ROC pode ser a melhor estratégia. Também sugere que valores diferentes podem ser apropriados nas categorias de IMC.

Resumen: El modelo homeostático para evaluar la resistencia a la insulina (HOMA-IR) es un método para medir la resistencia a la insulina. Los cortes HOMA-IR para identificar el síndrome metabólico pueden variar entre las poblaciones y los niveles del índice de masa corporal (IMC). El objetivo fue investigar los cortes de HOMA-IR que mejor discriminaban individuos con resistencia a la insulina y con síndrome metabólico para cada categoría de IMC, en una extensa muestra de adultos sin diabetes en la base de referencia del Estudio Longitudinal de Salud del Adulto (ELSA-Brasil). Entre los 12.313 participantes con una media de edad de 51,2 años (DE 8,9), la prevalencia de síndrome metabólico fue 34,6%, y un 60,1% sufría sobrepeso u obesidad. La prevalencia de síndrome metabólico entre las categorías: peso normal, sobrepeso y obesidad fueron respectivamente, 13%, 43,2% y 60,7%. El punto de máxima sensibilidad combinada y especificidad de HOMA-IR para discriminar el síndrome metabólico fue 2,35 en toda la muestra, con valores crecientes en las categorías de IMC más altas. Esta investigación contribuye a entender mejor los valores HOMA-IR, asociados con resistencia a la insulina y síndrome metabólico en una gran muestra de adultos brasileños, además del planteamiento de que el uso de puntos de corte según la curva ROC es quizás la mejor estrategia a seguir. También sugiere que valores diferentes pueden ser apropiados a través de las categorías de IMC.

Work-Family Conflict and Ideal Cardiovascular Health Score in the ELSA-Brasil Baseline Assessment.

Background There are few data about the association between work-related stress and the American Heart Association ideal cardiovascular health (CVH) metrics. We studied the association between work-family conflict (WFC) and ideal CVH scores in the ELSA-Brasil (Brazilian Longitudinal Study of Adult Health) baseline study. Methods and Results We analyzed data of active workers (5424 men and 5967 women), aged 35 to 74 years, from 2008 to 2010. Ideal CVH scores were calculated based on the lifestyle and health metrics proposed by the American Heart Association, using data from questionnaires and clinical and laboratory examinations from the ELSA-Brasil study baseline. The WFC questionnaire was based on the Frone model, validated for Brazilian Portuguese. WFC domains (time and strain-based work interference with family, family interference with work, and lack of time for personal care and leisure) and frequency (never to rarely, sometimes, or frequently) were self-reported. Main models were adjusted for age, sex, race, educational level, income, and study site. Positive relative predicted score differences (rPSDs) indicate higher predicted scores. We found lower lifestyle ideal CVH scores among men (rPSD, -5.7%; P=0.002) and women (rPSD, -10.2%; P<0.001) with frequent lack of time for personal care and leisure. We found lower lifestyle ideal CVH scores among women with frequent strain-based work interference with family (rPSD, -5.1%; P=0.002), and family interference with work (rPSD, -8.6%; P=0.001). We found higher health ideal CVH scores among men with frequent WFC, which may be attributable to reverse causation. Conclusions We found significant associations between WFC and ideal CVH scores. These associations were heterogeneous according to sex.

Ideal cardiovascular health score at the ELSA-Brasil baseline and its association with sociodemographic characteristics.

BACKGROUND: The American Heart Association's ideal cardiovascular health (ICH) define criteria for seven metrics, four classified as lifestyle factors (diet, physical activity, smoking and body-mass index) and four classified as health factors (smoking, blood pressure, fasting plasma glucose and total cholesterol). We aimed to analyze ICH scores at the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline assessment and the associations with sociodemographic characteristics (age, sex, race, educational level, and family income). METHODS: We analyzed 13,356 ELSA-Brasil participants without cardiovascular disease using quasi-Poisson regression models to study the association between the ICH score and sociodemographic characteristics. RESULTS: Mean ICH scores were 2.5±1.3. Only 1047 (7.8%) participants had 5 or more ICH metrics. In adjusted models, age 65-74years was associated with lower ICH scores (-35.4%; 95% confidence interval [CI]: -37.6% to -33.1%) compared to age 35-44years. Women had higher ICH scores compared to men (+13.8%; 95%CI: +11.8% to +15.7%), mainly due to differences in the health factor ICH metrics. Participants of Black race had lower ICH scores compared to those of White race (-9.4%; 95%CI: -11.8% to -7.0%). Individuals with less than high school education had lower ICH scores than college-educated individuals (-17.2%; 95%CI: -20.0% to -14.2%). Low (<1245 USD) family income was also associated with lower ICH scores compared to those with high (≥3320 USD) family income (-4.4%, 95%CI: -7.2% to -1.6%). CONCLUSIONS: We found a low proportion of individuals with 5 or more ICH metrics. Age, sex, race, educational level and income were associated with ICH scores.

Life course socioeconomic adversities and 10-year risk of cardiovascular disease: cross-sectional analysis of the Brazilian Longitudinal Study of Adult Health.

OBJECTIVES: To investigate whether life course exposure to adverse socioeconomic positions (SEP) as well as maintaining a low SEP or decreasing the SEP intra- and intergeneration was associated with an increased 10-year cardiovascular disease (CVD) risk predicted by the Framingham Risk Score. METHODS: This is a cross-sectional analysis of baseline data (2008-2010) of 13,544 active workers from ELSA-Brasil cohort. Maternal education, leg length, social class of first occupation and education were used to evaluate childhood, youth and adulthood SEP. RESULTS: After considering adulthood SEP, exposure to early-life low SEP remained associated with an increased 10-year CVD risk. The 10-year CVD risk also rose as the number of exposures to low SEP throughout life increased. Compared to individuals in high-stable intragenerational trajectory, those in upward, downward, or stable low trajectory presented higher 10-year CVD risk. Increasing individuals' SEP over generation showed no increased risk of 10-year CVD risk compared to individuals in high-stable trajectory. CONCLUSIONS: Childhood may be a critical period for exposures to social adversities. Life course low SEP may also affect the 10-year CVD risk via accumulation of risk and social mobility.

Association between Cardiovascular Health Score and Carotid Intima-Media Thickness: Cross-Sectional Analysis of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) Baseline Assessment.

BACKGROUND: The American Heart Association aims to reduce the burden of cardiovascular disease in this decade by improving seven ideal cardiovascular health (CVH) characteristics in the population. The aim of this study was to quantify the association between the American Heart Association's CVH score and values for carotid intima-media thickness (CIMT) in the Brazilian Longitudinal Study of Adult Health baseline assessment. METHODS: The Brazilian Longitudinal Study of Adult Health is a multicenter cohort study of civil servants aged 35 to 74 years in Brazil. In this study, the investigators analyzed 9,662 individuals with no previous cardiovascular disease. The distribution of CIMT values (categorized into age-, sex-, and race-specific quartiles) was analyzed according to CVH scores using χ2 trend tests. Linear and multinomial regression models were built to evaluate the association between CIMT and CVH score. RESULTS: A significant increase was observed in the proportion of individuals within the first and second CIMT quartiles, as well as a decrease within the fourth quartile with higher CVH score strata (P for trend < .001). A 1-point increase in CVH score was associated in adjusted models with a decrease of 0.011 mm in CIMT and an odds ratio of 0.79 (95% CI, 0.77-0.81) of having CIMT in the fourth quartile. However, nearly 16% of individuals with optimal CVH scores had CIMT values in the highest quartile. CONCLUSIONS: In this study, significant associations were found between CIMT and CVH score in a large sample of middle-aged adults. However, a high CVH score did not warrant the absence of a significant subclinical atherosclerotic burden.

Social mobility and subclinical atherosclerosis in a middle-income country: Association of intra- and inter-generational social mobility with carotid intima-media thickness in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

Over the past half century Brazil has undergone a process of dramatic industrialization and urbanization. Cardiovascular diseases (CVD) have become common due to rapid demographic, epidemiologic, and nutritional transitions. The association of social mobility with subclinical CVD has been rarely explored, particularly in developing societies. We investigated the association of intra- and inter-generational social mobility with carotid intima-media thickness (IMT), a marker of subclinical or asymptomatic atherosclerosis, in a large Brazilian sample (ELSA-Brasil). We used baseline data (2008-2010) for 7343 participants from ELSA-Brasil. Intra-generational social mobility was defined as the change in occupational social class between participants' first occupation and current occupation. Inter-generational social mobility was defined as the change in occupational social class of the head of the household when the participant started working and participants' current occupation. Social mobility groups were classified as: stable high (reference), upward, downward and stable low. Linear regression models were used to examine the associations between type of social mobility and IMT. Compared to those who experienced stable high occupational status across generations, downward inter-generational mobility was associated with greater IMT. Additionally, those who declined the most in occupational status had the highest values of IMT, even after adjustments for lifestyle and cardiovascular factors. For intra-generational mobility, stable low versus stable high social mobility was independently associated with higher IMT. Subclinical atherosclerosis is patterned by socioeconomic status both within and across generations, demonstrating an association even before symptoms of CVD appear. The health consequences of downward inter-generational social mobility were not fully explained by lifestyle and cardiovascular factors, whereas being consistently exposed to low occupational status within one's own adulthood was associated with greater IMT, suggesting a cumulative risk model. Primary prevention of atherosclerosis should be complemented by macrosocial policies aimed to reduce downward socioeconomic mobility between generations.

Associations of life course socioeconomic position and job stress with carotid intima-media thickness. The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

RATIONALE: The association between life course socioeconomic position (SEP) and subclinical atherosclerosis is not consistent across studies. Socioeconomic adversities early in life are related to an increased probability of a low occupational grade and more stressful jobs in adulthood. However, the role of job stress in explaining the life course social gradient in subclinical atherosclerosis is unknown. OBJECTIVES: To examine whether life course SEP is associated with carotid intima-media thickness (IMT) and to investigate whether this association is partially mediated by job stress. METHODS: This study used baseline data (2008-2010) for 8806 current workers from ELSA-Brasil. Maternal education, social class of first occupation and social class of current occupation were used to evaluate childhood, youth and adulthood SEP, respectively. Accumulation of risk across the life course was also evaluated. Job stress was assessed by the Swedish Demand-Control-Support Questionnaire. Directed acyclic graph and linear regression models were used. RESULTS: Low childhood SEP was associated with increased IMT only in women, but low youth and adulthood SEP were associated with higher IMT in both genders. The simultaneous adjustment for all SEP indicators showed that only adulthood SEP continued to be associated with IMT. However, higher IMT values were observed among men and women sequentially exposed to low SEP in more than one period of life. High-strain jobs and low job control were not associated with IMT independent of SEP. CONCLUSION: Our results support a model of the cumulative effects of exposures to SEP across the life span because the highest IMT values were observed in individuals sequentially exposed to low SEP in more than one period of life. We did not find that job stress explained the association between life course SEP and IMT, suggesting that strategies to address socioeconomic inequalities in CVD should target additional steps beyond reducing job stress.

Carotid intima-media thickness value distributions in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

OBJECTIVE: Carotid intima-media thickness (IMT) is a noninvasive measurement of early atherosclerosis. Most IMT studies have involved populations with low rates of racial blending. The aim of the present article is to describe IMT value distributions and analyze the influence of sex and race on IMT values in a large Brazilian sample, a setting with a high rate of racial admixture. METHODS: The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) is a multicenter cohort of 15,105 adult (aged 35-74 years) civil servants in six Brazilian cities. Baseline assessment included IMT measurements in both common carotid arteries. Race was self-reported. We studied the association between sex and race with IMT values using multiple linear regression models. We conducted analyses in all and low-risk individuals, defined as those without classical cardiovascular risk factors. RESULTS: We analyzed complete IMT data from 10,405 ELSA-Brasil participants. We present nomograms by age for all and low-risk individuals, stratified by sex and race. We found that men had significantly higher maximal IMT values compared with women (ß = 0.058; P < 0.001). This association remained for low-risk individuals (ß = 0.027; P = 0.001). In addition, Brown and White individuals had lower maximal IMT values compared with Black individuals for all (ß = -0.034 and ß = -0.054, respectively; P < 0.001) and low-risk individuals (ß = -0.027; P = 0.013 and ß = -0.035; P < 0.001, respectively). CONCLUSION: We found significantly higher IMT values in men. We found significantly higher IMT values in Black individuals than White and Brown individuals. These results persisted when analyses were restricted to low-risk individuals.

Negative life events and migraine: a cross-sectional analysis of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline data.

BACKGROUND: Stress is a typical migraine trigger. However, the impact of negative life events on migraine activity is poorly studied. The aim of this study is to investigate the association between negative life events and migraine using data from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline assessment. METHODS: ELSA-Brasil is a multicenter cohort study conducted in six Brazilian cities. Baseline assessment included validated questionnaires for headache classification and the occurrence of five pre-specified negative life events (financial hardship, hospitalization other than for childbirth, death of a close relative, robbery and end of a love relationship), focusing on a 12-month period before evaluation. We built crude and adjusted logistic regression models to study the association between the occurrences of negative life events and migraine diagnosis and activity. RESULTS: We included 4,409 individuals with migraine and 4,457 participants without headache (reference). After adjustment for age, sex, race, income and educational level, we found that the occurrence of a negative life event (Odds ratio = 1.31; 95% confidence interval = 1.19-1.45) was associated with migraine. However, after stratifying with subgroup analyses, only financial hardship (Odds ratio = 1.65; 95% confidence interval = 1.47-1.87) and hospitalization (Odds ratio = 1.47; 95% confidence interval = 1.25-1.72) were independently associated with migraine. Further adjustment for a current major depression episode and report of religious activity did not significantly change the results. Considering migraine frequency as (a) less than once per month, (b) once per month to once per week, or (c) more than once per week, financial hardship and hospitalization remained significantly associated with migraine in all episode frequency strata, with higher odds ratios for higher frequencies in adjusted models. We also observed a significant association between the death of a close relative and the highest migraine frequency stratum (Odds ratio = 1.38; 95% confidence interval = 1.09-1.75) in full-adjusted model. CONCLUSIONS: The occurrence of financial hardship and hospitalization had a direct and independent association with migraine diagnosis and frequency. The death of a close relative was also independently associated with the highest migraine frequency stratum.