Racial Inequities in the Control of Hypertension and the Explanatory Role of Residential Segregation: a Decomposition Analysis in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

The mechanisms underlying racial inequities in uncontrolled hypertension have been limited to individual factors. We investigated racial inequities in uncontrolled hypertension and the explanatory role of economic segregation in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). All 3897 baseline participants with hypertension (2008-2010) were included. Uncontrolled hypertension (SBP ≥ 140 mmHg or DBP ≥ 90 mmHg), self-reported race (White/Brown/Black people), and neighborhood economic segregation (low/medium/high) were analyzed cross-sectionally. We used decomposition analysis, which describes how much a disparity would change (disparity reduction; explained portion) and remain (disparity residual; unexplained portion) upon removing racial differences in economic segregation (i.e., if Black people had the distribution of segregation of White people, how much we would expect uncontrolled hypertension to decrease among Black people). Age- and gender-adjusted prevalence of uncontrolled hypertension (39.0%, 52.6%, and 54.2% for White, Brown, and Black participants, respectively) remained higher for Black and Brown vs White participants, regardless of economic segregation. Uncontrolled hypertension showed a dose-response pattern with increasing segregation levels for White but not for Black and Brown participants. After adjusting for age, gender, education, and study center, unexplained portion (disparity residual) of race on uncontrolled hypertension was 18.2% (95% CI 13.4%; 22.9%) for Black vs White participants and 12.6% (8.2%; 17.1%) for Brown vs White participants. However, explained portion (disparity reduction) through economic segregation was - 2.1% (- 5.1%; 1.3%) for Black vs White and 0.5% (- 1.7%; 2.8%) for Brown vs White participants. Although uncontrolled hypertension was greater for Black and Brown vs White people, racial inequities in uncontrolled hypertension were not explained by economic segregation.

The effect modification of occupational social class in the association between sex and type 2 diabetes: results from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

We evaluated data from 14,156 baseline participants of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) collected from 2008 to 2010, to analyze the effect modification of occupational social class on the association between sex and prevalence of type 2 diabetes. The crude and age-adjusted prevalence, according to sex and occupational social class, were estimated using generalized linear models with binomial distribution and logarithmic link function. This model was also used to estimate prevalence ratios (PR), adjusting for age group, race/skin color, and maternal education. The effect modification was measured in the multiplicative and additive scales. Males had higher crude and age-adjusted prevalence in all occupational social class strata. As occupational social class increases, the prevalence among males and females decreases. The PR of males to females decreased according to occupational class: 66% (PR = 1.66; 95%CI: 1.44; 1.90), 39% (PR = 1.39; 95%CI: 1.02; 1.89), and 28% (PR = 1.28; 95%CI: 0.94; 1.75) in the high, middle, and low occupational social classes, respectively. We found an inverse effect of the occupational social class on the association between sex and type 2 diabetes on the multiplicative scale, suggesting that it acts as an effect modifier.

The effect modification of occupational social class in the association between sex and type 2 diabetes: results from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) / O efeito da modificação da classe social ocupacional na associação entre sexo e diabetes tipo 2: resultados do Estudo Longitudinal de Saúde do Adulto no Brasil (ELSA-Brasil) / El efecto del cambio de clase social ocupacional en la asociación entre sexo y diabetes tipo 2: resultados del Estudio Longitudinal de Salud del Adulto en Brasil (ELSA-Brasil)

We evaluated data from 14,156 baseline participants of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) collected from 2008 to 2010, to analyze the effect modification of occupational social class on the association between sex and prevalence of type 2 diabetes. The crude and age-adjusted prevalence, according to sex and occupational social class, were estimated using generalized linear models with binomial distribution and logarithmic link function. This model was also used to estimate prevalence ratios (PR), adjusting for age group, race/skin color, and maternal education. The effect modification was measured in the multiplicative and additive scales. Males had higher crude and age-adjusted prevalence in all occupational social class strata. As occupational social class increases, the prevalence among males and females decreases. The PR of males to females decreased according to occupational class: 66% (PR = 1.66; 95%CI: 1.44; 1.90), 39% (PR = 1.39; 95%CI: 1.02; 1.89), and 28% (PR = 1.28; 95%CI: 0.94; 1.75) in the high, middle, and low occupational social classes, respectively. We found an inverse effect of the occupational social class on the association between sex and type 2 diabetes on the multiplicative scale, suggesting that it acts as an effect modifier.

Nós avaliamos dados de 14.156 participantes do Estudo Longitudinal de Saúde do Adulto no Brasil (ELSA-Brasil) coletados entre 2008 e 2010 para analisar o efeito de modificação da classe social ocupacional na associação entre sexo e prevalência de diabetes tipo 2. A prevalência bruta e ajustada por idade, de acordo com sexo e classe social ocupacional, foram estimadas usando modelos lineares generalizados com distribuição binomial e função de ligação de logaritmo. Esse modelo também foi utilizado para estimar razões de prevalência (RP), ajustando para faixa etária, raça e escolaridade materna. Medimos a modificação do efeito nas escalas multiplicativa e aditiva. Os homens apresentaram prevalência bruta e ajustada por idade mais alta em todos os estratos de classe social ocupacional. À medida que a classe social ocupacional aumenta, há uma redução na prevalência entre homens e mulheres. A RP de homens para mulheres diminuiu de acordo com a classe ocupacional: foi de 66% (RP = 1,66; IC95%: 1,44; 1,90), 39% (RP = 1,39; IC95%: 1,02; 1,89) e 28% (RP = 1,28; IC95%: 0,94; 1,75) nas classes sociais ocupacionais alta, média e baixa, respectivamente. Houve um efeito inverso da classe social ocupacional na associação entre sexo e diabetes tipo 2 na escala multiplicativa, sugerindo que ela atua como um modificador de efeito.

Evaluamos datos de 14.156 participantes del Estudio Longitudinal de Salud de Adultos en Brasil (ELSA-Brasil) recopilados entre 2008 y 2010 para analizar el efecto del cambio de clase social ocupacional en la asociación entre género y prevalencia de diabetes tipo 2. La prevalencia bruta y ajustada por edad según el sexo y la clase social ocupacional se estimaron utilizando modelos lineales generalizados con distribución binomial y función de enlace logarítmico. Este modelo también se utilizó para estimar las razones de prevalencia (RP) ajustando por grupo de edad, raza y educación materna. Medimos la modificación del efecto en las escalas multiplicativa y aditiva. Los hombres tuvieron mayor prevalencia bruta y ajustada por edad en todos los estratos de clase social ocupacional. A medida que aumenta la clase social ocupacional, se reduce la prevalencia entre hombres y mujeres. La RP de hombres a mujeres disminuyó de acuerdo con la clase ocupacional: fue del 66% (RP = 1,66; IC95%: 1,44; 1,90), 39% (RP = 1,39; IC95%: 1,02; 1,89) y 28% (RP = 1,28; IC95%: 0,94; 1,75) en las clases sociales ocupacionales alta, media y baja, respectivamente. Hubo un efecto inverso de la clase social ocupacional en la asociación entre el sexo y la diabetes tipo 2 en la escala multiplicativa, lo que sugiere que actúa como un modificador del efecto.

Racial inequalities in multimorbidity: baseline of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

BACKGROUND: Evidence of multimorbidity has come mainly from high-income regions, while disparities among racial groups have been less explored. This study examined racial differences in multimorbidity in the multiracial cohort of the Longitudinal Study of Adult Health (Estudo Longitudinal de Saúde do Adulto), ELSA-Brasil. METHODS: The study examined baseline (2008-2010) data for 14 099 ELSA-Brasil participants who self-reported being white, mixed-race, or black. A list of 16 morbidities was used to evaluate multimorbidity, operationalised by simple count into ≥ 2, ≥ 3, ≥ 4, ≥ 5 and ≥ 6 morbidities, in addition to evaluating the number of coexisting conditions. Prevalence ratios (PR) were estimated from logistic models and a quantile model was used to examine racial differences graphically in the distribution quantiles for the number of morbidities. RESULTS: Overall prevalence of multimorbidity (≥ 2 morbidities) was 70% and, after controlling for age and sex, was greater among mixed-race and black participants - by 6% (PR: 1.06; 95% CI: 1.03-1.08) and 9% (PR: 1.09; 95% CI: 1.06-1.12), respectively - than among white participants. As the cutoff value for defining multimorbidity was raised, so the strength of the association increased, especially among blacks: if set at ≥ 6 morbidities, the prevalence was 27% greater for those of mixed-race (PR: 1.27; 95% CI: 1.07-1.50) and 47% greater for blacks (PR: 1.47; 95% CI: 1.22-1.76) than for whites. The disparities were smaller in the lower morbidity distribution quantiles and larger in the upper quantiles, indicating a heavier burden of disease, particularly on blacks. CONCLUSIONS: Multimorbidity was common among adults and older adults in a Brazilian cohort, but important racial inequalities were found. Raising the cutoff point for defining multimorbidity revealed stronger associations between race/skin colour and multimorbidity, indicating a higher prevalence of multimorbidity among mixed-race and black individuals than among whites and that the former groups coexisted more often with more complex health situations (with more coexisting morbidities). Interventions to prevent and manage the condition of multimorbidity that consider the social determinants of health and historically discriminated populations in low- and middle-income regions are necessary.

Racial discrimination is associated with greater arterial stiffness and carotid intima-media thickness: the ELSA-Brasil study.

PURPOSE: The association between racial discrimination and subclinical cardiovascular markers remains under-examined. We aimed to investigate the association of race/skin color and racial discrimination with pulse wave velocity (PWV) and carotid intima-media thickness (c-IMT) in the Brazilian context. METHODS: We used data from 13,284 participants from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline with information of PWV and 9850 for c-IMT. Self-reported race/skin color and perceived racial discrimination were the exposures. PWV and c-IMT were used continuously and categorizing according to cutoff that indicates increased cardiovascular risk. Linear and logistic regression models were used. RESULTS: Experience of racial discrimination was reported by 7% of total participants, but this prevalence was much higher among Blacks than Browns (PWV sample: 31,9% vs. 6,1%; c-IMT sample: 33,7% vs. 6,8%). After adjustments for age, sex, and research center, Blacks and Browns presented higher means of PWV and c-IMT and had greater chances of PWV>10 m/s and c-IMT≥75th percentile than Whites. The magnitude of all these associations were higher among Blacks and Browns with racial discrimination. In final models adjusted for education this pattern of association remained the same, although an attenuation in the magnitude of the association has been observed. CONCLUSIONS: Blacks and Browns presented worse profiles of subclinical cardiovascular markers compared to Whites and those exposed to racial discrimination seem to have an additional cardiovascular risk.

Racism and racial iniquities in poor self-rated health: the role of intergenerational social mobility in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). / Racismo e iniquidade racial na autoavaliação de saúde ruim: o papel da mobilidade social intergeracional no Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil).

Blacks and Browns have major health disadvantages, are less likely to rise in the social hierarchy throughout the course of life, and pertain to lower socioeconomic levels than Whites as a result of structural racism. However, little is known about the mediating role of intergenerational mobility in the association between race/skin color and health. The aim of the present study was to investigate the association between racism and self-rated health and to verify to what extent intergenerational social mobility mediates this association. This was a cross-sectional study conducted with data from 14,386 participants from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline (2008-2010). Maternal education, education of the participant, socio-occupational class of the head of household, and socio-occupational class of the participant were used in the indicators of intergenerational social mobility (educational and socio-occupational). Logistic regression models were used. The prevalence of poor self-rated health was 15%, 24%, and 28% among Whites, Browns, and Blacks, respectively. After adjustments for age, sex, and research center, greater chances of poor self-rated health were found among Blacks (OR = 2.15; 95%CI: 1.92-2.41) and Browns (OR = 1.82; 95%CI: 1.64-2.01) when compared to Whites. Intergenerational educational and socio-occupational mobility mediated, respectively, 66% and 53% of the association between race/color and poor self-rated health in Blacks, and 61% and 51% in Browns, respectively. Results confirm racial iniquity in self-rated health and point out that unfavorable intergenerational social mobility is an important mechanism to explain this iniquity.

Pretos e pardos apresentam grandes desvantagens de saúde, possuem menores chances de ascensão na hierarquia social no curso de vida e menores níveis socioeconômicos do que brancos como resultado do racismo estrutural. Entretanto, pouco se sabe sobre o papel mediador da mobilidade intergeracional na associação entre racismo e saúde. O objetivo do presente estudo foi investigar a associação entre racismo e a autoavaliação de saúde, e verificar em que medida a mobilidade social intergeracional media essa associação. Estudo transversal realizado com dados de 14.386 participantes da linha de base (2008-2010) do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil). Escolaridade materna, escolaridade do participante, classe sócio-ocupacional do chefe de família e classe sócio-ocupacional do participante compuseram os indicadores de mobilidade social intergeracional (educacional e sócio-ocupacional). Modelos de regressão logística foram utilizados. A prevalência de autoavaliação de saúde ruim foi de 15%, 24% e 28% entre brancos, pardos e pretos, respectivamente. Após ajustes por idade, sexo e centro de investigação foram encontradas maiores chances de autoavaliação de saúde ruim entre pretos (OR = 2,15; IC95%: 1,92-2,41) e pardos (OR = 1,82; IC95%: 1,64-2,01) quando comparados aos brancos. A mobilidade educacional e sócio-ocupacional intergeracional mediaram, respectivamente, 66% e 53% da associação entre a raça/cor e autoavaliação de saúde ruim em pretos, e 61% e 51% em pardos, respectivamente. Resultados confirmam a iniquidade racial na autoavaliação de saúde e apontam que a mobilidade social intergeracional desfavorável é um importante mecanismo para explicar essa iniquidade.

Negros y mulatos presentan grandes desventajas de salud, poseen menores oportunidades de ascensión en la jerarquía social en el trascurso de su vida, y menores niveles socioeconómicos que los blancos, como resultado del racismo estructural. No obstante, poco se sabe sobre el papel mediador de la movilidad intergeneracional en la asociación entre racismo y salud. El objetivo de este estudio fue investigar la asociación entre racismo y autoevaluación de salud, así como verificar en qué medida la movilidad social intergeneracional interfiere en esa asociación. Se trata de un estudio transversal, realizado con datos de 14.386 participantes de la base de referencia (2008-2010) del Estudio Longitudinal de Salud de Adultos (ELSA-Brasil). La escolaridad materna, del participante, clase socio-ocupacional del jefe de familia y clase socio-ocupacional del participante compusieron los indicadores de movilidad social intergeneracional (educacional y socio-ocupacional). Se utilizaron modelos de regresión logística. La prevalencia de autoevaluación de mala salud fue de 15%, 24% y 28% entre blancos, mulatos/mestizos y negros, respectivamente. Tras los ajustes por edad, sexo y centro de investigación, se encontraron mayores oportunidades de autoevaluación de mala salud entre negros (OR = 2,15; IC95%: 1,92-2,41) y mulatos/mestizos (OR = 1,82; IC95%: 1,64-2,01), cuando se compara con los blancos. La movilidad educacional y socio-ocupacional intergeneracional mediaron, respectivamente, 66% y 53% de la asociación entre raza/color y autoevaluación de mala salud en negros, y 61% y 51% en mulatos/mestizos, respectivamente. Los resultados confirman la inequidad racial en la autoevaluación de salud y apuntan que la movilidad social intergeneracional desfavorable es un importante mecanismo para explicar esa inequidad.

Racismo e iniquidade racial na autoavaliação de saúde ruim: o papel da mobilidade social intergeracional no Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil) / Racismo e inequidad racial en la autoevaluación de mala salud: el papel de la movilidad social intergeneracional en el Estudio Longitudinal de Salud de Adultos (ELSA-Brasil) / Racism and racial iniquities in poor self-rated health: the role of intergenerational social mobility in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

Resumo: Pretos e pardos apresentam grandes desvantagens de saúde, possuem menores chances de ascensão na hierarquia social no curso de vida e menores níveis socioeconômicos do que brancos como resultado do racismo estrutural. Entretanto, pouco se sabe sobre o papel mediador da mobilidade intergeracional na associação entre racismo e saúde. O objetivo do presente estudo foi investigar a associação entre racismo e a autoavaliação de saúde, e verificar em que medida a mobilidade social intergeracional media essa associação. Estudo transversal realizado com dados de 14.386 participantes da linha de base (2008-2010) do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil). Escolaridade materna, escolaridade do participante, classe sócio-ocupacional do chefe de família e classe sócio-ocupacional do participante compuseram os indicadores de mobilidade social intergeracional (educacional e sócio-ocupacional). Modelos de regressão logística foram utilizados. A prevalência de autoavaliação de saúde ruim foi de 15%, 24% e 28% entre brancos, pardos e pretos, respectivamente. Após ajustes por idade, sexo e centro de investigação foram encontradas maiores chances de autoavaliação de saúde ruim entre pretos (OR = 2,15; IC95%: 1,92-2,41) e pardos (OR = 1,82; IC95%: 1,64-2,01) quando comparados aos brancos. A mobilidade educacional e sócio-ocupacional intergeracional mediaram, respectivamente, 66% e 53% da associação entre a raça/cor e autoavaliação de saúde ruim em pretos, e 61% e 51% em pardos, respectivamente. Resultados confirmam a iniquidade racial na autoavaliação de saúde e apontam que a mobilidade social intergeracional desfavorável é um importante mecanismo para explicar essa iniquidade.

Resumen: Negros y mulatos presentan grandes desventajas de salud, poseen menores oportunidades de ascensión en la jerarquía social en el trascurso de su vida, y menores niveles socioeconómicos que los blancos, como resultado del racismo estructural. No obstante, poco se sabe sobre el papel mediador de la movilidad intergeneracional en la asociación entre racismo y salud. El objetivo de este estudio fue investigar la asociación entre racismo y autoevaluación de salud, así como verificar en qué medida la movilidad social intergeneracional interfiere en esa asociación. Se trata de un estudio transversal, realizado con datos de 14.386 participantes de la base de referencia (2008-2010) del Estudio Longitudinal de Salud de Adultos (ELSA-Brasil). La escolaridad materna, del participante, clase socio-ocupacional del jefe de familia y clase socio-ocupacional del participante compusieron los indicadores de movilidad social intergeneracional (educacional y socio-ocupacional). Se utilizaron modelos de regresión logística. La prevalencia de autoevaluación de mala salud fue de 15%, 24% y 28% entre blancos, mulatos/mestizos y negros, respectivamente. Tras los ajustes por edad, sexo y centro de investigación, se encontraron mayores oportunidades de autoevaluación de mala salud entre negros (OR = 2,15; IC95%: 1,92-2,41) y mulatos/mestizos (OR = 1,82; IC95%: 1,64-2,01), cuando se compara con los blancos. La movilidad educacional y socio-ocupacional intergeneracional mediaron, respectivamente, 66% y 53% de la asociación entre raza/color y autoevaluación de mala salud en negros, y 61% y 51% en mulatos/mestizos, respectivamente. Los resultados confirman la inequidad racial en la autoevaluación de salud y apuntan que la movilidad social intergeneracional desfavorable es un importante mecanismo para explicar esa inequidad.

Abstract: Blacks and Browns have major health disadvantages, are less likely to rise in the social hierarchy throughout the course of life, and pertain to lower socioeconomic levels than Whites as a result of structural racism. However, little is known about the mediating role of intergenerational mobility in the association between race/skin color and health. The aim of the present study was to investigate the association between racism and self-rated health and to verify to what extent intergenerational social mobility mediates this association. This was a cross-sectional study conducted with data from 14,386 participants from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline (2008-2010). Maternal education, education of the participant, socio-occupational class of the head of household, and socio-occupational class of the participant were used in the indicators of intergenerational social mobility (educational and socio-occupational). Logistic regression models were used. The prevalence of poor self-rated health was 15%, 24%, and 28% among Whites, Browns, and Blacks, respectively. After adjustments for age, sex, and research center, greater chances of poor self-rated health were found among Blacks (OR = 2.15; 95%CI: 1.92-2.41) and Browns (OR = 1.82; 95%CI: 1.64-2.01) when compared to Whites. Intergenerational educational and socio-occupational mobility mediated, respectively, 66% and 53% of the association between race/color and poor self-rated health in Blacks, and 61% and 51% in Browns, respectively. Results confirm racial iniquity in self-rated health and point out that unfavorable intergenerational social mobility is an important mechanism to explain this iniquity.

Social position and anthropometric status among adults in the ELSA-Brasil study: a latent class analysis.

The objective of the present study was to evaluate the association between social position and anthropometric status in women and men Brazilian adult. This was a cross-sectional study that used baseline data collected from 2008 to 2010 for the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil, in Portuguese), in the six major Brazilian state capital cities. A total of 15,105 active and retired civil servants aged from 35 to 74 years. Two latent variables were defined by latent class analysis, social position and anthropometric status. Both constructs and the analyses were separately evaluated by sex. Associations were assessed using multivariate logistic regression analysis with adjustment for age, self-reported skin color/race, and marital status. Around 44% of the women and 26% of the men were classified as overweight or obese. Social position tended to be lower in women (43.2%) and higher among men (40.4%). Heavier women were more likely to be black and brown-skinned, whereas slimmer women were more likely to be white. After adjustment, women's weight increased as social position decreased (OR = 1.52; 95%CI: 1.36-1.70), whereas in men weight decreased as social position decreased (OR = 0.87; 95%CI: 0.76-0.99). Social position affected the anthropometric status of women and men differently, with body patterns also being affected by ethnicity/skin color, showing the potentiality of taking the intersectional perspective when investigating the possible social determinants of the phenomenon.

Life Course Socioeconomic Position, Intergenerational Social Mobility, and Hypertension Incidence in ELSA-Brasil.

BACKGROUND: Life course epidemiology is a powerful framework to unravel the role of socioeconomic position (SEP) disparities in hypertension (HTN). This study investigated whether life course SEP is associated with HTN incidence. Specifically, to test whether cumulative low SEP throughout life and unfavorable intergenerational social mobility increased HTN incidence. METHODS: Longitudinal analysis of 8,754 ELSA-Brasil participants without HTN or cardiovascular in visit 1 (2008-2010). The response variable was the incidence of HTN between visits 1 and 2 (2012-2014). The explanatory variables were childhood, youth, and adulthood SEP, cumulative low SEP, and intergenerational social mobility. Associations were estimated by incidence rate ratios (IRRs) obtained by generalized linear models, with Poisson distribution and logarithmic link function, after adjustment for sociodemographic, behavioral, and health factors. RESULTS: The incidence of HTN was 43.2/1,000 person-years, being higher in males, elderly (70-74 years), self-declared black, and low SEP individuals. After considering sociodemographic factors, low SEP in childhood, youth, and adulthood remained statistically associated with increased HTN incidence. Individuals in the third (IRR: 1.26; 95% confidence interval (CI): 1.11-1.44) and fourth top quartiles (IRR: 1.29; 95% CI: 1.11-1.49) of cumulative low SEP, vs. first, as well as those with low stable intergenerational trajectory (IRR: 1.29; 95% CI: 1.16-1.43), vs. high stable, also had increased HTN incidence rates. CONCLUSIONS: Socioeconomic disparities at all phases of the life cycle appear to raise HTN incidence rates, being the individuals with greater accumulation of exposure to low SEP and with more unfavorable intergenerational mobility at greatest risk, even in a short follow-up time.

Racial inequality, racial discrimination and obesity incidence in adults from the ELSA-Brasil cohort.

BACKGROUND: This study investigated whether self-reported race/skin colour and perceived racial discrimination predict higher obesity incidence after approximately 4-year follow-up of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). We also investigated whether these associations are modified by educational level. METHODS: Following exclusion of individuals defined as obese (body mass index ≥30 kg/m2) at baseline, associations between race/skin colour and obesity incidence between the first (2008-2010) and second (2012-2014) visits were investigated in 10 130 participants. Next, associations between perceived racial discrimination and obesity incidence among black (n=1532) and brown (n=2958) individuals were investigated separately. Racial discrimination (yes/no) was assessed using the Lifetime Major Event Scale. Logistic regression models adjusted for age, sex and research site were used. All analyses were stratified for educational level. RESULTS: Obesity risk was higher in Blacks with high education compared with white individuals to the same education level (OR: 2.22; 95% CI 1.62 to 3.04) following adjustments. After adjustments, obesity incidence was higher among black individuals reporting racial discrimination compared with peers who did not report this experience, but only among the low education group (OR: 1.64; 95% CI 1.08 to 2.51). No statistical association with perceived discrimination was observed among brown individuals. CONCLUSION: Results are congruent with findings from other studies reporting associations between racial inequality and obesity incidence and also suggest racial discrimination may be one of the mechanisms leading to such inequalities. Also, it supports the paradox theory by which education modify the association in distinct directions.

Social position and anthropometric status among adults in the ELSA-Brasil study: a latent class analysis / Posição social e estado antropométrico entre adultos no estudo ELSA-Brasil: uma análise de classes latentes / Posición social y estatus antropométrico entre adultos en el estudio ELSA-Brasil: un análisis de clase latente

Abstract: The objective of the present study was to evaluate the association between social position and anthropometric status in women and men Brazilian adult. This was a cross-sectional study that used baseline data collected from 2008 to 2010 for the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil, in Portuguese), in the six major Brazilian state capital cities. A total of 15,105 active and retired civil servants aged from 35 to 74 years. Two latent variables were defined by latent class analysis, social position and anthropometric status. Both constructs and the analyses were separately evaluated by sex. Associations were assessed using multivariate logistic regression analysis with adjustment for age, self-reported skin color/race, and marital status. Around 44% of the women and 26% of the men were classified as overweight or obese. Social position tended to be lower in women (43.2%) and higher among men (40.4%). Heavier women were more likely to be black and brown-skinned, whereas slimmer women were more likely to be white. After adjustment, women's weight increased as social position decreased (OR = 1.52; 95%CI: 1.36-1.70), whereas in men weight decreased as social position decreased (OR = 0.87; 95%CI: 0.76-0.99). Social position affected the anthropometric status of women and men differently, with body patterns also being affected by ethnicity/skin color, showing the potentiality of taking the intersectional perspective when investigating the possible social determinants of the phenomenon.

Resumo: O objetivo do estudo foi avaliar a associação entre posição social e o estado antropométrico em brasileiros adultos de ambos os sexos. O estudo transversal usou dados coletados entre 2008 e 2010 pelo Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil), nas seis maiores capitais brasileiras. Um total de 15.105 funcionários públicos, ativos e aposentados, de ambos os sexos, entre 35 e 74 anos de idade. Duas variáveis latentes foram definidas pela análise de classes latentes: posição social e estado antropométrico. Os construtos e análises foram avaliados separadamente por sexo. As associações foram avaliadas com o uso de análise de regressão logística multivariada, ajustada para idade, cor/raça e estado civil. Em torno de 44% das mulheres e 26% dos homens foram classificados com sobrepeso ou obesidade. A posição social tendia a ser mais baixa nas mulheres (43,2%) e mais alta nos homens (40,4%). Houve uma proporção maior de mulheres com sobrepeso ou obesidade entre as pretas e pardas, e proporção maior de mulheres magras entre as brancas. Nas mulheres, após ajustes, o peso aumentava na medida em que a posição social diminuía (OR = 1,52; IC95%: 1,36-1,70), enquanto nos homens o peso diminuía junto com a diminuição da posição social (OR = 0,87; IC95%: 0,76-0,99). A posição social afetou de maneira diferente o estado antropométrico de mulheres e homens, com perfis corporais afetados também pela raça/cor da pele, indicando o potencial de levar em conta a perspectiva interseccional ao investigar os possíveis determinantes sociais do fenômeno.

Resumen: El objetivo de este estudio fue evaluar la asociación entre posición social y estatus antropométrico de adultos brasileños de ambos sexos. Fue un estudio transversal, realizado usando datos de referencia recogidos entre 2008 y 2010, del Estudio Longitudinal Brasileño de Salud en Adultos (ELSA-Brasil), llevado a cabo en seis de las mayores capitales de estado brasileñas. Un total de 15.105 activos y jubilados, mujeres y hombres funcionarios públicos de 35 a 74 años de edad. Se definieron dos variables latentes mediante análisis de clases latentes: posición social y estatus antropométrico. Ambos constructos y análisis fueron evaluados separadamente por sexo. Las asociaciones fueron evaluadas usando una regresión logística multivariada con ajuste por edad, color de piel/raza autoinformado y estatus marital. Alrededor de un 44% de las mujeres y un 26% de los hombres fueron clasificados como con sobrepeso u obesos. La posición social tendió a ser más baja en mujeres (43,2%) y más alta entre hombres (40,4%). Las mujeres con más peso tenían más probabilidad de ser negras y mulatas/mestizas y las mujeres más delgadas tenían más probabilidad de ser blancas. En mujeres, tras el ajuste, se incrementó más el peso cuanto mayor decrecía la posición social (OR = 1,52; IC95%: 1,36-1,70), mientras en hombres el peso decrecía al igual que la posición social (OR = 0,87; IC95%: 0,76-0,99). La posición social afectó diferentemente al estatus antropométrico de mujeres y hombres, con los patrones corporales también estando afectados por etnicidad/color de piel, mostrando su potencialidad tomando en consideración la perspectiva transversal, cuando se está investigando los posibles determinantes sociales del fenómeno.

Polypharmacy, socioeconomic indicators and number of diseases: results from ELSA-Brasil.

OBJECTIVE: To estimate the prevalence of polypharmacy, describe the pharmacotherapeutic classes used, and investigate whether polypharmacy is associated with demographic and socioeconomic indicators, regardless of the number of diseases, among participants in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline (2008-2010). METHOD: In this analysis, 14,523 adults and elderly (35-74 years) participated. Polypharmacy was characterized as regular use of five or more medicines. The demographic and socioeconomic indicators analyzed were: gender, age, education level, per capita family income, and access to private health insurance. The independent association between demographic and economic indicators and polypharmacy was estimated by binary logistic regression. RESULTS: The prevalence of polypharmacy was 11.7%. The most used drugs were those with action on the cardiovascular system. After adjustments, including by number of diseases, the chances of being on polypharmacy treatment were significantly higher among women, older participants and those with greatest number of diseases. Individuals without health insurance had lower chance to be under polypharmacy, as well as those with lower income. CONCLUSION: The occurrence of polypharmacy among ELSA-Brasil baseline participants was mainly due to drugs for the treatment of chronic diseases. The relation between polypharmacy and the female gender, as well as its association with old age, are in consonance with the results obtained in other studies. Despite the absence of an association between polypharmacy and education level, the income and health insurance results reinforce the existence of social inequalities regarding drug use.

Prediction of Liver Steatosis Applying a New Score in Subjects from the Brazilian Longitudinal Study of Adult Health.

GOALS: To develop a noninvasive algorithm for diagnosis of liver steatosis and to compare its diagnostic value with available predictive models. BACKGROUND: Liver steatosis represents the most frequent liver disease worldwide. STUDY: This cross-sectional study analyzed data from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Patients were randomly divided into training (n=6571) and validation (n=3286) cohort. Abdominal ultrasound (US), used to grade steatosis, and overnight fasting blood tests were performed at the same day. Fatty Liver Index (FLI), Hepatic Steatosis Index, and Nonalcoholic Fatty Liver Disease-Liver Fat Score were calculated. A backward stepwise multivariate logistic regression analysis was used to develop the new predictive model, Steato-ELSA. RESULTS: In total, 9857 subjects [58% female, age=51 (interquartile range, 45 to 58) years, body mass index=26.4 (23.9 to 29.6) Kg/m] were included. Body mass index, waist circumference, homeostasis model of assessment of insulin resistance, transaminases, and triglycerides were independently associated with steatosis in the multivariate model (Hosmer-Lemeshow P=0.279). In the validation cohort, the area under the receiver-operator characteristics (95% confidence interval) for prediction of mild and moderate steatosis were: (i) 0.768 (0.751-0.784) and 0.829 (0.810-0.848) for Steato-ELSA; (ii) 0.762 (0.745-0.779) and 0.819 (0.799-0.838) for Fatty Liver Index; (iii) 0.743 (0.727-0.761) and 0.800 (0.779-0.822) for Hepatic Steatosis Index; and (iv) 0.719 (0.701-0.737) and 0.769 (0.747-0.791) for Nonalcoholic Fatty Liver Disease-Liver Fat Score. Steato-ELSA performed significantly better than other models and yielded sensitivity (Se)/specificity (Sp) (95% confidence interval): (i) for mild steatosis (score ≥0.386): Se=65.6% (63.0-68.3) and Sp=73.7% (71.8-75.6); (ii) for moderate steatosis (score ≥0.403): Se=83.5% (80.0-86.9) and Sp=68.7% (67.0-70.4). CONCLUSIONS: Steato-ELSA is an accurate and inexpensive tool that uses simple parameters to identify individuals at high risk of liver steatosis.

Polypharmacy, socioeconomic indicators and number of diseases: results from ELSA-Brasil / Polifarmácia, indicadores socioeconômicos e número de doenças: resultados do ELSA-Brasil

ABSTRACT: Objective: To estimate the prevalence of polypharmacy, describe the pharmacotherapeutic classes used, and investigate whether polypharmacy is associated with demographic and socioeconomic indicators, regardless of the number of diseases, among participants in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline (2008-2010). Method: In this analysis, 14,523 adults and elderly (35-74 years) participated. Polypharmacy was characterized as regular use of five or more medicines. The demographic and socioeconomic indicators analyzed were: gender, age, education level, per capita family income, and access to private health insurance. The independent association between demographic and economic indicators and polypharmacy was estimated by binary logistic regression. Results: The prevalence of polypharmacy was 11.7%. The most used drugs were those with action on the cardiovascular system. After adjustments, including by number of diseases, the chances of being on polypharmacy treatment were significantly higher among women, older participants and those with greatest number of diseases. Individuals without health insurance had lower chance to be under polypharmacy, as well as those with lower income. Conclusion: The occurrence of polypharmacy among ELSA-Brasil baseline participants was mainly due to drugs for the treatment of chronic diseases. The relation between polypharmacy and the female gender, as well as its association with old age, are in consonance with the results obtained in other studies. Despite the absence of an association between polypharmacy and education level, the income and health insurance results reinforce the existence of social inequalities regarding drug use.

RESUMO: Objetivo: Estimar a prevalência de polifarmácia, descrever as classes farmacoterapêuticas utilizadas e investigar se a polifarmácia está associada a indicadores demográficos e socioeconômicos, independentemente do número de morbidades, entre os participantes na linha de base do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil) (2008-2010). Métodos: Participaram desta análise 14.523 adultos e idosos (35-74 anos). A polifarmácia foi caracterizada como uso regular de cinco ou mais medicamentos. Os indicadores demográficos e socioeconômicos analisados foram: sexo, idade, escolaridade, renda familiar per capita e acesso a plano de saúde particular. A associação independente entre os indicadores demográficos e econômicos e polifarmácia foi estimada por meio de regressão logística binária. Resultados: A prevalência de polifarmácia foi de 11,7%. Os medicamentos mais utilizados foram aqueles com ação no sistema cardiovascular. Após ajustes, incluindo número de doenças, a chance de estar sob tratamento com polifarmácia foi significativamente maior entre mulheres, participantes mais velhos e aqueles com maior número de doenças. Participantes de baixa renda e aqueles sem plano privado de saúde, no entanto, tiveram menor chance de estar sob polifarmácia. Conclusão: A ocorrência de polifarmácia entre os participantes da linha de base do ELSA-Brasil deveu-se principalmente a medicamentos para o tratamento de doenças crônicas. A relação entre polifarmácia e sexo feminino, bem como sua associação com maior idade, estão em consonância com os resultados obtidos em outros estudos. Apesar da ausência de associação entre a polifarmácia e a escolaridade, os resultados de renda e plano privado de saúde reforçam a existência de desigualdades sociais em relação ao uso de medicamentos.

Brazilian Longitudinal Study of Adult Health (ELSA-Brasil): socio-occupational class as an effect modifier for the relationship between adiposity measures and self-rated health.

BACKGROUND: Little is known about the role of social class in the association between adiposity measures and self-rated health, and several studies have evaluated its influence as a confounder. The aim of the study is to investigate whether social class is an effect modifier in the association between adiposity measures and self-rated health in participants in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). METHOD: Cross-sectional design, including 6453 men and 7686 women. Body mass index (kg/m2) and waist circumference (cms) were assessed. Self-rated health was categorized as good, fair and poor. Socio-occupational class was based on the participants' occupation, education and per capita income. Multicovariate ordinal logistic model was used to evaluate the association between adiposity measures and self-rated health. RESULTS: For women, the low and medium socio-occupational class effects were higher for those with waist circumference between 80 and 88 cm or overweight. For men, the low and medium socio-occupational class effects were higher for those with adequate waist circumference or normal body mass index. CONCLUSIONS: Social class is an effect modifier in the association between body mass index or waist circumference and self-rated health.

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

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

Racial differences in the association between early socioeconomic position, birth weight, and arterial stiffness in adults from ELSA-Brasil.

PURPOSE: We investigated the association between social and nutritional adversities in childhood and increased arterial stiffness in adulthood, according to race/skin color. METHODS: We used baseline data (2008-2010) from 13,365 adults (aged 34-75 years) from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Arterial stiffness was assessed by carotid-femoral pulse wave velocity (cfPWV). Childhood social and nutritional adversities were assessed by maternal education and birth weight. Race/skin color was self-reported. RESULTS: The lower the maternal education, the higher the cfPWV in adulthood in Whites, Browns, and Blacks. This association was no longer significant after adjusting for the participant's education level in Whites, but it persisted after full adjustment among Browns (low vs. high maternal education: ß = 0.18, 95% confidence interval: 0.01; 0.34) and Blacks (low vs. high maternal education: ß = 0.44, 95% confidence interval: 0.18; 0.70). On the other hand, the association between low birth weight and higher cfPWV was found only among Whites. CONCLUSIONS: Our findings regarding the association between maternal education and arterial stiffness are consistent with the disproportionate burden of cardiovascular disease-related morbidity and mortality in Blacks and Browns. The fact that the association between birth weight and arterial stiffness was only present in Whites may have reflected a survival bias.

Focusing neighborhood context and self-rated health in the Pró-Saúde Study.

The influence of neighborhood characteristics on self-rated health has been little studied. A multilevel approach using hierarchical models was applied to analyze the relationship between the socioeconomic characteristics in 621 neighborhoods (level 2) in the city of Rio de Janeiro, Brazil, and the self-rated health of 3,054 university employees (level 1) from the baseline of the Pró-Saúde Study. Neighborhoods were created using the SKATER algorithm (Spatial 'K'luster Analysis by Tree Edge Removal) to cluster census tracts according to four indicators and a minimum population of 5,000 people. After adjustment for individual factors (per capita income, schooling, age, sex, ethnicity, health-related behavior and chronic diseases), low level of neighborhood income and higher numbers of members per household were significantly associated with poor self-rated health. Participants living in medium income-level neighborhoods were 34% more likely to self-rate their health as being poor. Those living in areas with a higher density of members per household were 50% more likely to present poor self-rated health. Neighborhood context influences self-rated health, beyond the effect of individual factors. Worsening neighborhood socioeconomic conditions affect health adversely, which in turn increasing the chance of poor self-rated health.

Intragenerational Social Mobility and Changes in Blood Pressure: Longitudinal Analysis From the ELSA-Brasil Study.

BACKGROUND: During the past 4 decades, the highest worldwide blood pressure (BP) levels have shifted from high-income countries to low- and middle-income countries. We investigated the association of intragenerational social mobility with changes in BP and also with the incidence of hypertension over a 4-year follow-up. METHODS: Data for 6,529 baseline participants from ELSA-Brasil born between 1938 and 1975 were used. Based on a social mobility matrix, occupational social mobility was defined as the change in occupational social class between participants' first occupation and current occupation (stable high; upward; downward; stable low). Incident hypertension was defined as systolic blood pressure (SBP) ≥ 140 mm Hg or diastolic blood pressure (DBP) ≥ 90 mm Hg or use of antihypertensive medication. Hypertensive participants at baseline were excluded. Mixed effects regression models were used. RESULTS: Compared to the stable high group, the downwardly mobile group showed a higher increase over time in both SBP (ß = 1.49, 95% CI 0.60; 2.37) and DBP (ß = 0.96, 95% CI 0.32; 1.59) after adjustments for background characteristics and also proximal risk factors such as health-related behaviors and body mass index as time-dependent covariates, and diabetes. In contrast, upward mobility had no influence on BP changes (ß = 0.67, 95% CI -0.07; 1.41 for SBP, and ß = 0.47, 95% CI -0.05; 1.00 for DBP). Social mobility was not associated with the incidence of hypertension. CONCLUSIONS: We showed socioeconomic inequalities in BP progression over the life course. The longitudinal changes in BP varied by social mobility groups in the context of low- and middle-income countries, where high BP has become most prevalent.

At the intersection of place, race, and health in Brazil: Residential segregation and cardio-metabolic risk factors in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

Residential segregation is the spatial manifestation of entrenched socioeconomic and racial inequities and is considered a fundamental cause of racial inequalities in health. Despite the well-documented racialized spatial inequalities that exist in urban areas throughout Brazil, few empirical investigations have examined the link between residential segregation and health and considered its implications for racial health inequalities in this setting. In the present study, we used data from the Brazilian Longitudinal Study of Adult Health (2008-2010) to examine the association between economic residential segregation and two major cardio-metabolic risk factors-hypertension and diabetes. We also examined whether associations were stronger for historically marginalized racial groups in Brazil. Residential segregation was calculated for study-defined neighborhoods using the Getis-Ord Local Gi* statistic and was based on household income data from the 2010 IBGE demographic census. Multivariable logistic regression models were used to examine associations. In our sample, Blacks and Browns were more likely to live in economically segregated neighborhoods. After taking into account income, education, and other demographic characteristics we found that individuals living in the most economically segregated neighborhoods were 26% more likely to have hypertension and 50% more likely to have diabetes than individuals living in more affluent areas. Although Blacks and Browns living in highly segregated neighborhoods had higher prevalence of hypertension and diabetes compared to Whites, we observed no statistically significant racial differences in the associations with residential segregation. Our findings suggest that residential segregation may be an important structural determinant of cardio-metabolic risk factors in Brazil. Moreover, the systematic and disproportionate exposure of Blacks and Browns to highly segregated neighborhoods may implicate these settings as potential drivers of racial inequalities in cardio-metabolic risk factors in urban settings in Brazil.