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1.  Secondhand Smoke Exposure and Subclinical Cardiovascular Disease: The Multi‐Ethnic Study of Atherosclerosis 
Background
Few studies have evaluated the association between secondhand smoke (SHS) and subclinical cardiovascular disease among ethnically diverse populations. This study assesses the impact of SHS on inflammation and atherosclerosis (carotid intima‐media thickness, coronary artery calcification, and peripheral arterial disease).
Methods and Results
We examined 5032 nonsmoking adults aged 45 to 84 years without prior cardiovascular disease participating in the Multi‐Ethnic Study of Atherosclerosis (MESA) from 2000 to 2002. SHS exposure was determined by self‐report, and urinary cotinine was measured in a representative subset (n=2893). The multi‐adjusted geometric mean ratios (95% CIs) for high‐sensitivity C‐reactive protein and interleukin‐6 comparing 407 participants with SHS ≥12 h/wk versus 3035 unexposed participants were 1.13 (1.02–1.26) and 1.04 (0.98–1.11), respectively. The multi‐adjusted geometric mean ratio for carotid intima‐media thickness was 1.02 (0.97–1.07). Fibrinogen and coronary artery calcification were not associated with SHS. The prevalence of peripheral arterial disease (ankle‐brachial index ≤0.9 or ≥1.4) was associated with detectable urinary cotinine (odds ratio, 2.10; 95% CI, 1.09–4.04) but not with self‐reported SHS. Urinary cotinine was not associated with inflammation or carotid intima‐media thickness.
Conclusions
Despite limited exposure assessment, this study supports the association of SHS exposure with inflammation and peripheral arterial disease.
doi:10.1161/JAHA.115.002965
PMCID: PMC5210438  PMID: 27993830
ankle‐brachial index; atherosclerosis; carotid intima‐media thickness; coronary artery calcium; inflammation; peripheral artery disease; secondhand smoke; smoking; Cardiovascular Disease; Epidemiology; Risk Factors; Lifestyle; Primary Prevention
2.  Job strain, occupational category, and hypertension prevalence: The Multi-Ethnic Study of Atherosclerosis 
Objective
To assess associations of occupational categories and job characteristics with prevalent hypertension.
Methods
We analyzed 2,517 Multi-Ethnic Study of Atherosclerosis (MESA) participants, working 20+ hours per week, in 2002–4.
Results
Higher job decision latitude was associated with a lower prevalence of hypertension, prevalence ratio (PR)=0.78 (95% CI 0.66–0.91) for the top vs. bottom quartile of job decision latitude. However, associations differed by occupation: decision latitude was associated with a higher prevalence of hypertension in healthcare support occupations (interaction p=.02). Occupation modified associations of gender with hypertension: a higher prevalence of hypertension in women (vs men) was observed in healthcare support and in blue-collar occupations (interaction p=.03).
Conclusions
Lower job decision latitude is associated with hypertension prevalence in many occupations. Further research is needed to determine reasons for differential impact of decision latitude and gender on hypertension across occupations.
doi:10.1097/JOM.0000000000000533
PMCID: PMC4636023  PMID: 26539765
job strain; occupation; blood pressure; hypertension
3.  Coronary calcification in SLE: comparison with the Multi-Ethnic Study of Atherosclerosis 
Rheumatology (Oxford, England)  2015;54(11):1976-1981.
Objective. Accelerated atherosclerosis is a major cause of morbidity and death in SLE. The purpose of this study was to determine whether the prevalence and extent of coronary artery calcium (CAC) is higher in female SLE patients compared with a non-SLE sample from the Multi-Ethnic Study of Atherosclerosis (MESA).
Methods. CAC was measured in 80 female SLE patients and 241 female MESA controls from the Baltimore Field Centre, ages 45–64 years, without evidence of clinical cardiovascular disease. Binary regression was used to estimate the ratio of CAC prevalence in SLE vs MESA controls, controlling for demographic and cardiovascular risk factors. To compare the groups with respect to the quantity of CAC among those with non-zero Agatston scores, we used linear models in which the outcome was a log-transformed Agatston score.
Results. The prevalence of CAC was substantially higher in SLE. The differences were most pronounced and statistically significant in those aged 45–54 years (58% vs 20%, P < 0.0001), but were still observed among those aged 55–65 years (57% vs 36%, P = 0.069). After controlling for age, ethnicity, education, income, diabetes mellitus, hypertension, hyperlipidaemia, high-density lipoprotein levels, smoking, education and BMI, SLE patients still had a significantly higher prevalence of CAC than controls. Among those with CAC, the mean log Agatston score did not differ significantly between SLE and MESA participants.
Conclusion. Women with SLE have a higher prevalence of CAC than comparable women without SLE, even after adjusting for traditional cardiovascular risk factors, especially among those aged 45–54 years.
doi:10.1093/rheumatology/kev198
PMCID: PMC4715250  PMID: 26106213
systemic lupus erythematosus; atherosclerosis; coronary artery calcium; inflammation; MESA; computed tomography; statins; cardiovascular; Agatston score; cohort
4.  Trait Anger But Not Anxiety Predicts Incident Type 2 Diabetes: The Multi-Ethnic Study of Atherosclerosis (MESA) 
Psychoneuroendocrinology  2015;60:105-113.
Objective
Prior studies have shown a bidirectional association between depression and type 2 diabetes mellitus (T2DM); however, the prospective associations of anger and anxiety with T2DM have not been established. We hypothesized that trait anger and anxiety would predict incident T2DM, independently of depressive symptoms.
Research Design and Methods
In the Multi-ethnic Study of Atherosclerosis (MESA), we prospectively examined the association of trait anger and trait anxiety (assessed via the Spielberger Trait Anger and Anxiety Scales, respectively) with incident T2DM over 11.4 years in 5,598 White, Black, Hispanic, and Chinese participants (53.2% women, mean age 61.6 years) at baseline without prevalent T2DM or cardiovascular disease. We used Cox proportional hazards models to calculate the hazard ratios (HR) of incident T2DM by previously defined anger category (low, moderate, high), and anxiety quartile, as there were no previously defined categories.
Results
High total trait anger was associated with incident T2DM (HR 1.50; 95% CI 1.08–2.07) relative to low total trait anger. The association was attenuated following adjustment for waist circumference (HR 1.32; 95% CI 0.94–1.86). Higher anger reaction was also associated with incident T2DM (HR=1.07; 95% CI 1.03–1.11) that remained significant after adjusting for potential confounders/explanatory factors. In contrast, trait anxiety did not predict incident T2DM.
Conclusions
High total trait anger and anger reaction are potential modifiable risk factors for T2DM. Further research is needed to explore the mechanisms of the anger-diabetes relationship and to develop preventive interventions.
doi:10.1016/j.psyneuen.2015.06.007
PMCID: PMC4526333  PMID: 26142567
5.  Associations of coronary heart disease with common carotid artery near and far wall intima-media thickness (IMT): the Multi-Ethnic Study of Atherosclerosis 
Background
Intima-media thickness (IMT) measured on ultrasound images of the common carotid artery (CCA) is associated with cardiovascular risk factors and events. Based on the physics of ultrasound, CCA far wall IMT measurements are favored over near wall measurements but this theoretical advantage is not well studied.
Methods
We studied 6606 members of the Multi-Ethnic Study of Atherosclerosis (MESA), a longitudinal cohort study (mean age 62.1 years; 52.7% female) who had near wall and far wall CCA IMT measurements. Multivariable linear regression models were used to estimate model goodness-of-fit of Framingham risk factors (FRF) with near wall IMT, far wall IMT, and combined mean IMT. Multivariable Cox proportional hazards models were used to estimate hazard ratios for incident coronary heart disease (CHD) events for each IMT variable. Change in Harrell’s C-statistic was used to compare the incremental value of each IMT variable when added to FRF.
Results
Mean IMT had the strongest association with risk factors (R2 = 0.31), followed by the near wall (R2 = 0.26) and far wall IMT (R2 = 0.22). Far wall IMT improved the prediction of coronary artery disease events over the FRF (change in C-statistic of 0.012; 95% confidence intervals: 0.006, 0.017; p < 0.001) as did mean IMT (p = 0.004) but near wall IMT did not.
Conclusions
Far wall CCA IMT showed the strongest association with incident CHD whereas mean IMT had the strongest associations with risk factors. This difference might affect the selection of appropriate IMT variables in different studies.
doi:10.1016/j.echo.2015.04.001
PMCID: PMC4567434  PMID: 25944425
risk factors; common carotid artery; ultrasound; coronary heart disease; intima media thickness; carotid artery bifurcation
6.  Multi-site Extracoronary Calcification Indicates Increased Risk of Coronary Heart Disease and All-Cause Mortality: the Multi-Ethnic Study of Atherosclerosis 
Background
Cardiovascular calcification outside of the coronary tree, known as extracoronary calcification (ECC), is highly prevalent, often occurs concurrently in multiple sites, and yet its prognostic value is unclear.
Objective
To determine whether multi-site ECC is associated with coronary heart disease (CHD) events, CHD mortality and all-cause mortality.
Methods
We evaluated 5,903 participants from the Multi-Ethnic Study of Atherosclerosis (MESA) without diabetes who underwent computed tomography imaging for calcification of the aortic valve, aortic root, mitral valve, and thoracic aorta. Participants were followed for 10.3 years. Multivariable adjusted hazard ratios estimated risk of outcomes for increasing numbers of ECC sites (0,1,2,3 and 4), and receiver operator characteristic (ROC) analysis assessed model discrimination.
Results
Prevalence of any ECC was 45%; median age was 62. Compared to those without ECC, those with ECC in 4 sites had increased hazards of 4.5 and 7.1 and 2.3 for CHD events, CHD mortality and all-cause mortality, respectively, independent of traditional risk factors (TRF) (all p≤0.05), and had ≥2-fold increased hazards for outcomes independent of coronary artery calcification (CAC). Each additional site of ECC was positively associated with each outcome in a graded fashion. When added to TRF, ECC significantly increased the area under the ROC curve (AUC) for all outcomes, and modestly increased the AUC for mortality beyond TRF+CAC (0.799 to 0.802; p=0.03).
Conclusion
Increasing multi-site ECC has a graded association with higher CHD and mortality risk, contributing information beyond TRF. Multi-site ECC incidentally identified on imaging can be used to improve individualized risk prediction.
doi:10.1016/j.jcct.2015.03.012
PMCID: PMC4582663  PMID: 26043963
extracoronary calcification; CHD events; mortality; risk prediction; cardiovascular imaging
7.  Relation of Anthropometric Obesity and Computed Tomography measured Non-alcoholic Fatty Liver Disease (From the Multi-Ethnic Study of Atherosclerosis) 
The American journal of cardiology  2015;116(4):541-546.
We hypothesized that anthropometric measures of abdominal obesity would have a stronger positive association with non-alcoholic fatty liver disease (NAFLD) measured by non-contrast computed tomography versus general measures of obesity. The Multi-Ethnic Study of Atherosclerosis (MESA) is comprised of participants aged 45–84 years free of known cardiovascular disease. We studied 4,088 participants with adequate liver and spleen CT-imaging and no prior use of oral steroids, class 3 anti-arrhythmics, moderately-heavy alcohol use, or cirrhosis. Prevalent NAFLD was defined as a liver:spleen Hounsfield attenuation ratio of <1. Multivariable log-linear regression modeled the association of 4 obesity measures—weight, body mass index, waist circumference and waist-to-hip ratio—with prevalent NAFLD. Receiver operator curve analysis compared NAFLD discrimination. Median age was 63 years, and 55% were female. For each obesity measure, adjusted prevalence ratios for NAFLD were 4–5 fold greater in the highest versus the lowest quartile (p<0.001). Waist circumference and body mass index had the highest prevalence ratios, and waist circumference had the best discrimination, for NAFLD in the total population; although an abnormal body mass index categorized individuals with NAFLD as well if not better than waist circumference. In ethnic-specific analysis, Whites and Chinese had the strongest association of obesity and NAFLD compared to other ethnicities. In conclusion, though waist circumference provided the best discrimination for NAFLD, body mass index may perform similarly well in clinical settings to screen for NAFLD.
doi:10.1016/j.amjcard.2015.05.012
PMCID: PMC4522195  PMID: 26070222
Obesity; Abdominal Obesity; Liver Disease; Epidemiology
8.  Is the Association of Hypertension with Cardiovascular Events Stronger Among the Lean and Normal Weight than Among the Overweight and Obese? The Mesa Study 
Hypertension  2015;66(2):286-293.
Previous studies that suggest the association of hypertension with cardiovascular disease (CVD) events is stronger in the lean/normal weight than in the obese have either included smokers, diabetics, or cancer patients, or did not account for central obesity. This study examines the interaction of adiposity with hypertension on CVD events using BMI-based definitions of overweight and obesity as well as waist circumference (WC) to assess adiposity.
In the Multi-Ethnic Study of Atherosclerosis, we classified 3657 nonsmoking men and women, free of baseline clinical CVD, diabetes and cancer, into 7 BMI-WC combinations defined by ethnicity-specific BMI (normal, overweight, class 1 obese, and class 2/3 obese) and ethnicity- and sex-specific WC categories (optimal or nonoptimal). Adjusted absolute event rates per 1000 person-years and relative risks (RRs) (95% confidence intervals) for CVD events for hypertension (BP ≥ 140/90 or taking medication) vs. no hypertension computed within adiposity categories were: 9.3 vs. 1.9 and 4.96 (2.56-9.60) for normal BMI/optimal WC, 13.2 vs. 4.2 and 3.13 (0.99-9.86) for normal BMI/nonoptimal WC, 9.0 vs. 4.5 and 2.00 (1.19-3.36) for overweight BMI/optimal WC, 8.4 vs. 5.6 and 1.50 (0.88-2.54) for overweight BMI/nonoptimal WC,14.1 vs. 2.1 and 6.75 (0.69-65.57) for class 1 obese/optimal WC, 10.1 vs. 3.7 and 2.69 (1.41-5.16) for class 1 obese/nonoptimal WC, and 9.9 vs. 6.9 and 1.45(0.60-3.52) for class 2/3 obese/WC pooled.
This study found a large RR of CVD events associated with hypertension for normal BMI participants and more importantly similarly high absolute risks for both normal and obese BMI with hypertension.
doi:10.1161/HYPERTENSIONAHA.114.04863
PMCID: PMC4828916  PMID: 26077561
hypertension; obesity; blood pressure; cardiovascular disease; waist circumference; follow-up studies; risk
9.  Coronary Artery Calcium Score and Association with Recurrent Nephrolithiasis: The Multi-Ethnic Study of Atherosclerosis 
The Journal of urology  2015;195(4 Pt 1):971-976.
Purpose
Subclinical coronary artery calcification is an established predictor of cardiovascular events. While a history of kidney stones has been linked to subclinical carotid atherosclerosis, to our knowledge no study has examined its relationship with coronary artery calcification. We studied the association between kidney stone history and prevalent coronary artery calcification in MESA (Multi-Ethnic Study of Atherosclerosis).
Materials and Methods
MESA is a multisite cohort study of participants 45 to 84 years old without known cardiovascular disease at baseline from 2000 to 2002. Computerized tomography was done in 3,282 participants at followup in 2010 to 2012 to determine coronary artery calcification and kidney stone history was assessed by self-report. Coronary artery calcification scores were categorized as none—0, mild—1 to 99, moderate—100 to 399 or severe—400 or greater. Cross-sectional analysis was performed adjusting for demographic and dietary factors related to kidney stones.
Results
The prevalence of kidney stone disease history was approximately 9%, mean ± SD participant age was 69.5 ± 9.3 years, 39% of participants were Caucasian, 47% were men and 69% had detectable coronary artery calcification (score greater than 0). No difference in the score was seen between single stone formers and nonstone formers. Recurrent kidney stone formation was associated with moderate or severe calcification on multivariable logistic regression vs none or mild calcification (OR 1.80, 95% CI 1.22–2.67). When coronary artery calcification scores were separated into none, mild, moderate and severe calcification, recurrent stone formation was associated with a higher score category on multivariable ordinal logistic regression (OR 1.44 per category, 95% CI 1.04–2.01).
Conclusions
Recurrent kidney stone formation is associated with subclinical coronary atherosclerosis. This association appeared stronger with coronary artery calcification severity than with coronary artery calcification presence.
doi:10.1016/j.juro.2015.10.001
PMCID: PMC4966606  PMID: 26454103
kidney; urolithiasis; coronary artery disease; arteriosclerosis; recurrence
10.  Association of Sleep Apnea and Snoring With Incident Atrial Fibrillation in the Multi-Ethnic Study of Atherosclerosis 
American Journal of Epidemiology  2015;182(1):49-57.
The association between sleep apnea and atrial fibrillation (AF) has not been examined in a multiethnic adult population in prospective community-based studies. We prospectively (2000–2011) investigated the associations of physician-diagnosed sleep apnea (PDSA), which is considered more severe sleep apnea, and self-reported habitual snoring without PDSA (HS), a surrogate for mild sleep apnea, with incident AF in white, black, and Hispanic participants in the Multi-Ethnic Study of Atherosclerosis (MESA) who were free of clinical cardiovascular disease at baseline (2000–2002). Cox proportional hazards models were used to assess the associations, with adjustment for socioeconomic status, traditional vascular disease risk factors, race/ethnicity, body mass index, diabetes, chronic kidney disease, alcohol intake, and lipid-lowering therapy. Out of 4,395 respondents to a sleep questionnaire administered in MESA, 181 reported PDSA, 1,086 reported HS, and 3,128 reported neither HS nor PDSA (unaffected). Over an average 8.5-year follow-up period, 212 AF events were identified. As compared with unaffected participants, PDSA was associated with incident AF in the multivariable analysis, but HS was not (PDSA: hazard ratio = 1.76, 95% confidence interval: 1.03, 3.02; HS: hazard ratio = 1.02, 95% confidence interval: 0.72, 1.44). PDSA, a marker of more severe sleep apnea, was associated with higher risk of incident AF in this analysis of MESA data.
doi:10.1093/aje/kwv004
PMCID: PMC4479113  PMID: 25977516
atrial fibrillation; longitudinal studies; sleep apnea; snoring
11.  The Association of Nonalcoholic Fatty Liver Disease, Obesity, and Metabolic Syndrome, with Systemic Inflammation and Subclinical Atherosclerosis: The Multi-Ethnic Study of Atherosclerosis (MESA) 
Atherosclerosis  2015;239(2):629-633.
Introduction
We characterized the association of 3 metabolic conditions – obesity, metabolic syndrome, and nonalcoholic fatty liver disease (NAFLD) – with increased inflammation and subclinical atherosclerosis.
Methods
We conducted cross-sectional analysis of 3,976 participants from the Multi-Ethnic Study of Atherosclerosis (MESA) with adequate CT imaging to diagnose NAFLD. Obesity was defined as BMI ≥30 kg/m2, metabolic syndrome by AHA/NHLBI criteria, and NAFLD using non-contrast cardiac CT and a liver/spleen attenuation ratio (L/S) <1. Increased inflammation was defined as high sensitivity C-reactive protein (hsCRP) ≥2 mg/L and subclinical atherosclerosis as coronary artery calcium (CAC) >0. We studied the association of a stepwise increase in number of these metabolic conditions (0–3) with increased inflammation and CAC, stratifying results by gender and ethnicity.
Results
Mean age of participants was 63 (±10) years, 45% were male, 37% white, 10% Chinese, 30% African American, and 23% Hispanic. Adjusting for obesity, metabolic syndrome and traditional risk factors, NAFLD was associated with a prevalence odds ratio for hsCRP ≥2 mg/L and CAC >0 of 1.47 (1.20–1.79) and 1.37 (1.11–1.68) respectively. There was a positive interaction between female gender and NAFLD in the association with hsCRP ≥2 mg/L (p= 0.006), with no interaction by race. With increasing number of metabolic conditions, there was a graded increase in prevalence odds ratios of hsCRP ≥2 mg/L and CAC >0.
Conclusion
NAFLD is associated with increased inflammation and CAC independent of traditional risk factors, obesity and metabolic syndrome. There is a graded association between obesity, metabolic syndrome, and NAFLD with inflammation and CAC.
doi:10.1016/j.atherosclerosis.2015.02.011
PMCID: PMC4406399  PMID: 25683387
12.  The Relationship of Cigarette Smoking with Inflammation and Subclinical Vascular Disease: The Multi-Ethnic Study of Atherosclerosis 
Objectives
We sought to assess the impact of smoking status, cumulative pack-years, and time since cessation (the latter in former-smokers only) on three important domains of cardiovascular disease (CVD): inflammation, vascular dynamics and function, and subclinical atherosclerosis.
Approach and Results
The MESA cohort enrolled 6,814 adults without prior CVD. Smoking variables were determined by self-report and confirmed with urinary cotinine. We examined cross-sectional associations between smoking parameters and; 1) inflammatory biomarkers (high-sensitivity C-reactive protein [hsCRP], interleukin-6 [IL-6], and fibrinogen); 2) vascular dynamics and function (brachial flow-mediated dilation [FMD] and carotid distensibility by ultrasound, as well as aortic distensibility by MRI); and 3) subclinical atherosclerosis (coronary artery calcification [CAC], carotid intima-media thickness [CIMT], and ankle-brachial index [ABI]). We identified 3,218 never-smokers, 2,607 former-smokers, and 971 current-smokers. Mean age was 62 years and 47% were male. There was no consistent association between smoking and vascular distensibility or FMD outcomes. In contrast, compared to never-smokers, the adjusted association between current-smoking and measures of either inflammation or subclinical atherosclerosis was consistently stronger than for former-smoking (e.g. odds-ratio (OR) for hs-CRP > 2mg/L of 1.7 [95%CI, 1.5-2.1] Vs. 1.2 [1.1-1.4], OR for CAC > 0 of 1.8 [1.5-2.1] Vs. 1.4 [1.2-1.6], respectively). Similar associations were seen for IL-6, fibrinogen, CIMT, and ABI. A monotonic relationship was also found between increasing pack-years exposure and elevated inflammatory markers. Further, current smokers with hsCRP > 2mg/L were more likely to have increased CIMT, abnormal ABI, and CAC > 75th percentile for age, sex and race (relative to smokers with hsCRP < 2mg/L, interaction p < 0.05 for all three outcomes). In contrast, time since quitting in former-smokers was independently associated with lower inflammation and atherosclerosis (e.g. OR for hsCRP > 2mg/L of 0.91 [0.88-0.95] and OR for CAC > 0 of 0.94 [0.90-0.97] for every 5-year cessation interval).
Conclusion
These findings expand our understanding of the harmful effects of smoking and help explain the cardiovascular benefits of smoking cessation.
doi:10.1161/ATVBAHA.114.304960
PMCID: PMC4484586  PMID: 25745060
Smoking; Inflammation; Atherosclerosis; Coronary Artery Calcium
13.  ERICA: prevalence of common mental disorders in Brazilian adolescents 
Revista de Saúde Pública  2016;50(Suppl 1):14s.
ABSTRACT
OBJECTIVE
To describe the prevalence of common mental disorders in Brazilian adolescent students, according to geographical macro-regions, school type, sex, and age.
METHODS
We evaluated 74,589 adolescents who participated in the Cardiovascular Risk Study in Adolescents (ERICA), a cross-sectional, national, school-based study conducted in 2013-2014 in cities with more than 100,000 inhabitants. A self-administered questionnaire and an electronic data collector were employed. The presence of common mental disorders was assessed using the General Health Questionnaire (GHQ-12). We estimated prevalence and 95% confidence intervals of common mental disorders by sex, age, and school type, in Brazil and in the macro-regions, considering the sample design.
RESULTS
The prevalence of common mental disorders was of 30.0% (95%CI 29.2-30.8), being higher among girls (38.4%; 95%CI 37.1-39.7) when compared to boys (21.6%; 95%CI 20.5-22.8), and among adolescents who were from 15 to 17 years old (33.6%; 95%CI 32.2-35.0) compared to those aged between 12 and 14 years (26.7%; 95%CI 25.8-27.6). The prevalence of common mental disorders increased with age for both sexes, always higher in girls (ranging from 28.1% at 12 years to 44.1% at 17 years) than in boys (ranging from 18.5% at 12 years to 27.7% at 17 years). We did not observe any significant difference by macro-region or school type. Stratified analyses showed higher prevalence of common mental disorders among girls aged from 15 to 17 years of private schools in the North region (53.1; 95%CI 46.8-59.4).
CONCLUSIONS
The high prevalence of common mental disorders among adolescents and the fact that the symptoms are often vague mean these disorders are not so easily identified by school administrators or even by health services. The results of this study can help the proposition of more specific prevention and control measures, focused on highest risk subgroups.
doi:10.1590/S01518-8787.2016050006690
PMCID: PMC4767030  PMID: 26910549
Adolescent; Mental Disorders, epidemiology; Prevalence; Mental Health; Cross-Sectional Studies
14.  ERICA: patterns of alcohol consumption in Brazilian adolescents 
Revista de Saúde Pública  2016;50(Suppl 1):8s.
ABSTRACT
OBJECTIVE
To describe the patterns of alcohol consumption in Brazilian adolescents.
METHODS
We investigated adolescents who participated in the Study of Cardiovascular Risks in Adolescents (ERICA). This is a cross-sectional, national and school-based study, which surveyed adolescents of 1,247 schools from 124 Brazilian municipalities. Participants answered a self-administered questionnaire with a section on alcoholic beverages consumption. Measures of relative frequency (prevalence), and their 95% confidence intervals, were estimated for the following variables: use of alcohol beverages in the last 30 days, frequency of use, number of glasses or doses consumed in the period, age of the first use of alcohol, and most consumed type of drink. Data were estimated for country and macro-region, sex, and age group. The module survey of the Stata program was used for data analysis of complex sample.
RESULTS
We evaluated 74,589 adolescents, who accounted for 72.9% of eligible students. About 1/5 of adolescents consumed alcohol at least once in the last 30 days and about 2/3 in one or two occasions during this period. Among the adolescents who consumed alcoholic beverages, 24.1% drank it for the first time before being 12 years old, and the most common type of alcoholic beverages consumed by them were drinks based on vodka, rum or tequila, and beer.
CONCLUSIONS
There is a high prevalence of alcohol consumption among adolescents, as well as their early onset of alcohol use. We also identified a possible change in the preferred type of alcoholic beverages compared with previous research.
doi:10.1590/S01518-8787.2016050006684
PMCID: PMC4767031  PMID: 26910550
Adolescent; Alcohol Drinking epidemiology; Prevalence; Cross-Sectional Studies
15.  ERICA: prevalences of hypertension and obesity in Brazilian adolescents 
Revista de Saúde Pública  2016;50(Suppl 1):9s.
ABSTRACT
OBJECTIVE
To estimate the prevalence of arterial hypertension and obesity and the population attributable fraction of hypertension that is due to obesity in Brazilian adolescents.
METHODS
Data from participants in the Brazilian Study of Cardiovascular Risks in Adolescents (ERICA), which was the first national school-based, cross-section study performed in Brazil were evaluated. The sample was divided into 32 geographical strata and clusters from 32 schools and classes, with regional and national representation. Obesity was classified using the body mass index according to age and sex. Arterial hypertension was defined when the average systolic or diastolic blood pressure was greater than or equal to the 95th percentile of the reference curve. Prevalences and 95% confidence intervals (95%CI) of arterial hypertension and obesity, both on a national basis and in the macro-regions of Brazil, were estimated by sex and age group, as were the fractions of hypertension attributable to obesity in the population.
RESULTS
We evaluated 73,399 students, 55.4% female, with an average age of 14.7 years (SD = 1.6). The prevalence of hypertension was 9.6% (95%CI 9.0-10.3); with the lowest being in the North, 8.4% (95%CI 7.7-9.2) and Northeast regions, 8.4% (95%CI 7.6-9.2), and the highest being in the South, 12.5% (95%CI 11.0-14.2). The prevalence of obesity was 8.4% (95%CI 7.9-8.9), which was lower in the North region and higher in the South region. The prevalences of arterial hypertension and obesity were higher in males. Obese adolescents presented a higher prevalence of hypertension, 28.4% (95%CI 25.5-31.2), than overweight adolescents, 15.4% (95%CI 17.0-13.8), or eutrophic adolescents, 6.3% (95%CI 5.6-7.0). The fraction of hypertension attributable to obesity was 17.8%.
CONCLUSIONS
ERICA was the first nationally representative Brazilian study providing prevalence estimates of hypertension in adolescents. Regional and sex differences were observed. The study indicates that the control of obesity would lower the prevalence of hypertension among Brazilian adolescents by 1/5.
doi:10.1590/S01518-8787.2016050006685
PMCID: PMC4767032  PMID: 26910553
Adolescent; Obesity, epidemiology; Hypertension, epidemiology; Cross-Sectional Studies
16.  ERICA: smoking prevalence in Brazilian adolescents 
Revista de Saúde Pública  2016;50(Suppl 1):12s.
ABSTRACT
OBJECTIVE
To estimate the prevalences of tobacco use, tobacco experimentation, and frequent smoking among Brazilian adolescents.
METHODS
We evaluated participants of the cross-sectional, nation-wide, school-based Study of Cardiovascular Risks in Adolescents (ERICA), which included 12- to 17-year-old adolescents from municipalities of over 100 thousand inhabitants. The study sample had a clustered, stratified design and was representative of the whole country, its geographical regions, and all 27 state capitals. The information was obtained with self-administered questionnaires. Tobacco experimentation was defined as having tried cigarettes at least once in life. Adolescents who had smoked on at least one day over the previous 30 days were considered current cigarette smokers. Having smoked cigarettes for at least seven consecutive days was an indicator for regular consumption of tobacco. Considering the complex sampling design, prevalences and 95% confidence intervals were estimated according to sociodemographic and socio-environmental characteristics.
RESULTS
We evaluated 74,589 adolescents. Among these, 18.5% (95%CI 17.7-19.4) had smoked at least once in life, 5.7% (95%CI 5.3-6.2) smoked at the time of the research, and 2.5% (95%CI 2.2-2.8) smoked often. Adolescents aged 15 to 17 years had higher prevalences for all indicators than those aged 12 to 14 years. The prevalences did not differ significantly between sexes. The highest prevalences were found in the South region and the lowest ones, in the Northeast region. Regardless of sex, the prevalences were found to be higher for adolescents who had had paid jobs, who lived with only one parent, and who reported having been in contact with smokers either inside or outside their homes. Female public school adolescents were found to smoke more than the ones from private schools.
CONCLUSIONS
Tobacco use among adolescents is still a challenge. Intending to reduce the prevalence of tobacco use among young people, especially the ones under socioeconomic vulnerability conditions, Brazil must consolidate and increase effective public health care measures.
doi:10.1590/S01518-8787.2016050006741
PMCID: PMC4767033  PMID: 26910545
Adolescent; Tobacco use, epidemiology; Prevalence; Survey
17.  ERICA: prevalence of metabolic syndrome in Brazilian adolescents 
Revista de Saúde Pública  2016;50(Suppl 1):11s.
ABSTRACT
OBJECTIVE
To determine the prevalence of metabolic syndrome and its components in Brazilian adolescents.
METHODS
We evaluated 37,504 adolescents who were participants in the Study of Cardiovascular Risks in Adolescents (ERICA), a cross-sectional, school-based, national study. The adolescents, aged from 12 to 17 years, lived in cities with populations greater than 100,000 inhabitants. The sample was stratified and clustered into schools and classes. The criteria set out by the International Diabetes Federation were used to define metabolic syndrome. Prevalences of metabolic syndrome were estimated according to sex, age group, school type and nutritional status.
RESULTS
Of the 37,504 adolescents who were evaluated: 50.2% were female; 54.3% were aged from 15 to 17 years, and 73.3% were from public schools. The prevalence of metabolic syndrome was 2.6% (95%CI 2.3-2.9), slightly higher in males and in those aged from 15 to 17 years in most macro-regions. The prevalence was the highest in residents from the South macro-region, in the younger female adolescents and in the older male adolescents. The prevalence was higher in public schools (2.8% [95%CI 2.4-3.2]), when compared with private schools (1.9% [95%CI 1.4-2.4]) and higher in obese adolescents when compared with nonobese ones. The most common combinations of components, referring to 3/4 of combinations, were: enlarged waist circumference (WC), low HDL-cholesterol (HDL-c) and high blood pressure; followed by enlarged WC, low HDL-c and high triglycerides; and enlarged WC, low HDL-c, high triglycerides and blood pressure. Low HDL was the second most frequent component, but the highest prevalence of metabolic syndrome (26.8%) was observed in the presence of high triglycerides.
CONCLUSIONS
ERICA is the first Brazilian nation-wide study to present the prevalence of metabolic syndrome and describe the role of its components. Despite the prevalence of Metabolic Syndrome being low, the high prevalences of some components and participation of others in the syndrome composition shows the importance of early diagnosis of this changes, even if not grouped within the metabolic syndrome.
doi:10.1590/S01518-8787.2016050006701
PMCID: PMC4767042  PMID: 26910546
Adolescent; Metabolic Syndrome, epidemiology; Risk Factors; Cardiovascular Diseases; Cross-Sectional Studies
18.  Social Engagement and Chronic Disease Risk Behaviors: The Multi-Ethnic Study of Atherosclerosis 
Preventive medicine  2014;0:61-66.
Objective
Although engagement in social networks is important to health, multiple different dimensions exist. This study identifies which dimensions are associated with chronic disease risk behaviors.
Method
Cross-sectional data on social support, loneliness, and neighborhood social cohesion from 5381 participants, aged 45–84 from the Multi-Ethnic Study of Atherosclerosis was used.
Results
After adjusting for individual characteristics and all social engagement variables, social support was associated with lower smoking prevalence (PR=0.88, 95% CI: 0.82, 0.94), higher probability of having quit (PR=1.03, 95% CI: 1.01, 1.06) and a slightly higher probability of achieving physical activity recommendations (PR=1.03, 95% CI: 1.01, 1.06). Neighborhood social cohesion was associated with very slightly higher probability of achieving recommended (PR=1.03, 95% CI: 1.01, 1.05) or any regular (PR=1.0, 95% CI: 1.01, 1.04) physical activity, and a higher probability of consuming at least five daily fruit and vegetable servings (PR=1.05, 95% CI: 1.01, 1.09).
Conclusion
Both social support and neighborhood social cohesion, a less commonly considered aspect of social engagement, appear to be important for chronic disease prevention interventions and likely act via separate pathways.
doi:10.1016/j.ypmed.2014.12.008
PMCID: PMC4329061  PMID: 25524614
social engagement; social support; neighborhood social cohesion; physical activity; smoking
19.  Coronary Artery Calcium and Incident Cerebrovascular Events in an Asymptomatic Multi Ethnic Cohort. MESA 
JACC. Cardiovascular imaging  2014;7(11):1108-1115.
Objective
We assessed the predictive value of coronary artery calcium (CAC) score for CVA events in an asymptomatic multi-ethnic cohort.
Background
The coronary artery calcium (CAC) score, a measure of atherosclerotic burden, has been shown to improve prediction of coronary heart disease events. However, the predictive value of CAC for cerebrovascular (CVA) events is unclear.
Methods
CAC was measured at baseline exam of participants (N=6779) of the Multi Ethnic Study of atherosclerosis (MESA) and then followed for an average of 9.5(2.4) years for the diagnosis of incident CVA defined as all strokes or TIAs.
Results
During the follow up 234(3.5%) adjudicated CVA events occurred. In Kaplan Meier analysis the presence of CAC was associated with a lower CVA event - free survival versus CAC absent (Log rank χ2 = 59.8, p<0.0001). Log transformed CAC was associated with increased risk for CVA after adjusting for age, gender, race/ethnicity, BMI, systolic and diastolic blood pressure, total cholesterol, HDL-C, cigarette smoking status, blood pressure medication use, statin use and interim atrial fibrillation[hazard ratio(95% CI): 1.13(1.07 – 1.20),p<0.0001]. The ACC/AHA recommended CAC cut off was also an independent predictor of CVA and strokes [HR (95%CI): 1.70(1.24–2.35),p=0.001 and 1.59(1.11–2.27), p=0.01 respectively]. CAC was an independent predictor of CVA when analysis was stratified by gender or race/ethnicity, and improved discrimination for CVA when added to the full model (c statistic: 0.744 vs. 0.755). CAC also improved the discriminative ability of the Framingham stroke risk score for CVA.
Conclusion
CAC is an independent predictor of CVA events, and improves the discrimination afforded by current stroke risk factors or the Framingham stroke risk score for incident CVA in an initially asymptomatic multi-ethnic adult cohort.
doi:10.1016/j.jcmg.2014.07.009
PMCID: PMC4254694  PMID: 25459592
Coronary artery calcium score; cerebrovascular disease; risk prediction; prevention
20.  Significance of a Positive Family History for Coronary Heart Disease in Patients with a Zero Coronary Artery Calcium Score (From the Multi-Ethnic Study of Atherosclerosis [MESA]) 
The American journal of cardiology  2014;114(8):1210-1214.
While a coronary artery calcium score of 0 is associated with a very low 10-year risk for cardiac events, this risk is non-zero. A family history of CHD and has been associated with more subclinical atherosclerosis than individuals without a family history of CHD. The purpose of this study was to assess the significance of a family history for coronary heart disease (CHD) among individuals with a coronary artery calcium (CAC) score of 0. The MESA cohort includes 6,814 participants free of clinical CVD at baseline. Positive family history was defined as reporting a parent, sibling, or child who had a heart attack. Time to incident CHD or CVD event was modeled using multivariable Cox regression. 3,185 subjects were identified from the original MESA cohort as having a baseline CAC score of 0 (mean age 58 years, 37% male). Over a median follow-up of 10 years, 101 (3.2%) participants had CVD events and 56 (1.8%) had CHD events. In age and gender adjusted analyses, a family history of CHD was associated with an approximate 70% increase in CVD (HR 1.73, 95% CI 1.17-2.56) and CHD (HR 1.72, 95% CI 1.01-2.91) events. CVD events remained significant after further adjustment for ethnicity, risk factors and baseline medication use. In conclusion, asymptomatic individuals with a 0 CAC score and a positive family history of CHD are at increased risk for CVD and CHD events compared to those without a family history of CHD, although absolute event rates remain low.
doi:10.1016/j.amjcard.2014.07.043
PMCID: PMC4177938  PMID: 25152422
coronary calcium; family history; low risk
21.  The Sex and Race Specific Relationship between Anthropometry and Body Fat Composition Determined from Computed Tomography: Evidence from the Multi-Ethnic Study of Atherosclerosis 
PLoS ONE  2015;10(10):e0139559.
Background
Few studies have investigated the relationship of anthropometric measurements with computed tomography (CT) body fat composition, and even fewer determined if these relationships differ by sex and race.
Methods
CT scans from 1,851 participants in the population based Multi-Ethnic Study of Atherosclerosis were assessed for visceral and subcutaneous fat areas by semi-automated segmentation of body compartments. Regression models were used to investigate relationships for anthropometry with visceral and subcutaneous fat separately by sex and race/ethnicity.
Results
Participants were 50% female, 41% Caucasian, 13% Asian, 21% African American, and 25% Hispanic. For visceral fat, the positive relationship with weight (p = 0.028), waist circumference (p<0.001), waist to hip ratio (p<0.001), and waist to height ratio (p = 0.05) differed by sex, with a steeper slope for men. That is, across the range of these anthropometric measures the rise in visceral fat is faster for men than for women. Additionally, there were differences by race/ethnicity in the relationship with height (p<0.001), weight (p<0.001), waist circumference (p<0.001), hip circumference (p = 0.006), and waist to hip ratio (p = 0.001) with the Hispanic group having shallower slopes. For subcutaneous fat, interaction by sex was found for all anthropometric indices at p<0.05, but not for race/ethnicity.
Conclusion
The relationship between anthropometry and underlying adiposity differs by sex and race/ethnicity. When anthropometry is used as a proxy for visceral fat in research, sex-specific models should be used.
doi:10.1371/journal.pone.0139559
PMCID: PMC4598154  PMID: 26448048
23.  Sex and race/ethnic disparities in the cross-sectional association between depressive symptoms and muscle mass: the Multi-ethnic Study of Atherosclerosis 
BMC Psychiatry  2015;15:221.
Background
The cross-sectional area of total muscle mass has been reported to decrease by about 40% for those 20–60 years of age. Depressive symptoms may discourage motivation to engage in physical activity such as strength training shown to negate muscle loss. Inflammation related to depressive symptoms may also contribute to muscle atrophy. Physiological differences by sex and race/ethnicity may also modify the association between depression and muscle mass. Evidence on the relationship between depression (or depressive symptoms) and adiposity has been mounting; however, little is known about the depressive symptoms-muscle mass association. We sought to determine the association between elevated depressive symptoms (EDS) and lean muscle mass and whether this varies by sex and race/ethnicity.
Methods
Evaluating 1605 adults (45–84 years of age) from the Multi-ethnic Study of Atherosclerosis Abdominal Body Composition, Inflammation and Cardiovascular Disease Study, we examined the cross-sectional association between EDS (Center for Epidemiologic Studies for Depression Scale score ≥ 16 and/or antidepressant use) and computed tomography-measured abdominal lean muscle mass using linear regression. Muscles were evaluated as a whole and by functionality (locomotion vs. stabilization/posture). Covariates included height, body mass index, sociodemographics, comorbidities, inflammatory markers and health behaviors (pack-years of smoking, alcohol locomotion compared to men, total intentional exercise, daily caloric intake). Sex and race/ethnicity were assessed as potential modifiers. Statistical significance was at a p < 0.05 for main effects and < 0.20 for interaction.
Results
Men with elevated depressive symptoms had 5.9 cm2 lower lean muscle mass for locomotion compared to men without EDS, fully-adjusted (CI = −10.5, −1.4, p = 0.011). This was statistically significantly different from the null finding among women (interaction p = 0.05). Chinese participants with EDS had 10.2 cm2 lower abdominal lean muscle mass for locomotion compared to those without EDS (fully-adjusted, CI = −18.3, −2.1, p = 0.014), which was significantly different from the null relationship among White participants (interaction p = 0.04). No association was observed between elevated depressive symptoms and muscle for stabilization/posture evaluating the whole population or stratified by sex or race/ethnicity.
Conclusions
In the presence of elevated depressive symptoms, men and Chinese participants may have lower muscle mass, particularly for locomotion.
Electronic supplementary material
The online version of this article (doi:10.1186/s12888-015-0604-9) contains supplementary material, which is available to authorized users.
doi:10.1186/s12888-015-0604-9
PMCID: PMC4574470  PMID: 26384322
24.  Erratum to: The study of cardiovascular risk in adolescents – ERICA: rationale, design and sample characteristics of a national survey examining cardiovascular risk factor profile in Brazilian adolescents 
BMC Public Health  2015;15:850.
doi:10.1186/s12889-015-2083-9
PMCID: PMC4559346  PMID: 26335689
25.  Difference by sex but not by race/ethnicity in the visceral adipose tissue-depressive symptoms association: The Multi-Ethnic Study of Atherosclerosis 
Psychoneuroendocrinology  2014;47:78-87.
Summary
Background
Prior studies have investigated the association of clinical depression and depressive symptoms with body weight (i.e. body mass index (BMI) and waist circumference), but few have examined the association between depressive symptoms and intra-abdominal fat. Of these a limited number assessed the relationship in a multi-racial/ethnic population.
Methods
Using data on 1017 men and women (45–84 years) from the Multi-Ethnic Study of Atherosclerosis (MESA) Body Composition, Inflammation and Cardiovascular Disease Study, we examined the cross-sectional association between elevated depressive symptoms (EDS) and CT-measured visceral fat mass at L2–L5 with multivariable linear regression models. EDS were defined as a Center for Epidemiological Studies Depression score ≥16 and/or anti-depressant use. Covariates included socio-demographics, inflammatory markers, health behaviors, comorbidities, and body mass index (BMI). Race/ethnicity (Whites [referent group], Chinese, Blacks and Hispanics) and sex were also assessed as potential modifiers.
Results
The association between depressive symptoms and visceral fat differed significantly by sex (p = 0.007), but not by race/ethnicity. Among men, compared to participants without EDS, those with EDS had greater visceral adiposity adjusted for BMI and age (difference = 122.5 cm2, 95% CI = 34.3, 210.7, p = 0.007). Estimates were attenuated but remained significant after further adjustment by socio-demographics, inflammatory markers, health behaviors and co-morbidities (difference = 94.7 cm2, 95% CI = 10.5, 178.9, p = 0.028). Among women, EDS was not significantly related to visceral adiposity in the fully adjusted model.
Conclusions
Sex, but not race/ethnicity, was found to modify the relationship between EDS and visceral fat mass. Among men, a significant positive association was found between depressive symptoms and visceral adiposity. No significant relationship was found among women.
doi:10.1016/j.psyneuen.2014.05.004
PMCID: PMC4134940  PMID: 25001957
Elevated depressive symptoms; Visceral adipose tissue; Visceral fat mass; Sex; Race/ethnicity; Antidepressant use

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