Adiposidade e risco cardiovascular: razão cintura/altura

J Am Coll Cardiol. 2008 Aug 19;52(8):605-15.
Measures of obesity and cardiovascular risk among men and women.
Gelber RP, Gaziano JM, Orav EJ, Manson JE, Buring JE, Kurth T.
OBJECTIVES: This study examined associations between anthropometric measures (body mass index, waist circumference, waist-to-hip ratio, waist-to-height ratio [WHtR]) and risk of incident cardiovascular disease (CVD) (including nonfatal myocardial infarction, nonfatal ischemic stroke, and cardiovascular death). BACKGROUND: Controversy exists regarding the optimal approach to measure adiposity, and the utility of body mass index has been questioned. METHODS: Participants included 16,332 men in the Physicians' Health Study (mean age 61 years in 1991) and 32,700 women in the Women's Health Study (mean age 61 years in 1999). We used Cox proportional hazards models to determine relative risks and 95% confidence intervals (CIs) for developing CVD according to self-reported anthropometric indexes. RESULTS: A total of 1,505 CVD cases occurred in men and 414 occurred in women (median follow-up 14.2 and 5.5 years, respectively). Although WHtR demonstrated statistically the strongest associations with CVD and best model fit, CVD risk increased linearly and significantly with higher levels of all indexes. Adjusting for confounders, the relative risk for CVD was 0.58 (95% CI: 0.32 to 1.05) for men with the lowest WHtR (<0.45)>/=0.69; vs. WHtR 0.49 to <0.53).>/=0.68; vs. WHtR 0.47 to <0.52).>

Epidemiologia das citocinas

Epidemiology of Cytokines
The Women On the Move through Activity and Nutrition (WOMAN) Study Eric Wong1, Matthew Freiberg1,2, Russell Tracy3 and Lewis Kuller1
kullerl@edc.pitt.edu

American Journal of Epidemiology 2008 168(4):443-453; doi:10.1093/aje/kwn132
Using multiplex technology, the authors investigated the laboratory and biologic variation of a panel of cytokines (interleukin (IL)-1a, IL-1 receptor antagonist, IL-4, IL-6, IL-8, IL-10, interferon-inducible protein-10, monocyte chemoattractant protein-1, and tumor necrosis factor-) over 18 months and their relations to cardiovascular disease risk factors, hormone therapy, and weight loss. Data were obtained from the Woman On the Move through Activity and Nutrition (WOMAN) Study, a randomized clinical trial investigating the effect of nonpharmacologic interventions on subclinical atherosclerosis among overweight, postmenopausal women in Pennsylvania. The present analysis (February 2002–August 2005) comprised 290 women aged 52–62 years (mean age = 57 years). Most of the cytokines were detectable in a majority of the samples, and the between-individual biologic variation was greater than the within-individual biologic and laboratory variation. There was little association between use of hormone therapy at baseline or change in hormone therapy by 18 months and cytokine levels. Weight loss was associated with a decrease in levels of IL-1 receptor antagonist, IL-6, and C-reactive protein. The results suggest that a wide panel of cytokines may be measured simultaneously from one sample. There is large unexplained variability in cytokine levels that is probably due to genetic-environmental associations.
cytokines; hormones; inflammation; obesity; weight loss; women

Impacto da Prevenção na Redução da Doença Cardiovascular

(Circulation. 2008;118:576-585) coraçaodobrasil/estrategiasdeprevençao

The Impact of Prevention on Reducing the Burden of Cardiovascular Disease.

Richard Kahn, PhD; Rose Marie Robertson, MD, FAHA; Robert Smith, PhD; David Eddy, MD, PhD
E-mail rkahn@diabetes.org
Objective— Cardiovascular disease (CVD) is prevalent and expensive. While many interventions are recommended to prevent CVD, the potential effects of a comprehensive set of prevention activities on CVD morbidity, mortality, and costs have never been evaluated. We therefore determined the effects of 11 nationally recommended prevention activities on CVD-related morbidity, mortality, and costs in the United States.
Research Design and Methods— We used person-specific data from a representative sample of the US population (National Health and Nutrition Education Survey IV) to determine the number and characteristics of adults aged 20-80 years in the United States today who are candidates for different prevention activities related to CVD. We used the Archimedes model to create a simulated population that matched the real US population, person by person. We then used the model to simulate a series of clinical trials that examined the effects over the next 30 years of applying each prevention activity one by one, or altogether, to those who are candidates for the various activities and compared the health outcomes, quality of life, and direct medical costs to current levels of prevention and care. We did this under two sets of assumptions about performance and compliance: 100% success for each activity and lower levels of success considered aggressive but still feasible.
Results— Approximately 78% of adults aged 20-80 years alive today in the United States are candidates for at least one prevention activity. If everyone received the activities for which they are eligible, myocardial infarctions and strokes would be reduced by 63% and 31%, respectively. If more feasible levels of performance are assumed, myocardial infarctions and strokes would be reduced 36% and 20%, respectively. Implementation of all prevention activities would add 221 million life-years and 244 million quality-adjusted life-years to the US adult population over the coming 30 years, or an average of 1.3 years of life expectancy for all adults. Of the specific prevention activities, the greatest benefits to the US population come from providing aspirin to high-risk individuals, controlling pre-diabetes, weight reduction in obese individuals, lowering blood pressure in people with diabetes, and lowering LDL cholesterol in people with existing coronary artery disease (CAD). As currently delivered and at current prices, most prevention activities are expensive when considering direct medical costs; smoking cessation is the only prevention strategy that is cost-saving over 30 years.
Conclusions— Aggressive application of nationally recommended prevention activities could prevent a high proportion of the CAD events and strokes that are otherwise expected to occur in adults in the United States today. However, as they are currently delivered, most of the prevention activities will substantially increase costs. If preventive strategies are to achieve their full potential, ways must be found to reduce the costs and deliver prevention activities more efficiently

Adiposidade e Sobrevida pós Infarto do Miocárdio

Circulation. 2008;118:482-490

Relation Between Body Mass Index, Waist Circumference, and Death After Acute Myocardial Infarction

Marianne Zeller, PhD; Philippe Gabriel Steg, MD, PhD; Jack Ravisy, MD; Luc Lorgis, MD; Yves Laurent, MD; Pierre Sicard, PhD; Luc Janin-Manificat, MD; Jean-Claude Beer, MD; Hamid Makki, MD; Anne-Cécile Lagrost, MSc; Luc Rochette, PharmD, PhD; Yves Cottin, MD, PhD, for the RICO Survey Working Group
Background— An elevated body mass index (BMI) has been reported to be associated with a lower rate of death after acute myocardial infarction (AMI). However, waist circumference (WC) may be a better marker of cardiovascular risk than BMI. We used data from a contemporary French population-based cohort of patients with AMI to analyze the impact of WC and BMI on death rates.
Methods and Results— We evaluated 2229 consecutive patients with AMI. Patients were classified according to BMI as normal, overweight, obese, and very obese (BMI <25,>35 kg/m2, respectively) and as increased waistline (WC >88/102 cm for women/men) or normal. Half of the patients were overweight (n=1044), and one quarter were obese (n=397) or very obese (n=128). Increased WC was present in half of the patients (n=1110). Increased BMI was associated with a reduced death rate, with a 5% risk reduction for each unit increase in BMI (hazard ratio, 0.95; 95% CI, 0.93 to 0.98; P<0.001). In contrast, WC as a continuous variable had no impact on all-cause death (P=0.20). After adjustment for baseline predictors of death, BMI was not independently predictive of death. The group of patients with high WC but low BMI had increased 1-year death rate.
Conclusions— Neither BMI nor WC independently predicts death after AMI. Much of the inverse relationship between BMI and the rate of death after AMI is due to confounding by characteristics associated with survival. This study emphasizes the need to measure both BMI and WC because patients with a high WC and low BMI are at high risk of death.

Padrão de Dieta, Perda de Peso e Incidência de Diabetes

Low-Fat Dietary Pattern and Risk of Treated Diabetes Mellitus in Postmenopausal Women The Women's Health Initiative Randomized Controlled Dietary Modification Trial Lesley F. Tinker, PhD; Denise E. Bonds, MD, MPH; Karen L. Margolis, MD, MPH; JoAnn E. Manson, MD, DrPH; Barbara V. Howard, PhD; Joseph Larson, MS; Michael G. Perri, PhD; Shirley A. A. Beresford, PhD; Jennifer G. Robinson, MD, MPH; Beatriz Rodríguez, MD, PhD; Monika M. Safford, MD; Nanette K. Wenger, MD; Victor J. Stevens, PhD; Linda M. Parker, DSc Arch Intern Med. 2008;168(14):1500-1511.
Background Decreased fat intake with weight loss and increased exercise may reduce the risk of diabetes mellitus in persons with impaired glucose tolerance. This study was undertaken to assess the effects of a low-fat dietary pattern on incidence of treated diabetes among generally healthy postmenopausal women.
Methods A randomized controlled trial was conducted at 40 US clinical centers from 1993 to 2005, including 48 835 postmenopausal women aged 50 to 79 years. Women were randomly assigned to a usual-diet comparison group (n = 29 294 [60.0%]) or an intervention group with a 20% low-fat dietary pattern with increased vegetables, fruits, and grains (n = 19 541 [40.0%]). Self-reported incident diabetes treated with oral agents or insulin was assessed.
Results Incident treated diabetes was reported by 1303 intervention participants (7.1%) and 2039 comparison participants (7.4%) (hazard ratio, 0.96; 95% confidence interval, 0.90-1.03; P = .25). Weight loss occurred in the intervention group, with a difference between intervention and comparison groups of 1.9 kg after 7.5 years (P < .001). Subgroup analysis suggested that greater decreases in percentage of energy from total fat reduced diabetes risk (P for trend = .04), which was not statistically significant after adjusting for weight loss.
Conclusions A low-fat dietary pattern among generally healthy postmenopausal women showed no evidence of reducing diabetes risk after 8.1 years. Trends toward reduced incidence were greater with greater decreases in total fat intake and weight loss. Weight loss, rather than macronutrient composition, may be the dominant predictor of reduced risk of diabetes.

Suco de frutas e Incidência de Diabetes

Sugar-Sweetened Beverages and Incidence of Type 2 Diabetes Mellitus in African American Women Julie R. Palmer, ScD; Deborah A. Boggs, MS; Supriya Krishnan, DSc; Frank B. Hu, MD; Martha Singer, MPH; Lynn Rosenberg, ScD Arch Intern Med. 2008;168(14):1487-1492.
Background Type 2 diabetes mellitus is an increasingly serious health problem among African American women. Consumption of sugar-sweetened drinks was associated with an increased risk of diabetes in 2 studies but not in a third; however, to our knowledge, no data are available on African Americans regarding this issue. Our objective was to examine the association between consumption of sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes mellitus in African American women.
Methods A prospective follow-up study of 59 000 African American women has been in progress since 1995. Participants reported on food and beverage consumption in 1995 and 2001. Biennial follow-up questionnaires ascertained new diagnoses of type 2 diabetes. The present analyses included 43 960 women who gave complete dietary and weight information and were free from diabetes at baseline. We identified 2713 incident cases of type 2 diabetes mellitus during 338 884 person-years of follow-up. The main outcome measure was the incidence of type 2 diabetes mellitus.
Results The incidence of type 2 diabetes mellitus was higher with higher intake of both sugar-sweetened soft drinks and fruit drinks. After adjustment for confounding variables including other dietary factors, the incidence rate ratio for 2 or more soft drinks per day was 1.24 (95% confidence interval, 1.06-1.45). For fruit drinks, the comparable incidence rate ratio was 1.31 (95% confidence interval, 1.13-1.52). The association of diabetes with soft drink consumption was almost entirely mediated by body mass index, whereas the association with fruit drink consumption was independent of body mass index.
Conclusions Regular consumption of sugar-sweetened soft drinks and fruit drinks is associated with an increased risk of type 2 diabetes mellitus in African American women. While there has been increasing public awareness of the adverse health effects of soft drinks, little attention has been given to fruit drinks, which are often marketed as a healthier alternative to soft drinks.

Vigitel: longa vida!

Ontem, o Ministério da Saúde liberou na sua página (http://saude.gov.br) os resultados de 2006 do Vigitel, ou Vigilância de Fatores de Risco e de Proteção das Doenças Crônicas por Inquérito Telefônico. A imprensa divulgou amplamente, sempre enfatizando a diferença entre as capitais.

Esqueceram -os jornais - do principal. Esse belo estudo (que tive a oportunidade de ver nascer) da equipe do NUPENS da Faculdade de Saúde Pública da USP coordenado pelo Professor Carlos Augusto Monteiro com recurso do Ministério da Saúde também avaliou a distribuição desses fatores por nível de escolaridade. E, quase que invariavelmente, aqueles com menor escolaridade apresentam prevalência maior de fatores de risco e menor de fatores de proteção. No caso do tabagismo é incrível: aqueles com educação formal até 8 anos, a prevalência é de 24,2%, mas para quem estudou 12 anos ou mais, esse valor se reduz a 14,4%.

Alguns comentários sobre esse método:

(1) é muito, mas muito mais barato do que as pesquisas de porta em porta com amostragem e, a comparação com os estudos de prevalência de porta em porta são semelhantes;

(2) permite realizar estudos seriados anuais mostrando tendências de cada um dos fatores de risco e proteção;

(3) se por um lado deixa de diagnosticar os casos assintomáticos de hipertensão e diabetes, por outro consegue identificar o acesso a esse diagnóstico.

Aproveito o momento para cumprimentar o novo Ministro da Saúde e, solicitar a manutenção do Vigitel.

Obesidade em mulheres pobres: estudo da USP.

Um estudo sobre obesidade identificou paridade e raça como fatores associados em mulheres de renda baixa na cidade de São Paulo. Esse estudo foi a tese de Alessandra Carvalho Goulart, orientado por Isabela Martins Bensenor na Faculdade de Medicina da USP. A publicação encontra-se no Nutrition Research do mês de janeiro de 2007, cujo resumo segue abaixo.

Maiores informações e o texto com Profa Isabela Bensenor em

isabensenor@hu.usp.br . O autor do blogue é co-autor do estudo.

Race and parity as risk factors for obesity among low-income women in Brazil
Alessandra C. Goulart, Fernando M. Silvaa, Isac de Castro, Paulo A. Lotufo
Marly A. Cardoso, Isabela M. Bensenor
In recent years, several reports have indicated that obesity and associated chronic diseases presented a huge increase worldwide, especially in low-income women living in undeveloped countries. The aim of this study was to verify, in a cross-sectional way, the association among obesity, diet, lifestyle and socioeconomic factors among 116 low-income women (mean age, 42.6 F 13.4 years) living in a deprived neighborhood in the metropolitan area of Sao Paulo, the main city in Brazil. The sample was categorized in 3 strata according to body mass index (V25.0, 25-29.9, and z30.0 kg/m2). Anthropometric measurements and cardiovascular risk factors, as well as diet, lifestyle, and sociodemographic characteristics, were compared. Frequency of obesity was 28.4%—higher than the frequency of obesity observed in other Brazilian population samples. After
multivariate adjustment, compared with women with less than 3 childbirths, women with 3 childbirths or more were more overweight (odds ratio [OR], 3.4; 95% confidence interval [95% CI], 1.2-9.6) and more obese (OR, 5.3; 95% CI, 1.3-17.5). Compared to black women, white women were also more obese (OR, 9.9; 95% CI, 1.5-64.6). In this sample of low-income women, parity and race were the most important factors associated with obesity.