Prospective Urban Rural Epidemiology Study Research Articles

Associations of perceived built environment characteristics using NEWS questionnaires with all-cause mortality and major cardiovascular diseases: The prospective urban rural epidemiology (PURE)-China study

BackgroundDespite increased literature focusing on the role of the built environment (BE) in health, few cohort studies have quantitatively analyzed neighborhood walkability environment in relation to the risk of death and cardiovascular disease (CVD). This longitudinal study aimed at evaluating the association between perceived BE attributeswith mortality and major CVD based on the Prospective Urban Rural Epidemiology study in China (PURE-China). MethodsThe PURE-China study recruited 47,931 participants aged 35–70 years from 12 provinces of China between 2005 and 2009. The perceived BE information, including land use, street, aesthetics, and safety, was collected using the neighborhood environment walkability scale (NEWS) questionnaire, with higher scores indicating a more favorable rating. Two primary outcomes are all-cause mortality and major CVD event. The Cox frailty model with random intercepts was used to assess the association between the perceived total BE/subscales score and outcomes. ResultsOf 32,163 participants included in this study, 19,253 (59.9 %) were women, and the mean (SD) age was 51.0 (9.5) years. After a median follow-up period of 11.7 years (IQR 9.4 – 12.2), we observed that one standard deviation higher of combined BE scores was related to a lower risk of all-cause mortality (HR = 0.85; 95 %CI, 0.80–0.90), and major CVD events (HR = 0.95; 95 %CI, 0.90–0.99). The subscales of perceived BE were related to a lower risk, although a few were not significant. Land use mix-diversity and safety from crime were the two most significant subscales. Stronger risks were observed among urban and female participants. ConclusionFavorable perceived BE characteristics were linked with a lower risk of all-cause mortality and major CVD events in Chinese population, especially in urban areas and females. Our findings can be used by policymakers to take action to mitigate the adverse effect of poor community conditions on health, such as improving local amenities and transport connectivity, providing building paths for walking, running and cycling.

Physical Activity and Obesity Risk in Adults in Colombia: The Prospective Urban Rural Epidemiology (PURE) Study.

This study aimed to investigate longitudinal associations between physical activity levels and obesity in adults in Colombia, where participation in large amounts of light-intensity physical activity is a necessity for many people. Participation in moderate- and vigorous-intensity physical activity was assessed from 2005 to 2009, and obesity was assessed from 2011 to 2019 in men and women from the Prospective Urban Rural Epidemiology (PURE) study. Total physical activity level was categorized as low (<600 MET·min·wk -1 ), medium (600-3000 MET·min·wk -1 ), or high (>3000 MET·min·wk -1 ; 600 MET·min·wk -1 is equivalent to 150 min of moderate activity or 75 min of vigorous activity per week). Obesity was defined as body mass index ≥30 kg·m -2 . Analyses were adjusted for age, sex, smoking, socioeconomic status, diet, alcohol, sedentary time, and sleep. The main analysis included 3086 men and women aged 51 ± 9 yr at baseline (mean ± SD). Compared with the low physical activity group, the odds ratio (95% confidence interval) for obesity was 0.67 (0.53-0.85) in the medium physical activity group and 0.78 (0.62-0.98) in the high physical activity group after adjustment for potential confounders. Smoking is probably a major confounder, and it is noteworthy that similar associations were observed in participants who reported never smoking. The PURE study is the only prospective cohort study in Colombia. The present analysis is important because it suggests that even the busy people of Colombia could substantially reduce their risk of obesity by participating in moderate- and vigorous-intensity physical activity.

Sex Differences in Cardiovascular Disease Risk Factor Prevalence, Morbidity, and Mortality in Colombia: Findings from the Prospective Urban Rural Epidemiology (PURE) Study.

Controversies exist on whether the presence of cardiovascular risk factors and their association with major cardiovascular events (MACE) is different between men and women. Most of the evidence comes from high-income countries, hindering extrapolation of sociocultural and demographic factors of other regions. To evaluate sex differences in the prevalence of cardiovascular risk factors and the incidence of MACE and diabetes in Colombian adults. We performed a survival analysis from women and men aged 35-70 belonging to the Prospective Urban Rural Epidemiology-Colombia prospective study. Incidence rates for MACE composite (myocardial infarction, stroke, heart failure, death) and each outcome and diabetes were calculated. Kaplan-Meier curves and log-rank tests were performed. The association between demographic, behavioral, and metabolic variables with MACE and diabetes were evaluated with Cox proportional hazards models. 7,552 participants (50±9.7 years) were included; 64% were women. Women had higher hypertension prevalence, body mass index, levels of total cholesterol, LDL-c, and HDL-c but lower triglycerides levels. Women were more sedentary but fewer smokers or active alcohol consumers and had higher educational levels. After 12-year mean follow-up (SD 2.3), the incidence rate of MACE composite was higher in men [4.2 (3.6-4.9) vs. 3.2 (2.8-3.7) cases per 1000 person-years]. Diabetes had the greatest association with MACE (HR = 2.63 95%CI:1.85;3.76), followed by hypertension (HR = 1.75 95%CI:1.30;2.35), low relative grip strength (HR = 1.53 95%CI:1.15;2.02), smoking (HR = 1.47 95%CI: 1.11;1.93), low physical activity (HR = 1.42 95%CI: 1.03;1.96). When evaluating risk factors by sex, only an increased waist-to-hip ratio was more strongly associated with MACE in men (p-interaction <0.05). The composite MACE outcome was higher in men despite having a lower overall burden of risk factors. The risk factors contribution was similar, leading us to reconsider the need to carrying out differentiated cardiovascular risk prevention and management campaigns, at least in our region.

Risk factors for recognized and unrecognized SARS-CoV-2 infection: a seroepidemiologic analysis of the Prospective Urban Rural Epidemiology (PURE) study.

There are limited data on individual risk factors for SARS-CoV-2 infection (including unrecognized infection). In this seroepidemiologic substudy of an ongoing prospective cohort study of community-dwelling adults, participants were thoroughly characterized pre-pandemic. The SARS-CoV-2 infection was ascertained by serology. Among 8,719 participants from 11 high-, middle-, and low-income countries, 3,009 (35%) were seropositive for SARS-CoV-2. Characteristics independently associated with seropositivity were younger age (odds ratio, OR; 95% confidence interval, CI, per five-year increase: 0.95; 0.91-0.98) and body mass index >25 kg/m2 (OR, 95% CI: 1.16, 1.01-1.34). Smoking (as compared with never smoking, OR, 95% CI: 0.83, 0.70-0.97) and COVID-19 vaccination (OR, 95% CI: 0.70, 0.60-0.82) were associated with a reduced risk of seropositivity. Among seropositive participants, 83% were unaware of having been infected with SARS-CoV-2. Seropositivity and a lack of awareness of infection were more common in lower-income countries. The COVID-19 vaccination reduces the risk of SARS-CoV-2 infection (including recognized and unrecognized infections). Overweight or obesity is an independent risk factor for SARS-CoV-2 infection. Infection and lack of infection awareness are more common in lower-income countries.IMPORTANCEIn this large, international study, evidence of SARS-CoV-2 infection was obtained by testing blood specimens from 8,719 community-dwelling adults from 11 countries. The key findings are that (i) the large majority (83%) of community-dwelling adults from several high-, middle-, and low-income countries with blood test evidence of SARS-CoV-2 infection were unaware of this infection-especially in lower-income countries; and (ii) overweight/obesity predisposes to SARS-CoV-2 infection, while COVID-19 vaccination is associated with a reduced risk of SARS-CoV-2 infection. These observations are not attributable to other individual characteristics, highlighting the importance of the COVID-19 vaccination to prevent not only severe infection but possibly any infection. Further research is needed to understand the mechanisms by which overweight/obesity might increase the risk of SARS-CoV-2 infection.

Abstract 15439: Association of Vigorous Physical Activity With Cardiovascular Disease and Mortality in 136,766 Adults From High-Income, Middle-Income and Low-Income Countries: The Prospective Urban Rural Epidemiological (PURE) Study

Background: It’s recommended adults get 150-300 minutes of moderate physical activity (MPA) and/or 75-150 minutes of vigorous physical activity (VPA) per week. Some studies have found high VPA to be protective and others found it to be harmful. These studies have been conducted in high-income countries using recreational VPA as the exposure of interest. Purpose: To evaluate the effects of VPA with all-cause mortality, and cardiovascular disease (CVD) in countries at different economic levels. Methods: Participants aged 35-70 years were recruited from 21 countries at various stages of economic development. Physical activity (total, walking, MPA, VPA, as well as recreational vs. non-recreational PA) was assessed using the International Physical Activity Questionnaire. Primary clinical outcomes were the composite of mortality plus major CVD (CVD mortality, myocardial infarction, stroke, or heart failure) and mortality. A total of 136,766 participants without baseline CVD, cancer, and HIV were analyzed. Models were adjusted for age, sex, urban/rural residency, country income level, education, household wealth index, smoking, baseline chronic diseases, physical impairments, MPA, walking and centre as a random effect. Results: During the median follow-up of 11.5 (8.6-12.4) years, there were 9846 deaths and 7900 major CVD events. The median min/wk (IQR) for total PA, walking, MPA and VPA were 690 (250-1530), 40 (0-420), 330 (75-860), 0 (0-0). The mean VPA was 103±390 min/wk. Compared to no VPA, 150-299 minutes per week of VPA was associated with reduced risk for the composite outcome and mortality, HR = 0.82 (0.73,0.92) and 0.74 (0.64,0.86), respectively. When VPA was stratified into either recreational or non-recreational VPA, recreational VPA displayed a U-shape relationship, such that higher levels were associated with less benefit. Increasing non-recreational VPA continued to confer reduced risk even above 3000 min/wk. At any amount of moderate PA, higher VPA was associated with reduced risk for the composite outcome and mortality. Conclusion: Higher levels of VPA were associated with reduced risk for mortality and major CVD events up to more than 40 times the minimum recommended amount. At no point did VPA confer an increased risk.

Waist circumference cut-off points to identify major cardiovascular events and incident diabetes in Latin America: findings from the prospective Urban rural epidemiology study Colombia.

Abdominal obesity (AO) indirectly represents visceral adiposity and can be assessed by waist circumference (WC) measurement. In Latin America, cut-off points for the diagnosis of AO are based on Asian population data. We aim to establish the WC cut-off points to predict major cardiovascular events (MACE) and incident diabetes. We analyzed data from the cohort PURE study in Colombia. WC cut-off points were defined according to the maximum Youden index. Multivariate logistic regression was used to obtain associations between WC and MACE, diabetes, and cumulative incidence of outcomes visualized using Kaplan-Meier curves. After a mean follow-up of 12 years, 6,580 individuals with a mean age of 50.7 ± 9.7 years were included; 64.2% were women, and 53.5% were from rural areas. The mean WC was 85.2 ± 11.6 cm and 88.3 ± 11.1 cm in women and men, respectively. There were 635 cases of the MACE composite plus incident diabetes (5.25 events per 1,000 person-years). Using a cut-off value of 88.85 cm in men (sensitivity = 0.565) and 85.65 cm in women (sensitivity = 0.558) resulted in the highest value for the prediction of the main outcome. These values were associated with a 1.76 and 1.41-fold increased risk of presenting the composite outcome in men and women, respectively. We defined WC cut-off points of 89 cm in men and 86 cm in women to identify the elevated risk of MACE and incident diabetes. Therefore, we suggest using these values in cardiovascular risk assessment in Latin America.

Diet, cardiovascular disease, and mortality in 80 countries.

To develop a healthy diet score that is associated with health outcomes and is globally applicable using data from the Prospective Urban Rural Epidemiology (PURE) study and replicate it in five independent studies on a total of 245 000 people from 80 countries. A healthy diet score was developed in 147 642 people from the general population, from 21 countries in the PURE study, and the consistency of the associations of the score with events was examined in five large independent studies from 70 countries. The healthy diet score was developed based on six foods each of which has been associated with a significantly lower risk of mortality [i.e. fruit, vegetables, nuts, legumes, fish, and dairy (mainly whole-fat); range of scores, 0-6]. The main outcome measures were all-cause mortality and major cardiovascular events [cardiovascular disease (CVD)]. During a median follow-up of 9.3 years in PURE, compared with a diet score of ≤1 points, a diet score of ≥5 points was associated with a lower risk of mortality [hazard ratio (HR) 0.70; 95% confidence interval (CI) 0.63-0.77)], CVD (HR 0.82; 0.75-0.91), myocardial infarction (HR 0.86; 0.75-0.99), and stroke (HR 0.81; 0.71-0.93). In three independent studies in vascular patients, similar results were found, with a higher diet score being associated with lower mortality (HR 0.73; 0.66-0.81), CVD (HR 0.79; 0.72-0.87), myocardial infarction (HR 0.85; 0.71-0.99), and a non-statistically significant lower risk of stroke (HR 0.87; 0.73-1.03). Additionally, in two case-control studies, a higher diet score was associated with lower first myocardial infarction [odds ratio (OR) 0.72; 0.65-0.80] and stroke (OR 0.57; 0.50-0.65). A higher diet score was associated with a significantly lower risk of death or CVD in regions with lower than with higher gross national incomes (P for heterogeneity <0.0001). The PURE score showed slightly stronger associations with death or CVD than several other common diet scores (P < 0.001 for each comparison). A diet comprised of higher amounts of fruit, vegetables, nuts, legumes, fish, and whole-fat dairy is associated with lower CVD and mortality in all world regions, especially in countries with lower income where consumption of these foods is low.

P856 Associations of antibiotics, hormonal therapies, oral contraceptives, and long-term NSAIDs with Inflammatory Bowel Disease: results from the Prospective Urban Rural Epidemiology (PURE) study

Abstract Background Several medications have been considered to contribute to the aetiology of inflammatory bowel disease (IBD). This study assessed the association between medication use and risk of developing IBD using the Prospective Urban Rural Epidemiology (PURE) cohort. Methods This was a prospective cohort study of 133,137 individuals between the ages of 20-80 from 24 countries. Country-specific validated questionnaires documented baseline and follow-up medication use. Participants were followed prospectively at least every 3 years. The main outcome was development of IBD, including Crohn’s disease (CD) and ulcerative colitis (UC). Short-term (baseline but not follow-up use) and long-term use (baseline and subsequent follow-up use) was evaluated. Results are presented as adjusted odds ratios (aOR) with 95% confidence intervals (CI). Results During the median follow-up of 11.0 years [interquartile range (IQR) 9.2-12.2], we recorded 571 incident cases of IBD (143 CD and 428 UC). Higher risk of incident IBD was associated with baseline antibiotic use [aOR: 2.81 (95% CI: 1.67-4.73), p=0.0001] and hormonal medication use [aOR: 4.43 (95% CI: 1.78-11.01), p=0.001]. Among females, previous or current oral contraceptive use was also associated with IBD development [aOR: 2.17 (95% CI: 1.70-2.77), p=5.02E-10]. NSAID users were also observed to have increased risk of IBD [aOR: 1.80 (95% CI: 1.23-2.64), p=0.002], which was driven by long-term users [aOR: 5.58 (95% CI: 2.26-13.80), p&amp;lt;0.001]. All significant results were consistent in direction for CD and UC with low heterogeneity. Conclusion Antibiotics, hormonal medications, oral contraceptives, and long-term NSAID use were associated with increased odds of incident IBD after adjustment for covariates.

Normative reference values and predicting factors of handgrip strength for dominant and non-dominant hands among healthy Malay adults in Malaysia

IntroductionHandgrip strength (HGS) measures the maximum voluntary force of the hand, which has been used to assess individual health status indirectly. Although several factors related to HGS have been identified, studies among adults in Malaysia are lacking. This study aimed to provide the normative reference HGS values and determine its predictor factors among healthy adults of Malay ethnic in Malaysia.MethodologyThis study was a part of the Prospective Urban Rural Epidemiology (PURE) study carried out among adults aged between 35 to 70 years old residing in urban and rural Malaysian communities. A standardised questionnaire was used to assess the socio-demographic information and physical activity level of respondents who provided written informed consent to participate in this study. HGS was measured using Jamar’s dynamometer. A total of 3,446 healthy adults of Malay ethnic were included in this study. Descriptive data were used to derive the normative reference values for HGS using means and standard deviations stratified by age and gender. The predictors of HGS were determined using a general linear model (GLM).ResultsMean HGS ranged from 38.48 (± 9.40) kg for the dominant hand of men aged 35–40 years to 16.53 (± 5.69) kg for the non-dominant hand of women aged 61–70 years. The ANOVA indicated that there was a significant descending trend of HGS as age increased for both genders (p < 0.05). The ANOVA also revealed that participants working in blue- or white-collar jobs had higher HGS than their counterparts who are homemakers (p < 0.05). The GLM shows that, age, occupation type, socio-economic status (SES), physical activity level and BMI significantly predicted dominant HGS among male and meanwhile, only age, SES and BMI significantly predicted dominant HGS among female.ConclusionHGS normative values provided herein can serve as a guide for interpreting HGS measurements obtained from healthy Asian adults especially Malay ethnic. The clinicians and researcher can use the established HGS reference values as comparison in their patients or participants. Furthermore, during a rehabilitation process, the clinicians and researchers could use the normal score ranges to document the progress of HGS and provide feedback to the patients. Further study with prospective study design is needed to determine the causal effect association of the predictors and HGS.

Associations of Antibiotics, Hormonal Therapies, Oral Contraceptives, and Long-Term NSAIDS With Inflammatory Bowel Disease: Results From the Prospective Urban Rural Epidemiology (PURE) Study

Several medications have been suspected to contribute to the etiology of inflammatory bowel disease (IBD). This study assessed the association between medication use and the risk of developing IBD using the Prospective Urban Rural Epidemiology cohort. This was a prospective cohort study of 133,137 individuals between the ages of 20 and 80 from 24 countries. Country-specific validated questionnaires documented baseline and follow-up medication use. Participants were followed up prospectively at least every 3 years. The main outcome was the development of IBD, including Crohn's disease (CD) and ulcerative colitis (UC). Short-term (baseline but not follow-up use) and long-term use (baseline and subsequent follow-up use) were evaluated. Results are presented as adjusted odds ratios (aORs) with 95% CIs. During a median follow-up period of 11.0 years (interquartile range, 9.2-12.2 y), there were 571 incident IBD cases (143 CD and 428 UC). Incident IBD was associated significantly with baseline antibiotic (aOR, 2.81; 95% CI, 1.67-4.73; P= .0001) and hormonal medication use (aOR, 4.43; 95% CI, 1.78-11.01; P= .001). Among females, previous or current oral contraceptive use also was associated with IBD development (aOR, 2.17; 95% CI, 1.70-2.77; P < .001). Nonsteroidal anti-inflammatory drug users also were observed to have increased odds of IBD (aOR, 1.80; 95% CI, 1.23-2.64; P= .002), which was driven by long-term use (aOR, 5.58; 95% CI, 2.26-13.80; P < .001). All significant results were consistent in direction for CD and UC with low heterogeneity. Antibiotics, hormonal medications, oral contraceptives, and long-term nonsteroidal anti-inflammatory drug use were associated with increased odds of incident IBD after adjustment for covariates.

Association of the triglyceride glucose index as a measure of insulin resistance with mortality and cardiovascular disease in populations from five continents (PURE study): a prospective cohort study

The triglyceride glucose (TyG) index is an easily accessible surrogate marker of insulin resistance, an important pathway in the development of type 2 diabetes and cardiovascular diseases. However, the association of the TyG index with cardiovascular diseases and mortality has mainly been investigated in Asia, with few data available from other regions of the world. We assessed the association of insulin resistance (as determined by the TyG index) with mortality and cardiovascular diseases in individuals from five continents at different levels of economic development, living in urban or rural areas. We also examined whether the associations differed according to the country's economical development. We used the TyG index as a surrogate measure for insulin resistance. Fasting triglycerides and fasting plasma glucose were measured at the baseline visit in 141 243 individuals aged 35-70 years from 22 countries in the Prospective Urban Rural Epidemiology (PURE) study. The TyG index was calculated as Ln (fasting triglycerides [mg/dL] x fasting plasma glucose [mg/dL]/2). We calculated hazard ratios (HRs) using a multivariable Cox frailty model with random effects to test the associations between the TyG index and risk of cardiovascular diseases and mortality. The primary outcome of this analysis was the composite of mortality or major cardiovascular events (defined as death from cardiovascular causes, and non-fatal myocardial infarction, or stroke). Secondary outcomes were non-cardiovascular mortality, cardiovascular mortality, all myocardial infarctions, stroke, and incident diabetes. We also did subgroup analyses to examine the magnitude of associations between insulin resistance (ie, the TyG index) and outcome events according to the income level of the countries. During a median follow-up of 13·2 years (IQR 11·9-14·6), we recorded 6345 composite cardiovascular diseases events, 2030 cardiovascular deaths, 3038 cases of myocardial infarction, 3291 cases of stroke, and 5191 incident cases of type 2 diabetes. After adjusting for all other variables, the risk of developing cardiovascular diseases increased across tertiles of the baseline TyG index. Compared with the lowest tertile of the TyG index, the highest tertile (tertile 3) was associated with a greater incidence of the composite outcome (HR 1·21; 95% CI 1·13-1·30), myocardial infarction (1·24; 1·12-1·38), stroke (1·16; 1·05-1·28), and incident type 2 diabetes (1·99; 1·82-2·16). No significant association of the TyG index was seen with non-cardiovascular mortality. In low-income countries (LICs) and middle-income countries (MICs), the highest tertile of the TyG index was associated with increased hazards for the composite outcome (LICs: HR 1·31; 95% CI 1·12-1·54; MICs: 1·20; 1·11-1·31; pinteraction=0·01), cardiovascular mortality (LICs: 1·44; 1·15-1·80; pinteraction=0·01), myocardial infarction (LICs: 1·29; 1·06-1·56; MICs: 1·26; 1·10-1·45; pinteraction=0·08), stroke (LICs: 1·35; 1·02-1·78; MICs: 1·17; 1·05-1·30; pinteraction=0·19), and incident diabetes (LICs: 1·64; 1·38-1·94; MICs: 2·68; 2·40-2·99; pinteraction <0·0001). In contrast, in high-income countries, higher TyG index tertiles were only associated with an increased hazard of incident diabetes (2·95; 2·25-3·87; pinteraction <0·0001), but not of cardiovascular diseases or mortality. The TyG index is significantly associated with future cardiovascular mortality, myocardial infarction, stroke, and type 2 diabetes, suggesting that insulin resistance plays a promoting role in the pathogenesis of cardiovascular and metabolic diseases. Potentially, the association between the TyG index and the higher risk of cardiovascular diseases and type 2 diabetes in LICs and MICs might be explained by an increased vulnerability of these populations to the presence of insulin resistance. Full funding sources are listed at the end of the paper (see Acknowledgments).

The triglyceride glucose index and cardiovascular disease outcomes

In The Lancet Healthy Longevity, Patricio Lopez-Jaramillo and colleagues1 present results from the Prospective Urban Rural Epidemiology (PURE) study on the association between insulin resistance and cardiovascular disease outcomes. This study1 uses PURE data to introduce a novel cardiometabolic risk factor, the triglyceride glucose (TyG) index.

Associations of outdoor fine particulate matter (PM2.5) air pollution and symptoms of depression in the Prospective Urban Rural Epidemiology (PURE) study

Background/Aim: Emerging evidence suggests that outdoor fine particulate matter (PM2.5) exposure may be a risk factor for major depressive disorder (MDD). The Prospective Urban Rural Epidemiology (PURE) study provides the opportunity to assess this association using a large global cohort with comprehensive covariate data. Within this cohort, long-term PM2.5 exposure has been linked to cardiovascular disease, and increased risk of cardiovascular disease has been linked to having depressive symptoms. We built on this work by evaluating associations between outdoor PM2.5 and depressive symptoms at cohort baseline, across countries of different levels of economic development. Methods: In the PURE study, adults aged 35-70 from 21 high-, middle-, and low-income countries were assigned 3-year rolling mean outdoor PM2.5 estimates, based on their community of residence. Estimates were derived from ground monitoring, satellite retrievals, and chemical transport models. Participants completed the Short-Form Composite International Diagnostic Interview (CIDI-SF), for which validation studies indicate that reporting &amp;#x2265; 4 of 7 symptoms is predictive of MDD. Multivariate regression models will be used to estimate associations between PM2.5 concentrations and CIDI-SF scores. Results: Of 202,131 participants that enrolled in the PURE study (01/2003 – 07/2018), 155,447 had complete information on exposures, covariates, and depressive symptoms. The mean (SD) age was 50.9 (9.7) years, and 59.1% participants were female. The mean (SD) 3-year outdoor PM2.5 concentration at baseline was 47.5 &amp;#x3bc;g/m³ (32.6), ranging from 6 &amp;#x3bc;g/m³ in Vancouver, Canada to 140 &amp;#x3bc;g/m³ in Jaipur, India. 19.5% of participants reported feeling sad, blue, or depressed for two weeks or longer in the past year, and 12.2% reported &amp;#x2265; 4 depressive symptoms. Conclusions: The findings of this project can help evaluate the association between outdoor PM2.5 exposure and MDD on a multinational scale, and further establish the roles of related risk factors. Keywords: Ambient air pollution, mental health, depression

Behavioural risk factors and cardiovascular disease: are women at higher risk?

Previous work has reported that diabetes, smoking, and hypertension are more strongly associated with cardiovascular disease in women than in men. 1 Millett ERC Peters SAE Woodward M Sex differences in risk factors for myocardial infarction: cohort study of UK Biobank participants. BMJ. 2018; 363k4247 Google Scholar , 2 Manfrini O Yoon J van der Schaar M et al. Sex differences in modifiable risk factors and severity of coronary artery disease. J Am Heart Assoc. 2020; 9e017235 Crossref PubMed Scopus (23) Google Scholar In The Lancet, Marjan Walli-Attaei and colleagues 3 Walli-Attaei M Rosengren A Rangarajan S et al. Metabolic, behavioural, and psychosocial risk factors and cardiovascular disease in women compared with men in 21 high-income, middle-income, and low-income countries: an analysis of the PURE study. Lancet. 2022; 400: 811-821 Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar argue that studies on sex differences in cardiovascular risk factors are mainly from high-income countries and add to the literature by reporting their community-based study conducted in 21 high-income, middle-income, and low-income countries. In their analysis, Walli-Attaei and colleagues included 155 724 adults (90 934 [58·4%] women and 64 790 [41·5%] men) aged 35–70 years without a history of cardiovascular disease from the Prospective Urban Rural Epidemiological (PURE) study, who had a median follow-up of 10·1 years (IQR 8·5–12·0), and assessed the primary composite outcome of major cardiovascular events (cardiovascular disease deaths, myocardial infarction, stroke, and heart failure). As of data cutoff (Sept 13, 2021), 4280 major cardiovascular disease events had occurred in women (age standardised incidence rate of 5·0 events [95% CI 4·9–5·2] per 1000 person-years) and 4911 in men (8·2 [8·0–8·4] per 1000 person-years). The hazard ratios (HRs) for the composite outcome of major cardiovascular disease associated with metabolic risk factors were similar in women and in men, except for high non-HDL cholesterol, for which larger HRs were found in men (1·11 [95% CI 1·01–1·21] in women vs 1·28 [1·19–1·39] in men; pinteraction=0·0037). Larger HRs in men than in women were also observed for symptoms of depression (1·09 [0·98–1·21] in women vs 1·42 [1·25–1·60] in men; pinteraction=0·0002). By contrast, behavioural risk factors, such as consumption of a diet of PURE diet score of 4 or lower 3 Walli-Attaei M Rosengren A Rangarajan S et al. Metabolic, behavioural, and psychosocial risk factors and cardiovascular disease in women compared with men in 21 high-income, middle-income, and low-income countries: an analysis of the PURE study. Lancet. 2022; 400: 811-821 Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar and household air pollution, were more strongly associated with cardiovascular disease in women than in men (diet: HR 1·17 [95% CI 1·08–1·26] in women vs 1·07 [0·99–1·15] in men; pinteraction=0·0065; household air pollution: 1·10 [0·99–1·21] vs 1·06 [0·96–1·16]; pinteraction=0·0055). The difference in associations between women and men for risk factors and myocardial infarction followed a pattern similar to the results for the composite outcome of major cardiovascular disease, with the exception of systolic blood pressure (per 20 mm Hg), hypertension, and household air pollution, for which larger HRs were observed in women than in men. The difference in associations between women and men for risk factors and the composite outcome of major cardiovascular disease were similar among countries at different income levels. These findings raise several important issues. Metabolic, behavioural, and psychosocial risk factors and cardiovascular disease in women compared with men in 21 high-income, middle-income, and low-income countries: an analysis of the PURE studyLipid markers and depression are more strongly associated with the risk of cardiovascular disease in men than in women, whereas diet is more strongly associated with the risk of cardiovascular disease in women than in men. The similar associations of other risk factors with cardiovascular disease in women and men emphasise the importance of a similar strategy for the prevention of cardiovascular disease in men and women. Full-Text PDF

Metabolic, behavioural, and psychosocial risk factors and cardiovascular disease in women compared with men in 21 high-income, middle-income, and low-income countries: an analysis of the PURE study

There is a paucity of data on the prevalence of risk factors and their associations with incident cardiovascular disease in women compared with men, especially from low-income and middle-income countries. In the Prospective Urban Rural Epidemiological (PURE) study, we enrolled participants from the general population from 21 high-income, middle-income, and low-income countries and followed them up for approximately 10 years. We recorded information on participants' metabolic, behavioural, and psychosocial risk factors. For this analysis, we included participants aged 35-70 years at baseline without a history of cardiovascular disease, with at least one follow-up visit. The primary outcome was a composite of major cardiovascular events (cardiovascular disease deaths, myocardial infarction, stroke, and heart failure). We report the prevalence of each risk factor in women and men, their hazard ratios (HRs), and population-attributable fractions (PAFs) associated with major cardiovascular disease. The PURE study is registered with ClinicalTrials.gov, NCT03225586. In this analysis, we included 155 724 participants enrolled and followed-up between Jan 5, 2005, and Sept 13, 2021, (90 934 [58·4%] women and 64 790 [41·6%] men), with a median follow-up of 10·1 years (IQR 8·5-12·0). At study entry, the mean age of women was 49·8 years (SD 9·7) compared with 50·8 years (9·8) in men. As of data cutoff (Sept 13, 2021), 4280 major cardiovascular disease events had occurred in women (age-standardised incidence rate of 5·0 events [95% CI 4·9-5·2] per 1000 person-years) and 4911 in men (8·2 [8·0-8·4] per 1000 person-years). Compared with men, women presented with a more favourable cardiovascular risk profile, especially at younger ages. The HRs for metabolic risk factors were similar in women and men, except for non-HDL cholesterol, for which high non-HDL cholesterol was associated with an HR for major cardiovascular disease of 1·11 (95% CI 1·01-1·21) in women and 1·28 (1·19-1·39) in men, with a consistent pattern for higher risk among men than among women with other lipid markers. Symptoms of depression had a HR of 1·09 (0·98-1·21) in women and 1·42 (1·25-1·60) in men. By contrast, consumption of a diet with a PURE score of 4 or lower (score ranges from 0 to 8), was more strongly associated with major cardiovascular disease in women (1·17 [1·08-1·26]) than in men (1·07 [0·99-1·15]). The total PAFs associated with behavioural and psychosocial risk factors were greater in men (15·7%) than in women (8·4%) predominantly due to the larger contribution of smoking to PAFs in men (ie, 1·3% [95% CI 0·5-2·1] in women vs 10·7% [8·8-12·6] in men). Lipid markers and depression are more strongly associated with the risk of cardiovascular disease in men than in women, whereas diet is more strongly associated with the risk of cardiovascular disease in women than in men. The similar associations of other risk factors with cardiovascular disease in women and men emphasise the importance of a similar strategy for the prevention of cardiovascular disease in men and women. Funding sources are listed at the end of the Article.

Association of Sitting Time With Mortality and Cardiovascular Events in High-Income, Middle-Income, and Low-Income Countries

High amounts of sitting time are associated with increased risks of cardiovascular disease (CVD) and mortality in high-income countries, but it is unknown whether risks also increase in low- and middle-income countries. To investigate the association of sitting time with mortality and major CVD in countries at different economic levels using data from the Prospective Urban Rural Epidemiology study. This population-based cohort study included participants aged 35 to 70 years recruited from January 1, 2003, and followed up until August 31, 2021, in 21 high-income, middle-income, and low-income countries with a median follow-up of 11.1 years. Daily sitting time measured using the International Physical Activity Questionnaire. The composite of all-cause mortality and major CVD (defined as cardiovascular death, myocardial infarction, stroke, or heart failure). Of 105 677 participants, 61 925 (58.6%) were women, and the mean (SD) age was 50.4 (9.6) years. During a median follow-up of 11.1 (IQR, 8.6-12.2) years, 6233 deaths and 5696 major cardiovascular events (2349 myocardial infarctions, 2966 strokes, 671 heart failure, and 1792 cardiovascular deaths) were documented. Compared with the reference group (<4 hours per day of sitting), higher sitting time (≥8 hours per day) was associated with an increased risk of the composite outcome (hazard ratio [HR], 1.19; 95% CI, 1.11-1.28; Pfor trend < .001), all-cause mortality (HR, 1.20; 95% CI, 1.10-1.31; Pfor trend < .001), and major CVD (HR, 1.21; 95% CI, 1.10-1.34; Pfor trend < .001). When stratified by country income levels, the association of sitting time with the composite outcome was stronger in low-income and lower-middle-income countries (≥8 hours per day: HR, 1.29; 95% CI, 1.16-1.44) compared with high-income and upper-middle-income countries (HR, 1.08; 95% CI, 0.98-1.19; P for interaction = .02). Compared with those who reported sitting time less than 4 hours per day and high physical activity level, participants who sat for 8 or more hours per day experienced a 17% to 50% higher associated risk of the composite outcome across physical activity levels; and the risk was attenuated along with increased physical activity levels. High amounts of sitting time were associated with increased risk of all-cause mortality and CVD in economically diverse settings, especially in low-income and lower-middle-income countries. Reducing sedentary time along with increasing physical activity might be an important strategy for easing the global burden of premature deaths and CVD.

Availability and Affordability of Medicines for Diabetes and Cardiovascular Disease across Countries: Information Learned from the Prospective Urban Rural Epidemiological Study

The global burden of diabetes and cardiovascular disease (CVD) is increasing and, while cardiovascular event incidence is falling in some high-income countries (HICs), increasing rates are being observed in many middle-income countries (MICs) and low-income countries (LICs). There have been discrepancies in the availability and affordability of medicines for diabetes and cardiovascular disease among countries, of which LICs and MICs have seen low availability and affordability. The Prospective Urban Rural Epidemiological (PURE) study is a large prospective cohort study of over 200,000 people aged 35–70 years from 27 HICs, MICs, and LICs across six geographical regions (Asia, Africa, Europe, South America, North America, and the Middle East). Analyses from this study have contributed greatly to the understanding of the determinants of cardio–metabolic health in LICs and MICs especially. Here, we discuss information learned from the PURE study regarding the availability and affordability of key medicines for diabetes and cardiovascular disease.

Differences and agreement between two portable hand-held spirometers across diverse community-based populations in the Prospective Urban Rural Epidemiology (PURE) study.

Portable spirometers are commonly used in longitudinal epidemiological studies to measure and track the forced expiratory volume in first second (FEV1) and forced vital capacity (FVC). During the course of the study, it may be necessary to replace spirometers with a different model. This raise questions regarding the comparability of measurements from different devices. We examined the correlation, mean differences and agreement between two different spirometers, across diverse populations and different participant characteristics. From June 2015 to Jan 2018, a total of 4,603 adults were enrolled from 628 communities in 18 countries and 7 regions of the world. Each participant performed concurrent measurements from the MicroGP and EasyOne spirometer. Measurements were compared by the intra-class correlation coefficient (ICC) and Bland-Altman method. Approximately 65% of the participants achieved clinically acceptable quality measurements. Overall correlations between paired FEV1 (ICC 0.88 [95% CI 0.87, 0.88]) and FVC (ICC 0.84 [0.83, 0.85]) were high. Mean differences between paired FEV1 (-0.038 L [-0.053, -0.023]) and FVC (0.033 L [0.012, 0.054]) were small. The 95% limits of agreement were wide but unbiased (FEV1 984, -1060; FVC 1460, -1394). Similar findings were observed across regions. The source of variation between spirometers was mainly at the participant level. Older age, higher body mass index, tobacco smoking and known COPD/asthma did not adversely impact on the inter-device variability. Furthermore, there were small and acceptable mean differences between paired FEV1 and FVC z-scores using the Global Lung Initiative normative values, suggesting minimal impact on lung function interpretation. In this multicenter, diverse community-based cohort study, measurements from two portable spirometers provided good correlation, small and unbiased differences between measurements. These data support their interchangeable use across diverse populations to provide accurate trends in serial lung function measurements in epidemiological studies.

Prototyping neural networks to evaluate the risk of adverse cardiovascular outcomes in the population

Aim. To develop a neural network basis for the design of artificial intelligence software to predict adverse cardiovascular outcomes in the population.Materials and Methods. Neural networks were designed using the database of 1,525 participants of PURE (Prospective Urban Rural Epidemiology Study), an international, multi-center, prospective study investigating disease risk factors in the urban and rural areas. As this study is still ongoing, we analysed only baseline data, therefore switching prognosis and diagnosis task. Because of its leading prevalence among other cardiovascular diseases, arterial hypertension was selected as an adverse outcome. Neural networks were designed employing STATISTICA Automated Neural Networks (SANN) software, manually selected, cross-validated, and transferred to the original graphical user interface software.Results. Input risk factors were gender, age, place of residence, concomitant diseases (i.e., coronary artery disease, chronic heart failure, diabetes mellitus, chronic obstructive pulmonary disease, and asthma), active or passive smoking, regular use of medications, family history of arterial hypertension, coronary artery disease or stroke, heart rate, body mass index, fasting blood glucose and cholesterol, high- and low-density lipoprotein cholesterol, and serum creatinine levels. Our neural networks showed a moderate efficacy in the virtual diagnostics of arterial hypertension (84.5%, or 1,289 successfully predicted outcomes out of 1,525, area under the ROC curve = 0.88), with almost equal sensitivity (83.6%) and specificity (85.3%), and were successfully integrated into graphical user interface that is necessary for the development of the commercial prognostication software. Cross-validation of this neural network on bootstrapped samples of virtual patients demonstrated sensitivity of 82.7 – 84.7%, specificity of 84.5 – 87.3%, and area under the ROC curve of 0.88 – 0.89.Conclusion. The artificial intelligence prognostication software to predict adverse cardiovascular outcomes in the population can be developed by a combination of automated neural network generation and analysis followed by manual selection, cross-validation, and integration into graphical user interface.

Variations in the association of height with mortality, cardiovascular disease and cancer in low-, middle- and high-income countries.

Final adult height is a useful proxy measure of childhood nutrition and disease burden. Tall stature has been previously associated with decreased risk of all-cause mortality, decreased risk of major cardiovascular events and an increased risk of cancer. However, these associations have primarily been derived from people of European and East Asian backgrounds, and there are sparse data from other regions of the world. The Prospective Urban-Rural Epidemiology study is a large, longitudinal population study done in 21 countries of varying incomes and sociocultural settings. We enrolled an unbiased sample of households, which were eligible if at least one household member was aged 35-70 years. Height was measured in a standardized manner, without shoes, to the nearest 0.1 cm. During a median follow-up of 10.1 years (interquartile range 8.3-12.0), we assessed the risk of all-cause mortality, major cardiovascular events and cancer. A total of 154 610 participants, enrolled since January 2003, with known height and vital status, were included in this analysis. Follow-up event data until March 2021 were used; 11 487 (7.4%) participants died, whereas 9291 (6.0%) participants had a major cardiovascular event and 5873 (3.8%) participants had a new diagnosis of cancer. After adjustment, taller individuals had lower hazards of all-cause mortality [hazard ratio (HR) per 10-cm increase in height 0.93, 95% confidence interval (CI) 0.90-0.96] and major cardiovascular events (HR 0.97, 95% CI 0.94-1.00), whereas the hazard of cancer was higher in taller participants (HR 1.23, 95% CI 1.18-1.28). The interaction p-values between height and country-income level for all three outcomes were <0.001, suggesting that the association with height varied by country-income level for these outcomes. In low-income countries, height was inversely associated with all-cause mortality (HR 0.88, 95% CI 0.84-0.92) and major cardiovascular events (HR 0.87, 95% CI 0.82-0.93). There was no association of height with these outcomes in middle- and high-income countries. The respective HRs for cancer in low-, middle- and high-income countries were 1.14 (95% CI 0.99-1.32), 1.12 (95% CI 1.04-1.22) and 1.20 (95% CI 1.14-1.26). Unlike high- and middle-income countries, tall stature has a strong inverse association with all-cause mortality and major cardiovascular events in low-income countries. Improved childhood physical development and advances in population-wide cardiovascular treatments in high- and middle-income countries may contribute to this gap. From a life-course perspective, we hypothesize that optimizing maternal and child health in low-income countries may improve rates of premature mortality and cardiovascular events in these countries, at a population level.