Prospective Urban Rural Epidemiology Research Articles

Dietary Fat Intake among Chinese Adults and Their Relationships with Blood Lipids: Findings from China Nutrition and Health Surveillance and Comparison with the PURE Study.

Dietary fat intake in the Chinese population has increased. The PURE (prospective urban rural epidemiology) study concluded the potential advantage of total fat and saturated fats (SFA) over carbohydrates on blood lipids with the inaccurate assessment of dietary fats. We investigated the dietary fat profile among 48,315 participants (aged 30−70 years, national representative) from the China Nutrition and Health Surveillance (2015−2017), determined the relationship of various fats with blood lipid biomarkers in the selected 39,115 participants, and compared the results with the PURE study. Dietary fat intake was calculated by using 3 days of 24 h recalls and food inventory. Serum lipid biomarkers were assessed at morning fasting state by health professionals. Plant fats (21.5% of total energy (TE)) dominated in total fat intake (69.5 g/day, 35.6% TE), with monounsaturated fats (MUFA) in the largest (13.8% TE) portion and plant oils as the major source (43.7%). Two thirds of the population consumed more than 30% TE from dietary fats and nearly half more than 35%, while 26.4% of them exceeded 10% TE from SFA. Total fat was positively associated with total cholesterol (TC), low-density lipoprotein cholesterol (LDL-c), but also high-density lipoprotein cholesterol (HDL-c), and negatively with triglyceride (TG)-to-HDL-c ratio (TGHDL) (all p-trend < 0.05). Replacing total fat with carbohydrate yielded adverse changes in most biomarkers (higher LDL-c, TG, and TGHDL, lower HDL-c, all p < 0.05) when total fat was low (<34.9% TE). Regardless of fat intake level, replacing plant fat or polyunsaturated fats (PUFA) with carbohydrate yielded the most adverse changes (higher TC, LDL-c, TG, TC-to-HDL-c ratio (TCHDL), and TGHDL, but lower HDL-c, all p < 0.01), while replacing animal fat/SFA with plant fat/PUFA yielded the most favorable changes (lower all biomarkers, all p < 0.01). The results suggested a less harmful effect of carbohydrate on blood lipids when total fat was high, and more beneficial effect of unsaturated fats, than the PURE. In conclusion, dietary fat intake in Chinese adults had reached quite a high level, but with a different profile from Western populations. Replacement of SFA (animal fat) with PUFA (plant fat) could most effectively improve blood lipids, while replacement with carbohydrate could slightly benefit only when total fat was high. The present results may be more applicable to the Chinese population than the PURE study.

Interaction of Depression and Unhealthy Diets on the Risk of Cardiovascular Diseases and All-Cause Mortality in the Chinese Population: A PURE Cohort Substudy.

This study aimed to identify the interaction of depression and diets on cardiovascular diseases (CVD) incident and death in China and key subpopulations. We included 40,925 participants from the Prospective Urban Rural Epidemiology (PURE)-China cohort which recruited participants aged 35-70 years from 45 urban and 70 rural communities. Depression was measured by the adapted Short-Form (CIDI-SF). The unhealthy diet was considered when the score of Alternative Healthy Eating Index was below the lowest tertile. The primary outcome was a composite outcome of incident CVD and all-cause mortality. Cox frailty models were used to examine the associations. During a median follow-up of 11.9 years (IQR: 9.6-12.6 years), depression significantly increased the risk of the composite outcome (HR = 2.00; 95% CI, 1.16-3.27), major CVD (HR = 1.82; 95% CI, 1.48-2.23), and all-cause mortality (HR = 2.21; 95% CI, 1.51-3.24) for the unhealthy diet group, but not for the healthy diet group. The interaction between depression and diet for the composite outcome was statistically significant (RERI = 1.19; 95% CI, 0.66-1.72; AP = 0.42, 95% CI, 0.27-0.61; SI = 3.30, 95% CI, 1.42-7.66; multiplicative-scale = 1.74 95% CI, 1.27-2.39), even in the subgroup and sensitivity analyses. In addition, the intake of vegetable and polyunsaturated fatty acids contributed most to the interaction of diets and depression. Depressive participants should focus on healthy diets, especially vegetables and polyunsaturated fatty acids, to avoid premature death and CVD.

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

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.

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

The Determinants of Undiagnosed Hypertension among Urban Community of Kuala Lumpur, Malaysia.

The prevalence of undiagnosed hypertension in Malaysia is 17.2%, which is higher compared to the known case of hypertension (13.1%) reported in 2015. For every two people diagnosed with hypertension, there will be three persons with undiagnosed hypertension; the trend has not changed since 2011. This study aimed to determine the determinants of undiagnosed hypertension among urban community of Kuala Lumpur, Malaysia. This was a cross-sectional study conducted among 206 participants in Kuala Lumpur, Malaysia from the ongoing Prospective Urban Rural Epidemiology (PURE) project. The samples with complete variable data were taken from the second year of follow-up, starting Jan 2014 till Dec 2015, through convenience sampling. Data were analyzed using descriptive analysis, simple logistic regression, and multivariable logistic regression. Multivariable logistic regression showed that only four determinants were associated with undiagnosed hypertension which were the age group of 35 to 49 yr old (aOR: 5.9, 95% CI: 1.8; 19.1), secondary education level (aOR: 2.3, 95% CI: 1.1; 4.6), normal BMI (aOR: 5.1, 95% CI: 1.5; 16.6), and non-diabetes mellitus (aOR: 5.5, 95% CI: 2.5; 12.0). The determinants of undiagnosed hypertension in this study showed that low-risk groups of hypertension were highly underdiagnosed. The low-risk group of hypertension was easily approached at their working place. Thus, routine health screening and awareness campaigns should be emphasized substantially at the working place to detect undiagnosed hypertension. Early detection will be beneficial as early management can be initiated to prevent further complications.

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.

Variations in the financial impact of the COVID-19 pandemic across 5 continents: A cross-sectional, individual level analysis.

SummaryBackgroundCOVID-19 has caused profound socio-economic changes worldwide. However, internationally comparative data regarding the financial impact on individuals is sparse. Therefore, we conducted a survey of the financial impact of the pandemic on individuals, using an international cohort that has been well-characterized prior to the pandemic.MethodsBetween August 2020 and September 2021, we surveyed 24,506 community-dwelling participants from the Prospective Urban-Rural Epidemiology (PURE) study across high (HIC), upper middle (UMIC)-and lower middle (LMIC)-income countries. We collected information regarding the impact of the pandemic on their self-reported personal finances and sources of income.FindingsOverall, 32.4% of participants had suffered an adverse financial impact, defined as job loss, inability to meet financial obligations or essential needs, or using savings to meet financial obligations. 8.4% of participants had lost a job (temporarily or permanently); 14.6% of participants were unable to meet financial obligations or essential needs at the time of the survey and 16.3% were using their savings to meet financial obligations. Participants with a post-secondary education were least likely to be adversely impacted (19.6%), compared with 33.4% of those with secondary education and 33.5% of those with pre-secondary education. Similarly, those in the highest wealth tertile were least likely to be financially impacted (26.7%), compared with 32.5% in the middle tertile and 30.4% in the bottom tertile participants. Compared with HICs, financial impact was greater in UMIC [odds ratio of 2.09 (1.88–2.33)] and greatest in LMIC [odds ratio of 16.88 (14.69–19.39)]. HIC participants with the lowest educational attainment suffered less financial impact (15.1% of participants affected) than those with the highest education in UMIC (22.0% of participants affected). Similarly, participants with the lowest education in UMIC experienced less financial impact (28.3%) than those with the highest education in LMIC (45.9%). A similar gradient was seen across country income categories when compared by pre-pandemic wealth status.InterpretationThe financial impact of the pandemic differs more between HIC, UMIC, and LMIC than between socio-economic categories within a country income level. The most disadvantaged socio-economic subgroups in HIC had a lower financial impact from the pandemic than the most advantaged subgroup in UMIC, with a similar disparity seen between UMIC and LMIC. Continued high levels of infection will exacerbate financial inequity between countries and hinder progress towards the sustainable development goals, emphasising the importance of effective measures to control COVID-19 and, especially, ensuring high vaccine coverage in all countries.FundingFunding for this study was provided by the Canadian Institutes of Health Research and the International Development Research Centre.

Variations in risks from smoking between high-income, middle-income, and low-income countries: an analysis of data from 179 000 participants from 63 countries

Separate studies suggest that the risks from smoking might vary between high-income (HICs), middle-income (MICs), and low-income (LICs) countries, but this has not yet been systematically examined within a single study using standardised approaches. We examined the variations in risks from smoking across different country income groups and some of their potential reasons. We analysed data from 134 909 participants from 21 countries followed up for a median of 11·3 years in the Prospective Urban Rural Epidemiology (PURE) cohort study; 9711 participants with myocardial infarction and 11 362 controls from 52 countries in the INTERHEART case-control study; and 11 580 participants with stroke and 11 331 controls from 32 countries in the INTERSTROKE case-control study. In PURE, all-cause mortality, major cardiovascular disease, cancers, respiratory diseases, and their composite were the primary outcomes for this analysis. Biochemical verification of urinary total nicotine equivalent was done in a substudy of 1000 participants in PURE. In PURE, the adjusted hazard ratio (HR) for the composite outcome in current smokers (vs never smokers) was higher in HICs (HR 1·87, 95% CI 1·65-2·12) than in MICs (1·41, 1·34-1·49) and LICs (1·35, 1·25-1·46; interaction p<0·0001). Similar patterns were observed for each component of the composite outcome in PURE, myocardial infarction in INTERHEART, and stroke in INTERSTROKE. The median levels of tar, nicotine, and carbon monoxide displayed on the cigarette packs from PURE HICs were higher than those on the packs from MICs. In PURE, the proportion of never smokers reporting high second-hand smoke exposure (≥1 times/day) was 6·3% in HICs, 23·2% in MICs, and 14·0% in LICs. The adjusted geometric mean total nicotine equivalent was higher among current smokers in HICs (47·2 μM) than in MICs (31·1 μM) and LICs (25·2 μM; ANCOVA p<0·0001). By contrast, it was higher among never smokers in LICs (18·8 μM) and MICs (11·3 μM) than in HICs (5·0 μM; ANCOVA p=0·0001). The variations in risks from smoking between country income groups are probably related to the higher exposure of tobacco-derived toxicants among smokers in HICs and higher rates of high second-hand smoke exposure among never smokers in MICs and LICs. Full funding sources are listed at the end of the paper (see Acknowledgments).

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.

Psychosocial Risk Factors and Cardiovascular Disease and Death in a Population-Based Cohort From 21 Low-, Middle-, and High-Income Countries

Stress may increase the risk of cardiovascular disease (CVD). Most studies on stress and CVD have been conducted in high-income Western countries, but whether stress is associated with CVD in other settings has been less well studied. To investigate the association of a composite measure of psychosocial stress and the development of CVD events and mortality in a large prospective study involving populations from 21 high-, middle-, and low-income countries across 5 continents. This population-based cohort study used data from the Prospective Urban Rural Epidemiology study, collected between January 2003 and March 2021. Participants included individuals aged 35 to 70 years living in 21 low-, middle-, and high-income countries. Data were analyzed from April 8 to June 15, 2021. All participants were assessed on a composite measure of psychosocial stress assessed at study entry using brief questionnaires concerning stress at work and home, major life events, and financial stress. The outcomes of interest were stroke, major coronary heart disease (CHD), CVD, and all-cause mortality. A total of 118 706 participants (mean [SD] age 50.4 [9.6] years; 69 842 [58.8%] women and 48 864 [41.2%] men) without prior CVD and with complete baseline and follow-up data were included. Of these, 8699 participants (7.3%) reported high stress, 21 797 participants (18.4%) reported moderate stress, 34 958 participants (29.4%) reported low stress, and 53 252 participants (44.8%) reported no stress. High stress, compared with no stress, was more likely with younger age (mean [SD] age, 48.9 [8.9] years vs 51.1 [9.8] years), abdominal obesity (2981 participants [34.3%] vs 10 599 participants [19.9%]), current smoking (2319 participants [26.7%] vs 10 477 participants [19.7%]) and former smoking (1571 participants [18.1%] vs 3978 participants [7.5%]), alcohol use (4222 participants [48.5%] vs 13 222 participants [24.8%]), and family history of CVD (5435 participants [62.5%] vs 20 255 participants [38.0%]). During a median (IQR) follow-up of 10.2 (8.6-11.9) years, a total of 7248 deaths occurred. During the course of follow-up, there were 5934 CVD events, 4107 CHD events, and 2880 stroke events. Compared with no stress and after adjustment for age, sex, education, marital status, location, abdominal obesity, hypertension, smoking, diabetes, and family history of CVD, as the level of stress increased, there were increases in risk of death (low stress: hazard ratio [HR], 1.09 [95% CI, 1.03-1.16]; high stress: 1.17 [95% CI, 1.06-1.29]) and CHD (low stress: HR, 1.09 [95% CI, 1.01-1.18]; high stress: HR, 1.24 [95% CI, 1.08-1.42]). High stress, but not low or moderate stress, was associated with CVD (HR, 1.22 [95% CI, 1.08-1.37]) and stroke (HR, 1.30 [95% CI, 1.09-1.56]) after adjustment. This cohort study found that higher psychosocial stress, measured as a composite score of self-perceived stress, life events, and financial stress, was significantly associated with mortality as well as with CVD, CHD, and stroke events.

The complex relationship between diet, symptoms, and intestinal inflammation in persons with inflammatory bowel disease: The Manitoba Living With IBD Study.

We aimed to examine whether an association exists between diet quality, based on the Prospective Urban Rural Epidemiology (PURE) Healthy Diet Score (HDS), and active inflammatory bowel disease (IBD). Participants were drawn from the Manitoba Living With IBD Study cohort. The Harvard Food Frequency Questionnaire (FFQ) was used to calculate the HDS at two time points: baseline and 1-year follow-up. Using generalized estimating equations (GEE) logistic regression, we assessed the association between the HDS and (1) the IBD Symptom Inventory (IBDSI); (2) intestinal inflammation, measured by fecal calprotectin (FCAL); and (3) self-reported IBD flares. There were 294 completed FFQs among 153 people. Of these, 100% had completed data about an IBD flare, 98% had FCAL measurements, and 96% had completed IBDSI scores. On a HDS scoring method of 0-8, the odds of FCAL >250 mcg/g were lower for participants with a HDS of 4 vs 0-3 (adjusted odds ratio [OR], 0.38; 95% CI, 0.19-0.77). When applying a second HDS scoring method (8-40), the odds of having an IBD flare were 3.6 times greater with a HDS between 21 and 24 compared with an HDS ≤20 (adjusted OR, 3.63; 95% CI, 1.03-12.78). We found that active inflammation was less likely among those with a moderate HDS , whereas symptomatic IBD flares were more likely. People may choose to consume a moderate amount of healthy foods such as fruits and vegetables, even knowing that those foods may cause a symptomatic flare.

Associations of unprocessed and processed meat intake with mortality and cardiovascular disease in 21 countries [Prospective Urban Rural Epidemiology (PURE) Study]: a prospective cohort study

Dietary guidelines recommend limiting red meat intake because it is a major source of medium- and long-chain SFAs and is presumed to increase the risk of cardiovascular disease (CVD). Evidence of an association between unprocessed red meat intake and CVD is inconsistent. The study aimed to assess the association of unprocessed red meat, poultry, and processed meat intake with mortality and major CVD. The Prospective Urban Rural Epidemiology (PURE) Study is a cohort of 134,297 individuals enrolled from 21 low-, middle-, and high-income countries. Food intake was recorded using country-specific validated FFQs. The primary outcomes were total mortality and major CVD. HRs were estimated using multivariable Cox frailty models with random intercepts. In the PURE study, during 9.5 y of follow-up, we recorded 7789 deaths and 6976 CVD events. Higher unprocessed red meat intake (≥250 g/wk vs. <50 g/wk) was not significantly associated with total mortality (HR: 0.93; 95% CI: 0.85, 1.02; P-trend=0.14) or major CVD (HR: 1.01; 95% CI: 0.92, 1.11; P-trend=0.72). Similarly, no association was observed between poultry intake and health outcomes. Higher intake of processed meat (≥150 g/wk vs. 0 g/wk) was associated with higher risk of total mortality (HR: 1.51; 95% CI: 1.08, 2.10; P-trend=0.009) and major CVD (HR: 1.46; 95% CI: 1.08, 1.98; P-trend=0.004). In a large multinational prospective study, we did not find significant associations between unprocessed red meat and poultry intake and mortality or major CVD. Conversely, a higher intake of processed meat was associated with a higher risk of mortality and major CVD.

Nonalcoholic Fatty Liver Disease: Indian Perspective.

Nonalcoholic Fatty Liver Disease: Indian Perspective.

The Impact of Common Epidemiological Factors on Gray and White Matter Volumes in Magnetic Resonance Imaging-Is Prevention of Brain Degeneration Possible?

Introduction: The aim of the study was to evaluate the impact of multiple risk factors (age, diabetes, hypertension, hyperlipidemia, BMI, smoking, alcohol) on the gray and white matter volumes as well as on the burden of white matter hyperintensities (WMH).Material and Methods: The study group consisted of 554 subjects (age range: 50–69 yrs, F/M: 367/187) recruited from the larger cohort of the Polish fraction of the Prospective Urban Rural Epidemiological (PURE) study. The participants answered questionnaires about their lifestyle, underwent physical and psychological examination (MoCA test), laboratory blood tests followed by brain MRI. Volumetric measurements of the total gray matter (GMvol), total white matter (WMvol) and WHM (WMHvol) normalized to the total intracranial volume were performed using the Computational Anatomy Toolbox 12 (CAT12) and Statistical Parametric Maps 12 (SPM12) based on 3D T1-weighted sequence. The influence of risk factors was assessed using multiple regression analysis before and after correction for multiple comparisons.Results: Older age was associated with lower GMvol and WMvol, and higher WMHvol (p < 0.001). Smaller GMvol volume was associated with higher WMHvol (p < 0.001). Higher WMHvol was associated with hypertension (p = 0.01) and less significantly with hyperlipidemia (only before correction p = 0.03). Diabetes, abnormal BMI, smoking and alcohol intake did not have any significant impact on GMvol, WMvol or WMHvol (p > 0.05). MoCA score was not influenced by any of the factors.Conclusions: Gray matter loss is strongly associated with the accumulation of WMH which seems to be potentially preventable by maintaining normal blood pressure and cholesterol levels.

Timing and Length of Nocturnal Sleep and Daytime Napping and Associations With Obesity Types in High-, Middle-, and Low-Income Countries

Obesity is a growing public health threat leading to serious health consequences. Late bedtime and sleep loss are common in modern society, but their associations with specific obesity types are not well characterized. To assess whether sleep timing and napping behavior are associated with increased obesity, independent of nocturnal sleep length. This large, multinational, population-based cross-sectional study used data of participants from 60 study centers in 26 countries with varying income levels as part of the Prospective Urban Rural Epidemiology study. Participants were aged 35 to 70 years and were mainly recruited during 2005 and 2009. Data analysis occurred from October 2020 through March 2021. Sleep timing (ie, bedtime and wake-up time), nocturnal sleep duration, daytime napping. The primary outcomes were prevalence of obesity, specified as general obesity, defined as body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 30 or greater, and abdominal obesity, defined as waist circumference greater than 102 cm for men or greater than 88 cm for women. Multilevel logistic regression models with random effects for study centers were performed to calculate adjusted odds ratios (AORs) and 95% CIs. Overall, 136 652 participants (81 652 [59.8%] women; mean [SD] age, 51.0 [9.8] years) were included in analysis. A total of 27 195 participants (19.9%) had general obesity, and 37 024 participants (27.1%) had abdominal obesity. The mean (SD) nocturnal sleep duration was 7.8 (1.4) hours, and the median (interquartile range) midsleep time was 2:15 am (1:30 am-3:00 am). A total of 19 660 participants (14.4%) had late bedtime behavior (ie, midnight or later). Compared with bedtime between 8 pm and 10 pm, late bedtime was associated with general obesity (AOR, 1.20; 95% CI, 1.12-1.29) and abdominal obesity (AOR, 1.20; 95% CI, 1.12-1.28), particularly among participants who went to bed between 2 am and 6 am (general obesity: AOR, 1.35; 95% CI, 1.18-1.54; abdominal obesity: AOR, 1.38; 95% CI, 1.21-1.58). Short nocturnal sleep of less than 6 hours was associated with general obesity (eg, <5 hours: AOR, 1.27; 95% CI, 1.13-1.43), but longer napping was associated with higher abdominal obesity prevalence (eg, ≥1 hours: AOR, 1.39; 95% CI, 1.31-1.47). Neither going to bed during the day (ie, before 8pm) nor wake-up time was associated with obesity. This cross-sectional study found that late nocturnal bedtime and short nocturnal sleep were associated with increased risk of obesity prevalence, while longer daytime napping did not reduce the risk but was associated with higher risk of abdominal obesity. Strategic weight control programs should also encourage earlier bedtime and avoid short nocturnal sleep to mitigate obesity epidemic.

Does a High-inflammatory Diet Increase the Risk of Inflammatory Bowel Disease? Results From the Prospective Urban Rural Epidemiology (PURE) Study: A Prospective Cohort Study

The empirical dietary inflammatory pattern (EDIP) was developed using data from the Nurses’ Health Study. 1 Tabung F.K. et al. J Nutr. 2016; 146: 1560-1570 Crossref PubMed Scopus (151) Google Scholar It is the weighted sum of 18 food groups, of which 9 are proinflammatory and 9 are anti-inflammatory, with higher scores suggesting proinflammatory diets and lower scores suggesting anti-inflammatory diets. The EDIP score has previously been validated in several populations and is correlated with systemic inflammatory markers. 1 Tabung F.K. et al. J Nutr. 2016; 146: 1560-1570 Crossref PubMed Scopus (151) Google Scholar , 2 Tabung F.K. et al. J Nutr. 2017; 147: 1567-1577 Crossref PubMed Scopus (61) Google Scholar , 3 Tabung F.K. et al. J Nutr. 2018; 148: 771-780 Crossref PubMed Scopus (28) Google Scholar A recent study by Lo et al 4 Lo C.H. et al. Gastroenterology. 2020; 159: 873-883 Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar concluded that people with higher EDIPs had a higher risk of developing Crohn’s disease (CD). Specifically, those in the highest quartile of EDIP scores had a 51% higher risk of CD compared with those in the lowest quartile. However, no association was seen between EDIP scores and risk of ulcerative colitis (UC). It is important to independently validate dietary predictors of inflammatory bowel disease (IBD), and so we evaluated whether higher EDIP scores were associated with a higher risk of developing IBD, using the Prospective Urban Rural Epidemiology (PURE) cohort. 5 Dehghan M. et al. Lancet. 2018; 392: 2288-2297 Abstract Full Text Full Text PDF PubMed Scopus (194) Google Scholar , 6 Miller V. et al. Lancet. 2017; 390: 2037-2049 Abstract Full Text Full Text PDF PubMed Scopus (289) Google Scholar , 7 Teo K. et al. JAMA. 2013; 309: 1613-1621 Crossref PubMed Scopus (224) Google Scholar

OP05 Association of ultra-processed food intake with risk of Inflammatory Bowel Disease from the prospective urban rural epidemiology (PURE) study: A prospective cohort study

Abstract Background Dietary factors may influence the risk of developing inflammatory bowel disease (IBD), but evidence from large, prospective studies is scarce. This study aimed to evaluate the relationship between ultra-processed food intake and the risk of developing IBD in the Prospective Urban Rural Epidemiology (PURE) cohort study. Methods This was a prospective cohort study among 21 low, middle, and high income countries across seven geographic regions of 116,087 individuals between the ages of 35–70 with at least one cycle of follow-up and complete baseline food frequency questionnaire (FFQ) data. Country-specific validated FFQs were used to document baseline dietary intake. Participants were followed prospectively at least every 3 years. The main clinical outcome for this study was development of IBD, including Crohn’s disease (CD) or ulcerative colitis (UC). Cox proportional hazard multivariable models were used to assess associations between ultra-processed food intake and risk of IBD. Results are presented as hazard ratios (HR) with 95% confidence intervals (CI). Results Participants were enrolled in the study between 2003 and 2016. During the median follow-up of 9.7 years (IQR 8.9–11.2), we recorded 467 incident cases of IBD (90 with CD and 377 with UC). Higher ultra-processed food intake was associated with a higher risk of incident IBD (HR 1.82, 95% CI 1.22 to 2.72 for ≥5 servings/day and HR 1.67, 95% CI 1.18 to 2.37, for 1–4 servings/day as compared to &amp;lt;1 serving/day, ptrend=0.006), after adjustment for potential confounding factors. Different subgroups of ultra-processed food including soft drinks, sweets, salty snacks, and processed meat each were associated with higher HR for IBD. Results were consistent in UC and CD with low heterogeneity. White meat, red meat, dairy, starch, fruits, vegetables, and legumes intake were not associated with incident IBD. Conclusion Higher ultra-processed food consumption was positively associated with development of IBD. Further studies are needed to identify the potential culprits within ultra-processed foods.