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Okamoto N, Hoshikawa T, Honma Y, Chibaatar E, Ikenouchi A, Harada M, Yoshimura R. Effect modification of tumor necrosis factor-α on the kynurenine and serotonin pathways in major depressive disorder on type 2 diabetes mellitus. Eur Arch Psychiatry Clin Neurosci 2024; 274:1697-1707. [PMID: 37991535 PMCID: PMC11422469 DOI: 10.1007/s00406-023-01713-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/29/2023] [Indexed: 11/23/2023]
Abstract
Major depressive disorder (MDD) is strongly associated with type 2 diabetes mellitus (T2DM). The kynurenine and serotonin pathways, as well as chronic low-grade inflammation, are being considered potential links between them. MDD associated with T2DM is less responsive to treatment than that without T2DM; however, the underlying mechanism remains unknown. We aimed to investigate the effects of inflammatory cytokines on the kynurenine and serotonin pathways in patients with comorbid MDD and T2DM and those with only MDD. We recruited 13 patients with comorbid MDD and T2DM and 27 patients with only MDD. We measured interleukin-6 and tumor necrosis factor-α (TNF-α) levels as inflammatory cytokines and metabolites of the kynurenine pathway and examined the relationship between the two. TNF-α levels were significantly higher in patients with comorbid MDD and T2DM than in those with only MDD in univariate (p = 0.044) and multivariate (adjusted p = 0.036) analyses. TNF-α showed a statistically significant effect modification (interaction) with quinolinic acid/tryptophan and serotonin in patients from both groups (β = 1.029, adjusted p < 0.001; β = - 1.444, adjusted p = 0.047, respectively). Limitations attributed to the study design and number of samples may be present. All patients were Japanese with mild to moderate MDD; therefore, the generalizability of our findings may be limited. MDD with T2DM has more inflammatory depression components and activations of the kynurenine pathway by inflammatory cytokines than MDD without T2DM. Hence, administering antidepressants and anti-inflammatory drugs in combination may be more effective in patients with comorbid MDD and T2DM.
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Affiliation(s)
- Naomichi Okamoto
- Department of Psychiatry, University of Occupational and Environmental Health, 807-8555, Kitakyushu, Fukuoka, 8078555, Japan.
| | - Takashi Hoshikawa
- Department of Psychiatry, University of Occupational and Environmental Health, 807-8555, Kitakyushu, Fukuoka, 8078555, Japan
| | - Yuichi Honma
- Third Department of Internal Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Enkhmurun Chibaatar
- Department of Psychiatry, University of Occupational and Environmental Health, 807-8555, Kitakyushu, Fukuoka, 8078555, Japan
| | - Atsuko Ikenouchi
- Department of Psychiatry, University of Occupational and Environmental Health, 807-8555, Kitakyushu, Fukuoka, 8078555, Japan
- Medical Center for Dementia, University Hospital, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Masaru Harada
- Third Department of Internal Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Reiji Yoshimura
- Department of Psychiatry, University of Occupational and Environmental Health, 807-8555, Kitakyushu, Fukuoka, 8078555, Japan
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Amsah N, Isa ZM, Ahmad N. Understanding the Relationship between Environmental Factors and Mental Health Status among Type 2 Diabetes Mellitus Patients: A Scoping Review. IRANIAN JOURNAL OF PUBLIC HEALTH 2024; 53:1924-1934. [PMID: 39429666 PMCID: PMC11490335 DOI: 10.18502/ijph.v53i9.16448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 02/11/2024] [Indexed: 10/22/2024]
Abstract
Background Type 2 diabetes mellitus (T2DM) is associated with a wide range of health outcomes, including an increased risk of depression and anxiety and a decline in quality of life. Even though the significance of biopsychological factors in the mental health status of T2DM patients has been discussed in other studies, the role of environmental factors has been lacking. Therefore, this review aimed to identify the relationship between environmental factors and mental health status among T2DM patients. Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews was utilized in this study. Using predetermined keywords, a systematic search was conducted on three electronic databases from 2005 to 2023, namely, Web of Science, Scopus, and PubMed. Articles written in English, and studies focusing on the research question are among the inclusion criteria. Ten articles were extracted that were relevant to the research question. Results Poor socioeconomic status, urban areas, the influence of neighborhood, greenness, and air pollution had associations with mental health status among T2DM patients. Conclusion The possible implications of these factors for mental health demand further research and policy consideration.
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Affiliation(s)
- Norizzati Amsah
- Department of Public Health Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - Zaleha Md Isa
- Department of Public Health Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - Norfazilah Ahmad
- Department of Public Health Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
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Ferreira NV, Gonçalves NG, Szlejf C, Goulart AC, de Souza Santos I, Duncan BB, Schmidt MI, Barreto SM, Caramelli P, Feter N, Castilhos RM, Drager LF, Lotufo P, Benseñor I, Suemoto CK. Optimal cardiovascular health is associated with slower cognitive decline. Eur J Neurol 2024; 31:e16139. [PMID: 38015440 PMCID: PMC11235920 DOI: 10.1111/ene.16139] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Life's Simple 7, a lifestyle and cardiovascular index associated with cognition, has been updated to Life's Essential 8 (LE8) to include sleep. LE8 has been related to cardiovascular outcomes but its association with cognition is unclear. METHODS In this longitudinal analysis of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), LE8 score was based on health behaviors (diet, physical activity, nicotine exposure, and sleep health) as well as health-related factors (body mass index, blood lipids, blood glucose, and blood pressure). Cognition was assessed in three waves, 4 years apart, using the Consortium to Establish a Registry for Alzheimer's Disease - Word List, semantic and phonemic verbal fluency, the Trail-Making Test B (TMT-B), and a global composite score. We used linear mixed-model analysis, inverse probability weighting, and interaction analysis. RESULTS At baseline, the mean age of the study cohort was 51.4 ± 8.9 years, 56% were women, and 53% were White. Higher baseline LE8 scores were associated with slower decline in global cognition (β = 0.001, 95% confidence interval [CI] 0.001, 0.002; p < 0.001), memory (β = 0.001, 95% CI 0.000, 0.002; p = 0.013), verbal fluency (β = 0.001, 95% CI 0.000, 0.002; p = 0.003), and TMT-B (β = 0.004, 95% CI 0.003, 0.005; p < 0.001). This association was mainly driven by LE8 health factors, particularly blood glucose and blood pressure. Age, sex, and race were modifiers of the association between LE8 and global cognitive decline (p < 0.001), suggesting it was more pronounced in older, male, and Black participants. CONCLUSIONS Higher baseline LE8 scores were associated with slower global and domain-specific cognitive decline during 8 years of follow-up, mainly due to health factors such as blood glucose and blood pressure. Sociodemographic factors were modifiers of this association.
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Affiliation(s)
- Naomi Vidal Ferreira
- Center for Clinical and Epidemiological Research, Hospital UniversitarioUniversidade de Sao PauloSao PauloBrazil
- Faculdade Adventista da AmazoniaBenevidesBrazil
| | | | - Claudia Szlejf
- Center for Clinical and Epidemiological Research, Hospital UniversitarioUniversidade de Sao PauloSao PauloBrazil
| | - Alessandra C. Goulart
- Center for Clinical and Epidemiological Research, Hospital UniversitarioUniversidade de Sao PauloSao PauloBrazil
| | - Itamar de Souza Santos
- Center for Clinical and Epidemiological Research, Hospital UniversitarioUniversidade de Sao PauloSao PauloBrazil
- Department of Internal Medicine, Faculdade de MedicinaUniversidade de Sao PauloSao PauloBrazil
| | - Bruce B. Duncan
- Postgraduate Program in EpidemiologyUniversidade Federal do Rio Grande do SulPorto AlegreBrazil
- Hospital de Clínicas de Porto AlegreUniversidade Federal do Rio Grande do SulPorto AlegreBrazil
| | - Maria Inês Schmidt
- Postgraduate Program in EpidemiologyUniversidade Federal do Rio Grande do SulPorto AlegreBrazil
- Hospital de Clínicas de Porto AlegreUniversidade Federal do Rio Grande do SulPorto AlegreBrazil
| | - Sandhi Maria Barreto
- Deparment of Preventive and Social Medicine, Faculdade de MedicinaUniversidade Federal de Minas GeraisBelo HorizonteBrazil
| | - Paulo Caramelli
- Behavioral and Cognitive Research Group, Departamento de Clínica Médica, Faculdade de MedicinaUniversidade Federal de Minas GeraisBelo HorizonteBrazil
| | - Natan Feter
- Postgraduate Program in EpidemiologyUniversidade Federal do Rio Grande do SulPorto AlegreBrazil
| | | | - Luciano F. Drager
- Unidade de Hipertensão, Instituto do Coracao (InCor), Hospital das Clinicas, Faculdade de MedicinaUniversidade de Sao PauloSao PauloBrazil
- Unidade de Hipertensão, Disciplina de Nefrologia, Hospital das Clinicas, Faculdade de MedicinaUniversidade de Sao PauloSao PauloBrazil
| | - Paulo Lotufo
- Center for Clinical and Epidemiological Research, Hospital UniversitarioUniversidade de Sao PauloSao PauloBrazil
| | - Isabela Benseñor
- Center for Clinical and Epidemiological Research, Hospital UniversitarioUniversidade de Sao PauloSao PauloBrazil
| | - Claudia Kimie Suemoto
- Division of Geriatrics, Faculdade de MedicinaUniversidade de Sao PauloSao PauloBrazil
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Ferreira NV, Bertola L, Santos IS, Goulart AC, Bittencourt MS, Barreto SM, Giatti L, Caramelli P, Pereira A, Lotufo PA, Bensenor IM, Suemoto CK. Association between carotid intima-media thickness and cognitive decline differs by race. Alzheimers Dement 2023; 19:3528-3536. [PMID: 36825689 DOI: 10.1002/alz.12996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
INTRODUCTION Common carotid intima-media thickness (cIMT) is a marker of subclinical atherosclerosis and is associated with cognitive decline. Although carotid atherosclerosis is more frequent in White than in Black participants, little is known whether race modifies the association between cIMT and cognitive decline. METHODS In this longitudinal analysis of the ELSA-Brasil, we assessed cIMT using ultrasound and cognitive performance using different domain tests. We used linear mixed models, interaction analysis, and race stratified analyses. RESULTS Baseline high IMT values were associated with memory (p < 0.001), verbal fluency (p < 0.001), TMT-B (p < 0.001)), and global cognitive decline (p < 0.001). Race was an effect modifier in the association between IMT and global cognitive decline (0.043), with stronger association in White (p < 0.001) than in Black (p = 0.009) participants. DISCUSSION Baseline IMT was associated with global and domain-specific cognitive decline and race modified this relationship, with stronger associations in White participants. HIGHLIGHTS Carotid intima-media thickness (cIMT) was associated with cognitive decline. cIMT and cognitive decline association was stronger in White than in Black participants. We used inverse probability weighting to address attrition bias.
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Affiliation(s)
- Naomi Vidal Ferreira
- Center for Clinical and Epidemiological Research, Hospital Universitario, Universidade de Sao Paulo, Sao Paulo, Brazil
- Adventist University of Sao Paulo, Engenheiro Coelho, Sao Paulo, Brazil
- Amazonia Adventist College, Benevides, Pará, Brazil
| | - Laiss Bertola
- Department of Psychiatry, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Itamar S Santos
- Center for Clinical and Epidemiological Research, Hospital Universitario, Universidade de Sao Paulo, Sao Paulo, Brazil
- Department of Internal Medicine, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Alessandra C Goulart
- Center for Clinical and Epidemiological Research, Hospital Universitario, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Marcio S Bittencourt
- Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sandhi Maria Barreto
- Departamento de Medicina Preventiva e Social, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Luana Giatti
- School of Medicine and Clinical Hospital, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Paulo Caramelli
- Behavioral and Cognitive Research Group, Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Alexandre Pereira
- Heart Institute, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Paulo Andrade Lotufo
- Center for Clinical and Epidemiological Research, Hospital Universitario, Universidade de Sao Paulo, Sao Paulo, Brazil
- Department of Internal Medicine, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Isabela M Bensenor
- Center for Clinical and Epidemiological Research, Hospital Universitario, Universidade de Sao Paulo, Sao Paulo, Brazil
- Department of Internal Medicine, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Claudia Kimie Suemoto
- Division of Geriatrics, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Sao Paulo, Brazil
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Biopsychosocial and Nutritional Factors of Depression among Type 2 Diabetes Mellitus Patients: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084888. [PMID: 35457752 PMCID: PMC9031597 DOI: 10.3390/ijerph19084888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/14/2022] [Accepted: 04/15/2022] [Indexed: 11/16/2022]
Abstract
The rising prevalence of depression among Type 2 Diabetes Mellitus (T2DM) patients has triggered an alarming situation, and further actions need to be taken by health care professionals and policymakers to curb the issue. There is a lack of evidence review in terms of the biopsychosocial and nutritional factors that are related to depression among T2DM. Hence, this review aimed to identify available evidence on the biopsychosocial and nutritional factors associated with depression among T2DM patients based on the existing literature. Articles were systematically searched from four databases, namely PubMed, Scopus, Web of Science, and EBSCOHost. The approach for the identification of the final articles followed PRISMA guidelines. The selected full-text articles were published between 2017 and 2021 in the English language, and included studies focused on depression among T2DM patients. Using AXIS tools, the eligible articles were evaluated to assess the quality of studies. A total of 19 studies were included in the review, and information related to research questions and associated factors was extracted. Biological, psychological, social, and nutritional factors were shown to be linked with depression among T2DM patients. Future studies need to considered using the biopsychosocial model and incorporating nutritional factors to manage the issues of depression among T2DM patients.
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van Duinkerken E, Moreno AB, Barreto SM, Giatti L, Viana MC, Nunes MA, Chor D, Griep RH. Response to comment on van Duinkerken et al. Biopsychosocial factors associated with a current depressive episode in diabetes: The ELSA-Brasil study. Diabet Med 2021; 38:e14435. [PMID: 33095937 DOI: 10.1111/dme.14435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/16/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Eelco van Duinkerken
- Department of Medical Psychology Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Amsterdam Diabetes Centre/Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Epilepsy Centre, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
- Department of Neurology, Hospital Universitário Gaffrée e Guinle - Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Arlinda B Moreno
- Department of Epidemiology and Quantitative Methods in Health, National School of Public Health Sérgio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Sandhi M Barreto
- Research Group on Epidemiology on Chronic and Occupational Diseases (GERMINAL), Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Luana Giatti
- Research Group on Epidemiology on Chronic and Occupational Diseases (GERMINAL), Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Maria Carmen Viana
- Section of Psychiatric Epidemiology (CEPEP), Department of Social Medicine, Postgraduate Program in Public Health, Federal University of Espírito Santo, Vitória, Brazil
| | - Maria A Nunes
- Postgraduate Program in Epidemiology, School of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Dora Chor
- Department of Epidemiology and Quantitative Methods in Health, National School of Public Health Sérgio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Rosane H Griep
- Laboratory of Health and Environment Education, Oswaldo Cruz Institute, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
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Chatwin H, Broadley M, Pouwer F. Comment on van Duinkerken et al. Biopsychosocial factors associated with a current depressive episode in diabetes: The ELSA-Brasil study. Diabet Med 2021; 38:e14418. [PMID: 33030264 DOI: 10.1111/dme.14418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 10/05/2020] [Indexed: 11/30/2022]
Affiliation(s)
- H Chatwin
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - M Broadley
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - F Pouwer
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- School of Psychology, Deakin University, Geelong, Australia
- STENO Diabetes Centre Odense, Odense, Denmark
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van Duinkerken E, Moreno AB, Eto FN, Lotufo P, Barreto SM, Giatti L, Viana MC, Nunes MA, Chor D, Griep RH. Biopsychosocial factors associated with a current depressive episode in diabetes: the ELSA-Brasil study. Diabet Med 2020; 37:1742-1751. [PMID: 32580244 PMCID: PMC7540479 DOI: 10.1111/dme.14349] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2020] [Indexed: 12/31/2022]
Abstract
AIMS Depression is more prevalent in people with diabetes, and is associated with worse diabetes outcomes. Depression in diabetes is more treatment resistant, and as underlying mechanisms are unknown, development of more effective treatment strategies is complicated. A biopsychosocial model may improve our understanding of the pathophysiology, and therewith help improving treatment options. METHODS Diabetes was diagnosed according to American Diabetes Association (ADA) criteria and a current depressive episode according to the International Classification of Diseases (ICD-10), based on the Clinical Interview Schedule Revised (CIS-R). From the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), we included 455 participants without diabetes with a current depressive episode and 10 900 without either diabetes or a current depressive episode. Furthermore, 2183 participants had diabetes alone and 106 had both diabetes and a current depressive episode. Variable selection was based on their relationship with depression and/or diabetes. Multinomial multivariate logistic regression was used to determine how the models differed between participants with and without diabetes. RESULTS A current depressive episode in diabetes was related to being older and female, having poorer education, financial problems, experiencing discrimination at work, home and school, higher waist circumference, albumin to creatinine ratio and insulin resistance, and the presence of hypertension and cardiovascular disease. In non-diabetes, a current depressive disorder was related to being female, not being black, low income, psychological and social factors, non-current alcohol use, lower HDL cholesterol, higher insulin resistance and the presence of cardiovascular disease. CONCLUSIONS A current depressive episode in the presence compared with the absence of diabetes was related more to biological than to psychosocial factors.
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Affiliation(s)
- E. van Duinkerken
- Department of Medical PsychologyAmsterdam University Medical Centres ‐ Vrije UniversiteitAmsterdamthe Netherlands
- Amsterdam Diabetes Centre/Department of Internal MedicineAmsterdam University Medical Centres ‐ Vrije UniversiteitAmsterdamthe Netherlands
- Epilepsy CentreInstituto Estadual do Cérebro Paulo NiemeyerRio de JaneiroBrazil
- Department of NeurologyHospital Universitário Gaffrée e Guinle ‐ Universidade Federal do Estado do Rio de JaneiroRio de JaneiroBrazil
| | - A. B. Moreno
- Department of Epidemiology and Quantitative Methods in HealthNational School of Public Health Sérgio Arouca, Fundação Oswaldo CruzRio de JaneiroBrazil
| | - F. N. Eto
- Department of Epidemiology and Quantitative Methods in HealthNational School of Public Health Sérgio Arouca, Fundação Oswaldo CruzRio de JaneiroBrazil
| | - P. Lotufo
- Department of Internal MedicineUniversity of São PauloSão PauloBrazil
| | - S. M. Barreto
- Research Group on Epidemiology on Chronic and Occupational Diseases (GERMINAL)Faculty of MedicineUniversidade Federal de Minas GeraisBelo HorizonteBrazil
| | - L. Giatti
- Research Group on Epidemiology on Chronic and Occupational Diseases (GERMINAL)Faculty of MedicineUniversidade Federal de Minas GeraisBelo HorizonteBrazil
| | - M. C. Viana
- Section of Psychiatric Epidemiology (CEPEP)Department of Social MedicinePostgraduate Program in Public HealthFederal University of Espírito SantoVitóriaBrazil
| | - M. A. Nunes
- Postgraduate Program in EpidemiologySchool of MedicineFederal University of Rio Grande do SulPorto AlegreBrazil
| | - D. Chor
- Department of Epidemiology and Quantitative Methods in HealthNational School of Public Health Sérgio Arouca, Fundação Oswaldo CruzRio de JaneiroBrazil
| | - R. H. Griep
- Laboratory of Health and Environment EducationOswaldo Cruz Institute, Fundação Oswaldo CruzRio de JaneiroBrazil
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