Association between Nonalcoholic Fatty Liver Disease and Carotid Artery Disease in a Community-Based Chinese Population: A Cross-Sectional Study

A comprehensive analysis of the impact of smoking on adverse clinical outcomes of steatotic liver diseases

Background

Metabolic dysfunction-associated steatotic liver disease (MASLD), previously known as non-alcoholic fatty liver disease (NAFLD), is an increasingly prevalent liver disorder.

Objectives

This study investigated the effect of smoking status on various clinical outcomes in MASLD and metabolic dysfunction and alcohol-associated liver disease (MetALD).

Design

This study is a retrospective cohort analysis utilizing data from the UK Biobank (Application ID: 117214). Participants were categorized as current, previous, or never smokers, and outcomes were analyzed using inverse probability of treatment weighting to adjust for confounders.

Methods

The primary outcomes were all-cause mortality and liver-related mortality. Secondary outcomes included incidence of liver cirrhosis, hepatic decompensation, cardio-cerebrovascular diseases (CVD), and hepatocellular carcinoma (HCC). Multivariate Cox proportional hazards models were employed to evaluate associations.

Results

Previous and never smokers had significantly lower hazard ratios (HRs) for mortality compared to current smokers in all cohorts (HR: 0.33, 95% confidence interval (CI): 0.31-0.35, p < 0.001 for never smokers in No SLD cohort, HR: 0.43, 95% CI: 0.41-0.44, p < 0.001 for never smokers in MASLD cohort, and HR: 0.41, 95% CI: 0.38-0.45, p < 0.001 for never smokers in MetALD cohort). Previous and never smokers showed significantly lower incidences of liver cirrhosis compared to current smokers across all cohorts, except for MetALD. Previous and never smokers showed lower incidences of CVD compared to current smokers. In the MASLD cohort, never smokers had the lowest incidence of hepatic decompensation and HCC. In the MetALD cohort, no significant differences were observed in the risk of hepatic decompensation and HCC between different smoking statuses.

Conclusion

Smoking is related to worse survival outcomes and higher incidences of liver cirrhosis and CVD in MASLD and MetALD cohorts. Therefore, smoking cessation and prevention are crucial strategies for reducing the burden of liver disease and improving patient prognosis.

Non-alcoholic fatty liver disease (NAFLD) and its association to cardiovascular disease: A comprehensive meta-analysis

Background

Non-alcoholic fatty liver disease (NAFLD) affects up to nearly a third of the Western population and has been inconsistently associated with cardiovascular diseases (CVDs). Therefore, we conducted a comprehensive meta-analysis to quantify the correlation of NAFLD with all major vascular diseases, acute coronary syndrome (ACS), subclinical atherosclerosis and endothelial dysfunction.

Methods

We searched PubMed and Embase for studies looking at the relationship between NAFLD and cardiovascular diseases published through September 2023. The parameters we used to assess cardiovascular diseases include acute coronary syndrome, brachial flow-mediated dilatation (FMD), serum asymmetric dimethylarginine (ADMA), carotid intima-media thickness (CIMT), and carotid stenosis (>50%). Data from these studies were then collected and meta-analysis was performed using the random effects model. RevMan v5.4 was used for statistical analysis.

Results

We interrogated a total of 114 publications which met our inclusion criteria. NAFLD patients showed statistically significant reduction in FMD% [MD: -4.83 (95% CI: -5.84 to 3.81, p < .00001)] and increased serum ADMA [MD: 0.08 (95% CI: 0.05-0.11, p < .00001)]. Mean CIMT was also increased in NAFLD patients [MD 0.13 (95% CI: 0.12-0.14, p < .00001)]. NAFLD showed a higher prevalence of pathological CIMT [MD: 0.11 (95% CI: 0.10-0.12, p < .00001)] and increased carotid plaques [OR: 2.08 (95% CI: 1.52-2.86, p < .00001)]. Furthermore, we demonstrated statistically significant increase in cardiovascular diseases among NAFLD patients compared to controls [OR: 1.92 (95% CI: 1.53-2.41, p < .00001)].

Conclusion

NAFLD is a strong predictor for endothelial dysfunction, subclinical atherosclerosis and cardiovascular disease. Further studies are required to determine whether incidental findings of fatty liver on abdominal ultrasonography should prompt the need for detailed assessment of other CVD risk factors.

Noninvasive liver fibrosis markers are independently associated with carotid atherosclerosis risk in patients with nonalcoholic fatty liver disease

OBJECTIVE

Nonalcoholic fatty liver disease (NAFLD) is considered an independent risk factor for cardiovascular disease (CVD). The overall morbidity and mortality of CVD increase with higher fibrosis stage in NAFLD. Carotid atherosclerosis (CAS) is an important predictor of cardiovascular events. However, the relationship between liver fibrosis degree and the risk of CAS in NAFLD patients remains uncertain. We aimed to investigate the relationship between noninvasive liver fibrosis markers and CAS risk in patients with NAFLD.

MATERIALS AND METHODS

This study included 3,302 participants with NAFLD. Participants were divided into a CAS group and a non-CAS group based on carotid artery ultrasound results. They were then stratified into quartiles using various noninvasive liver fibrosis markers (fibrosis-4 (FIB-4), modified FIB-4 (mFIB-4), aminotransferase to platelet ratio index (APRI), aminotransferase to alanine aminotransferase ratio (AAR), AAR-to-platelet ratio index (AARPRI), and Forns index) to assess the associations between these markers and the risk of CAS.

RESULTS

In the NAFLD population, individuals with CAS exhibited elevated levels of blood pressure, glucose, lipids, and noninvasive liver fibrosis markers (p < 0.001). The higher quartiles of noninvasive liver fibrosis markers, including FIB-4, mFIB-4, AAR, AARPRI, and Forns index, were significantly associated with increased risks of CAS, even after adjusting for multiple CVD risk factors.

CONCLUSIONS

In individuals with NAFLD, increased noninvasive liver fibrosis markers were independently associated with elevated CAS risk, which may be beneficial in assessing the risk of CVD in individuals with NAFLD.

Relation between non-alcoholic fatty liver disease and carotid artery intimal media thickness as a surrogate for atherosclerosis: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Non-alcoholic fatty liver disease (NAFLD), characterized by hepatic steatosis without heavy alcohol consumption or other chronic conditions, encompasses a spectrum from non-alcoholic fatty liver to non-alcoholic steatohepatitis leading to cirrhosis. This analysis aimed to investigate the correlation between NAFLD and carotid intimal media thickness (C-IMT), a non-invasive surrogate for atherosclerosis.

METHODOLOGY

Database searches, including PubMed, EMBASE and Cochrane Library, yielded studies up to April 2023. Included were studies exploring the NAFLD-C-IMT relationship in populations aged >18 years. Exclusions comprised non-English papers, those involving animals or pediatric populations and studies lacking control groups.

RESULTS

No statistical significance was noted between mild and moderate NAFLD compared to the control group regarding C-IMT [95% confidence intervals (CI): -0.03, 0.12] and (95% CI: -0.03, 0.21), respectively. There was a statistically significant difference only in the Severe NAFLD group ( P value 0.03). NAFLD with and without metabolic syndrome showed statistically significant differences compared to control regarding C-IMT (95% CI: 0.04, 0.12) and (95% CI: 0.01, 0.07), respectively. Fifty-nine studies were mentioned without classification of NAFLD severity and revealed a high statistically significant difference between NAFLD and controls regarding C-IMT with (95% CI: 0.09, 0.12, P < 0.00001). Stratified analysis according to sex was done in two studies and revealed statistical differences between NAFLD and control regarding C-IMT in both groups.

CONCLUSION

This meta-analysis underscores a significant association between NAFLD and increased C-IMT, emphasizing the importance of assessing C-IMT in NAFLD patients to identify cardiovascular risk and tailor therapeutic interventions for improved patient outcomes.

CT-Diagnosed Non-Alcoholic Fatty Liver Disease as a Risk Predictor of Symptomatic Carotid Plaque and Cerebrovascular Symptoms

We aimed to test whether computed tomography (CT)-diagnosed Non-Alcoholic Fatty Liver Disease (NAFLD) is a risk factor for cerebrovascular symptoms in patients with suspected atherosclerotic disease. A total of 550 patients (mean age 65.2 ± 8.8 years, 370 males) with carotid plaques who underwent carotid computed tomographic angiography (CTA) and unenhanced abdominal CT were retrospectively analyzed. NAFLD was diagnosed by abdominal CT. Carotid CTA assessed the presence of carotid artery stenosis or plaque. The relationship between NAFLD and cerebrovascular symptoms was analyzed using generalized estimating equations and receiver operating characteristic (ROC) analysis. The prevalence of NAFLD was significantly higher in symptomatic patients (76.5 vs 9.8%; P < .001). After adjusting for several confounding factors (e.g., hypertension and hyperlipidemia), univariate and multivariate logic regression analysis revealed that NAFLD was still strongly associated with cerebrovascular symptoms (odds ratio, 22.81; 95% CI 13.03-39.93; P < .001). ROC analysis showed that the area under the curve for discriminating symptomatic and asymptomatic plaques using NAFLD measurements was 0.833, with a sensitivity of 76.5% and a specificity of 90.2%. NAFLD is strongly associated with an increased risk of cerebrovascular symptoms. It may be an important predictor of symptomatic carotid plaque and cerebrovascular symptoms.

Impact of smoking cessation on non-alcoholic fatty liver disease prevalence: a systematic review and meta-analysis

OBJECTIVES

The negative effects of smoking on numerous cardiovascular and metabolic diseases have been widely acknowledged. However, the potential effect of smoking cessation is relatively unelucidated. The objective of this study is to explore whether the prevalence of non-alcoholic fatty liver disease (NAFLD) in former smokers differs from the prevalence in current smokers.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Four databases, that is, PubMed, Web of Science, Journal@Ovid and Scopus were searched from inception to 31 January 2023.

ELIGIBILITY CRITERIA

Population-based cross-sectional studies, including the baseline data of cohort studies with identified NAFLD diagnostic methods, and smoking status (current smoker or former smoker) of participants were included.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted the data including cigarette smoking status, country/region of studies, NAFLD diagnostic methods, sex, the average age and body mass index (BMI) of NAFLD participants and assessed the risk of bias with Agency for Healthcare Research and Quality (AHRQ) methodology checklist. Risk ratio (RR) of NAFLD prevalence in former smokers was pooled using the random-effects model.

RESULTS

28 studies involving 4 465 862 participants were included. Compared with current smokers, the RR of overall NAFLD prevalence in former smokers was 1.13 (95% CI: 1.08 to 1.19, prediction interval: 0.92-1.39). This result persisted after adjustment for diagnostic methods, country/region, sex, age and BMI. Sensitivity analysis and risk of bias assessment indicated a stable conclusion.

CONCLUSIONS

NAFLD prevalence in former smokers was at least not lower than that in current smokers and was partially related to increased BMI after smoking cessation, indicating that smoking cessation was possibly not a protective factor against NAFLD. Although the meta-analysis based on cross-sectional studies cannot conclude the causal relationships between smoking cessation and NAFLD onset, the potential onset of NAFLD associated with smoking cessation should be highlighted.

PROSPERO REGISTRATION NUMBER

CRD42023394944.

Combinatorial Use of Machine Learning and Logistic Regression for Predicting Carotid Plaque Risk Among 5.4 Million Adults With Fatty Liver Disease Receiving Health Check-Ups: Population-Based Cross-Sectional Study

BACKGROUND

Carotid plaque can progress into stroke, myocardial infarction, etc, which are major global causes of death. Evidence shows a significant increase in carotid plaque incidence among patients with fatty liver disease. However, unlike the high detection rate of fatty liver disease, screening for carotid plaque in the asymptomatic population is not yet prevalent due to cost-effectiveness reasons, resulting in a large number of patients with undetected carotid plaques, especially among those with fatty liver disease.

OBJECTIVE

This study aimed to combine the advantages of machine learning (ML) and logistic regression to develop a straightforward prediction model among the population with fatty liver disease to identify individuals at risk of carotid plaque.

METHODS

Our study included 5,420,640 participants with fatty liver from Meinian Health Care Center. We used random forest, elastic net (EN), and extreme gradient boosting ML algorithms to select important features from potential predictors. Features acknowledged by all 3 models were enrolled in logistic regression analysis to develop a carotid plaque prediction model. Model performance was evaluated based on the area under the receiver operating characteristic curve, calibration curve, Brier score, and decision curve analysis both in a randomly split internal validation data set, and an external validation data set comprising 32,682 participants from MJ Health Check-up Center. Risk cutoff points for carotid plaque were determined based on the Youden index, predicted probability distribution, and prevalence rate of the internal validation data set to classify participants into high-, intermediate-, and low-risk groups. This risk classification was further validated in the external validation data set.

RESULTS

Among the participants, 26.23% (1,421,970/5,420,640) were diagnosed with carotid plaque in the development data set, and 21.64% (7074/32,682) were diagnosed in the external validation data set. A total of 6 features, including age, systolic blood pressure, low-density lipoprotein cholesterol (LDL-C), total cholesterol, fasting blood glucose, and hepatic steatosis index (HSI) were collectively selected by all 3 ML models out of 27 predictors. After eliminating the issue of collinearity between features, the logistic regression model established with the 5 independent predictors reached an area under the curve of 0.831 in the internal validation data set and 0.801 in the external validation data set, and showed good calibration capability graphically. Its predictive performance was comprehensively competitive compared with the single use of either logistic regression or ML algorithms. Optimal predicted probability cutoff points of 25% and 65% were determined for classifying individuals into low-, intermediate-, and high-risk categories for carotid plaque.

CONCLUSIONS

The combination of ML and logistic regression yielded a practical carotid plaque prediction model, and was of great public health implications in the early identification and risk assessment of carotid plaque among individuals with fatty liver.

Association of nonalcoholic fatty liver disease and carotid media-intima thickness: A systematic review and a meta-analysis

Introduction

The relationship between cardiovascular disorders and nonalcoholic fatty liver disease (NAFLD) has been extensively studied. To better pool this data and make a more definite conclusion, we performed a meta-analysis to evaluate the association between NAFLD and the thickness of media and intima of carotid artery (CIMT) and cardiovascular disorders.

Methods

We searched PubMed, Ovid, Scopus, ProQuest, Web of Science, and the Cochrane Library, and analyzed the pooled data using R studio and the "metafor" package.

Results

The final analysis included a total of 59 studies with 16,179 cases and 26,120 control individuals. NAFLD was shown to be associated with an increase of 0.1231 mm (20.6%) in carotid artery intima-media thickness (CIMT) (p = 0.002, 95% confidence interval [CI]: 0.0462-0.2000) in individuals with NAFLD. The prevalence of atherosclerotic plaques in the carotid arteries and the occurrence of NAFLD are significantly correlated, according to a meta-analysis based on 17 distinct studies (p = 0.001, 1.28-1.43, 95% CI, odds ratio = 1.356).

Conclusion

Patients with increased CIMT are considerably more likely to have NAFLD. Large prospective investigations are required to corroborate these findings and their prognostic significance, along with the effectiveness of the available interventions.

Association between smoking and non-alcoholic fatty liver disease in Southeast Asia

An estimated 8 million people die each year from tobacco smoking, with an increasing frequency recently being observed in Southeast Asian countries, which is a preventable risk factor for mortality. NAFLD, fibrosis, advancement of hepatocellular carcinoma, and prognosis for those with severe liver disease are all negatively influenced. NAFLD and cigarette usage seem to be a direct link. Oxidative stress and oncogenic signals have been implicated in cancer development in animal models and human clinical trials. The elevated risk of cardiovascular disease and malignancies in those with steatohepatitis and those who have had liver transplants is exacerbated by smoking. We found that smoking cessation may increase treatment response and fibrosis regression rates, decrease hepatocellular carcinoma incidence, and improve liver transplant outcomes. In the last segment, we'll look at electronic cigarettes, a hot subject in public health right now, as well as additional repercussions of smoking.

2019 Global NAFLD Prevalence: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

The increasing rates of obesity and type 2 diabetes mellitus may lead to increased prevalence of nonalcoholic fatty liver disease (NAFLD). We aimed to determine the current and recent trends on the global and regional prevalence of NAFLD.

METHODS

Systematic search from inception to March 26, 2020 was performed without language restrictions. Two authors independently performed screening and data extraction. We performed meta-regression to determine trends in NAFLD prevalence.

RESULTS

We identified 17,244 articles from literature search and included 245 eligible studies involving 5,399,254 individuals. The pooled global prevalence of NAFLD was 29.8% (95% confidence interval [CI], 28.6%-31.1%); of these, 82.5% of included articles used ultrasound to diagnose NAFLD, with prevalence of 30.6% (95% CI, 29.2%-32.0%). South America (3 studies, 5716 individuals) and North America (4 studies, 18,236 individuals) had the highest NAFLD prevalence at 35.7% (95% CI, 34.0%-37.5%) and 35.3% (95% CI, 25.4%-45.9%), respectively. From 1991 to 2019, trend analysis showed NAFLD increased from 21.9% to 37.3% (yearly increase of 0.7%, P < .0001), with South America showing the most rapid change of 2.7% per year, followed by Europe at 1.1%.

CONCLUSIONS

Despite regional variation, the global prevalence of NAFLD is increasing overall. Policy makers must work toward reversing the current trends by increasing awareness of NAFLD and promoting healthy lifestyle environments.

Nonalcoholic Steatohepatitis (NASH) and Atherosclerosis: Explaining Their Pathophysiology, Association and the Role of Incretin-Based Drugs

Nonalcoholic steatohepatitis (NASH) is the most severe manifestation of nonalcoholic fatty liver disease (NAFLD), a common complication of type 2 diabetes, and may lead to cirrhosis and hepatocellular carcinoma. Oxidative stress and liver cell damage are the major triggers of the severe hepatic inflammation that characterizes NASH, which is highly correlated with atherosclerosis and coronary artery disease. Regarding drug therapy, research on the role of GLP-1 analogues and DPP4 inhibitors, novel classes of antidiabetic drugs, is growing. In this review, we outline the association between NASH and atherosclerosis, the underlying molecular mechanisms, and the effects of incretin-based drugs, especially GLP-1 RAs, for the therapeutic management of these conditions.

Non-alcoholic steatohepatitis and progression of carotid atherosclerosis in patients with type 2 diabetes: a Korean cohort study

BACKGROUND

There is increasing concern regarding cardiovascular risk in individuals with non-alcoholic fatty liver disease. This study was conducted to evaluate whether hepatic steatosis with or without fibrosis is associated with the progression of carotid atherosclerosis in patients with type 2 diabetes.

METHODS

From a longitudinal cohort, we enrolled 1120 patients with type 2 diabetes who underwent repeated carotid artery ultrasonography every 1-2 years. Ultrasonographic findings at baseline and after 6-8 years were compared. Presence of hepatic steatosis was mainly assessed by abdominal ultrasonography; patients with hepatic steatosis were further evaluated for hepatic fibrosis according to fibrosis-4 index. We investigated the association between liver status and atherosclerosis progression.

RESULTS

Of 1120 patients, 636 (56.8%) were classified as having hepatic steatosis at baseline. After 6-8 years, 431 (38.5%) showed atherosclerosis progression. Hepatic steatosis was significantly associated with atherosclerosis progression (adjusted odds ratio[AOR]: 1.370, 95% CI 1.025-1.832; p < 0.05). Among patients with hepatic steatosis, only individuals with fibrosis showed significant association with atherosclerosis progression (AOR: 1.615, 95% CI 1.005-2.598; p < 0.05). The association between hepatic fibrosis and atherosclerosis progression was significant in all metabolic subgroups regardless of age, body mass index, presence of metabolic syndrome, or insulin sensitivity (all p < 0.05). Furthermore, subjects with hepatic steatosis & fibrosis and ≥ 4 components of metabolic syndrome criteria showed markedly increased risk of atherosclerosis progression (AOR: 2.430, 95% CI 1.087-5.458; p < 0.05).

CONCLUSIONS

Hepatic steatosis with fibrosis is independently associated with the progression of carotid atherosclerosis in patients with type 2 diabetes.

A novel dipeptide from potato protein hydrolysate augments the effects of exercise training against high-fat diet-induced damages in senescence-accelerated mouse-prone 8 by boosting pAMPK / SIRT1/ PGC-1α/ pFOXO3 pathway

The pathological effects of obesity are often severe in aging condition. Although exercise training is found to be advantageous, the intensity of exercise performed is limited in aging condition. Therefore in this study we assessed the effect of a combined treatment regimen with a short-peptide IF isolated from alcalase potato-protein hydrolysates and a moderate exercise training for 15 weeks in a 6 month old HFD induced obese senescence accelerated mouse-prone 8 (SAMP8) mice model. Animals were divided into 6 groups (n=6) (C:Control+BSA); (HF:HFD+BSA); (EX:Control+ BSA+Exercise); (HF+IF:HFD+ IF); (HF+EX:HFD+Exercise); (HF+EX+IF:HFD+Exercise+IF). A moderate incremental swimming exercise training was provided for 6 weeks and after 3 weeks of exercise, IF was orally administered (1 mg/kg body Weight). The results show that combined administration of IF and exercise provides a better protection to aging animals by reducing body weight and regulated tissue damage. IF intake and exercise training provided protection against cardiac hypertrophy and maintains the tissue homeostasis in the heart and liver sections. Interestingly, IF and exercise training showed an effective upregulation in pAMPK/ SIRT1/ PGC-1α/ pFOXO3 mechanism of cellular longevity. Therefore, exercise training with IF intake is a possible strategy for anti-obesity benefits and superior cardiac and hepatic protection in aging condition.

Adherence to the Dietary Approaches to Stop Hypertension (DASH) diet is associated with lower presence of non-alcoholic fatty liver disease in middle-aged and elderly adults

OBJECTIVE

Previous studies have shown that the Dietary Approaches to Stop Hypertension (DASH) diet might contribute to managing risk factors of non-alcoholic fatty liver disease (NAFLD), but evidence is limited. We examined the association of DASH diet score (DASH-DS) with NAFLD, as well as the intermediary effects of serum retinol-binding protein-4 (RBP4), serum high-sensitivity C-reactive protein (hs-CRP), serum TAG, homeostasis model assessment of insulin resistance (HOMA-IR) and BMI.

DESIGN

We performed a cross-sectional analysis of a population-based cohort study. Dietary data and lifestyle factors were assessed by face-to-face interviews and the DASH-DS was then calculated. We assessed serum RBP4, hs-CRP and TAG and calculated HOMA-IR. The presence and degree of NAFLD were determined by abdominal sonography.

SETTING

Guangzhou, China.

PARTICIPANTS

Guangzhou Nutrition and Health Study participants, aged 40-75 years at baseline (n 3051).

RESULTS

After adjusting for potential covariates, we found an inverse association between DASH-DS and the presence of NAFLD (Ptrend = 0·009). The OR (95 % CI) of NAFLD for quintiles 2-5 were 0·78 (0·62, 0·98), 0·74 (0·59, 0·94), 0·69 (0·55, 0·86) and 0·77 (0·61, 0·97), respectively. Path analyses indicated that a higher DASH-DS was associated with lower serum RBP4, hs-CRP, TAG, HOMA-IR and BMI, which were positively associated with the degree of NAFLD.

CONCLUSIONS

Adherence to the DASH diet was independently associated with a marked lower prevalence of NAFLD in Chinese adults, especially in women and those without abdominal obesity, and might be mediated by reducing RBP4, hs-CRP, TAG, HOMA-IR and BMI.

Association between earthquake experience and depression 37 years after the Tangshan earthquake: a cross-sectional study

OBJECTIVE

To investigate the association between the Tangshan earthquake and depression after 37 years.

DESIGN AND SETTING

A cross-sectional study conducted in Tangshan from 2013 to 2014.

PARTICIPANTS

The sample included 5024 participants born before 28 July 1976 the date of the Tangshan earthquake, with available data on their earthquake experiences and depression 37 years post-earthquake.

OUTCOMES AND VARIABLES

The outcome was depression measured using the Center for Epidemiological Study and Depression Scale. The independent variable was earthquake experience, which was classified into three groups: no earthquake experience, earthquake experience without bereavement and earthquake experience with bereavement. Multivariable logistic regression analysis was used to evaluate the association between earthquake experience and depression after adjusting for gender, age at the time of the earthquake, smoking status, drinking status, education, income, residence in Tangshan 1 to 2 years post-earthquake, hypertension, diabetes and dyslipidaemia.

RESULTS

Of the 5024 participants, 641 experienced the Tangshan earthquake, and 98 experienced bereavement due to the earthquake. 37 years after the earthquake, survivors who had lost relatives during the earthquake were nearly three times (OR 2.82, 95% CI 1.24 to 6.39) as likely to have depression as those who had not experienced the earthquake, while those who had not lost relatives were 1.69 times as likely (OR 1.69, 95% CI 0.93 to 3.08). Stratified analyses showed that earthquake was significantly associated with depression in women with (OR 3.51, 95% CI 1.21 to 10.16) or without bereavement (OR 3.07, 95% CI 1.44 to 6.56) but not in men; this association was also significant in individuals over 18 years old at the time of the earthquake with (OR 13.16, 95% CI 3.08 to 56.3) or without bereavement (OR 3.39, 95% CI 1.31 to 8.87) but not in individuals less than 18 years old.

CONCLUSIONS

37 years after the Tangshan earthquake, earthquake experience was associated with depression among bereaved survivors, women and individuals over 18 years old at the time of the earthquake.