Annie Green Howard

Prevalence of Hypertension, Awareness, Treatment, and Control in the Hispanic Community Health Study/Study of Latinos

BACKGROUND The prevention and control of hypertension is an essential component for reducing the burden of cardiovascular diseases. Here we describe the prevalence of hypertension in diverse Hispanic/Latino background groups and describe the proportion who are aware of their diagnosis, receiving treatment, and having their hypertension under control. METHODS The Hispanic Community Health Study/Study of Latinos is a longitudinal cohort study of 16,415 Hispanics/Latinos, aged 18-74 years from 4 US communities (Bronx, NY; Chicago, IL; Miami, FL; and San Diego, CA). At baseline (2008-2011) the study collected extensive measurements and completed questionnaires related to research on cardiovascular diseases. Hypertension was defined as measured blood pressure ≥140/90mm Hg or use of antihypertensive medication. RESULTS The total age-adjusted prevalence of hypertension in this study was 25.5% as compared with 27.4% in non-Hispanic whites in the National Health and Nutrition Examination Survey. Prevalence of hypertension increased with increasing age groups and was highest in Cuban, Puerto Rican, and Dominican background groups. The percent with hypertension who were aware, being treated with medication, or had their hypertension controlled was lower compared with US non-Hispanic whites with hypertension and it was lowest in those without health insurance. CONCLUSIONS These findings indicate a significant deficit in treatment and control of hypertension among Hispanics/Latinos residing in the United States, particularly those without health insurance. Given the relative ease of identification of hypertension and the availability of low-cost medications, enabling better access to diagnostic and treatment services should reduce the burden of hypertension in Hispanic populations.

Longitudinal trajectories of BMI and cardiovascular disease risk: The national longitudinal study of adolescent health

In adulthood, excess BMI is associated with cardiovascular disease (CVD); it is unknown whether risk differs by BMI trajectories from adolescence to adulthood.

Intensive Blood Pressure Treatment Does Not Improve Cardiovascular Outcomes in Centrally Obese Hypertensive Individuals With Diabetes: The Action to Control Cardiovascular Risk in Diabetes (ACCORD) Blood Pressure Trial

OBJECTIVE The Action to Control Cardiovascular Risk in Diabetes (ACCORD) Blood Pressure Trial reported no differences in most cardiovascular disease (CVD) outcomes between intensive and standard blood pressure therapy in individuals with diabetes mellitus (DM) and hypertension. Many such individuals are centrally obese. Here we evaluate whether the trial outcomes varied by the level of central obesity. RESEARCH DESIGN AND METHODS The cohort included 4,687 people (47.7% women) with DM and hypertension. Mean age was 62.2, and mean follow-up was 4.7 years. Participants were randomly assigned to one of two blood pressure treatment strategies: intensive (systolic <120 mmHg) or standard (systolic <140 mmHg). Sex-specific quartiles of waist-to-height ratio were used as the measure of central obesity. The primary ACCORD outcome (a composite of nonfatal myocardial infarction [MI], nonfatal stroke, or CVD death) and three secondary outcomes (nonfatal MI, fatal or nonfatal stroke, and CVD death) were examined using proportional hazard models. RESULTS There was no evidence that the effect of intensively lowering blood pressure differed by quartile of waist-to-height ratio for any of the four outcomes (P > 0.25 in all cases). Controlling for waist-to-height quartile had no significant impact on previously published results for intensive blood pressure therapy. Waist-to-height ratio was significantly related to CVD mortality (hazard ratio 2.32 [95% CI 1.40–3.83], P = 0.0009 comparing the heaviest to lightest quartiles), but not to the other outcomes (P > 0.09 in all cases). CONCLUSIONS Intensive lowering of blood pressure versus standard treatment does not ameliorate CVD risk in individuals with DM and hypertension. These results did not vary by quartile of waist-to-height ratio.

Neighborhood socioeconomic status and food environment: a 20-year longitudinal latent class analysis among CARDIA participants

Cross-sectional studies suggest that neighborhood socioeconomic (SES) disadvantage is associated with obesogenic food environments. Yet, it is unknown how exposure to neighborhood SES patterning through adulthood corresponds to food environments that also change over time. We used latent class analysis (LCA) to classify participants in the U.S.-based Coronary Artery Risk Development in Young Adults study [n=5,114 at baseline 1985-1986 to 2005-2006] according to their longitudinal neighborhood SES residency patterns (upward, downward, stable high and stable low). For most classes of residents, the availability of fast food and non-fast food restaurants and supermarkets and convenience stores increased (p<0.001). Yet, socioeconomically disadvantaged neighborhood residents had fewer fast food and non-fast food restaurants, more convenience stores, and the same number of supermarkets in their neighborhoods than the advantaged residents. In addition to targeting the pervasive fast food restaurant and convenient store retail growth, improving neighborhood restaurant options for disadvantaged residents may reduce food environment disparities.

Multiple pathways from the neighborhood food environment to increased body mass index through dietary behaviors: A structural equation-based analysis in the CARDIA study.

OBJECTIVES To examine longitudinal pathways from multiple types of neighborhood restaurants and food stores to BMI, through dietary behaviors. METHODS We used data from participants (n=5114) in the United States-based Coronary Artery Risk Development in Young Adults study and a structural equation model to estimate longitudinal (1985-86 to 2005-06) pathways simultaneously from neighborhood fast food restaurants, sit-down restaurants, supermarkets, and convenience stores to BMI through dietary behaviors, controlling for socioeconomic status (SES) and physical activity. RESULTS Higher numbers of neighborhood fast food restaurants and lower numbers of sit-down restaurants were associated with higher consumption of an obesogenic fast food-type diet. The pathways from food stores to BMI through diet were inconsistent in magnitude and statistical significance. CONCLUSIONS Efforts to decrease the numbers of neighborhood fast food restaurants and to increase the numbers of sit-down restaurant options could influence diet behaviors. Availability of neighborhood fast food and sit-down restaurants may play comparatively stronger roles than food stores in shaping dietary behaviors and BMI.

Cadmium body burden and increased blood pressure in middle-aged American Indians: the Strong Heart Study

Cadmium (Cd) is an environmental pollutant that has been associated with cardiovascular disease in populations, but the relationship of Cd with hypertension has been inconsistent. We studied the association between urinary Cd concentrations, a measure of total body burden, and blood pressure in American Indians, a US population with above national average Cd burden. Urinary Cd was measured using inductively coupled plasma mass spectrometry, and adjusted for urinary creatinine concentration. Among 3714 middle-aged American Indian participants of the Strong Heart Study (mean age 56 years, 41% male, 67% ever-smokers, 23% taking antihypertensive medications), urinary Cd ranged from 0.01 to 78.48 μg g−1 creatinine (geometric mean=0.94 μg g−1) and it was correlated with smoking pack-year among ever-smokers (r2=0.16, P<0.0001). Participants who were smokers were on average light-smokers (mean 10.8 pack-years), and urinary Cd was similarly elevated in light- and never-smokers (geometric means of 0.88 μg g−1 creatinine for both categories). Log-transformed urinary Cd was significantly associated with higher systolic blood pressure in models adjusted for age, sex, geographic area, body mass index, smoking (ever vs never, and cumulative pack-years) and kidney function (mean blood pressure difference by lnCd concentration (β)=1.64, P=0.002). These associations were present among light- and never-smokers (β=2.03, P=0.002, n=2627), although not significant among never-smokers (β=1.22, P=0.18, n=1260). Cd was also associated with diastolic blood pressure among light- and never-smokers (β=0.94, P=0.004). These findings suggest that there is a relationship between Cd body burden and increased blood pressure in American Indians, a population with increased cardiovascular disease risk.

Time Trends of Dietary and Lifestyle Factors and Their Potential Impact on Diabetes Burden in China

OBJECTIVE To examine the secular trends in risk factors, estimate their impact on type 2 diabetes burden from 1991 to 2011, and project trends in the next 20 years. RESEARCH DESIGN AND METHODS Risk factor distributions were based on data from the China Health and Nutrition Survey 1991–2011. Diabetes cases attributable to all nonoptimal levels of each risk factor were estimated by applying the comparative risk assessment method. RESULTS In 2011, high BMI was the leading individual attributable factor for diabetes cases in China responsible for 43.8 million diabetes cases with a population-attributable fraction of 46.8%. Low whole-grain intake and high refined grain intake were the leading dietary risk factors in China responsible for 37.8 million and 21.8 million diabetes-attributable cases, respectively. The number of attributable diabetes cases associated with low physical activity, high blood pressure, and current smoking was 29.5, 21.6, and 9.8 million, respectively. Although intakes of low-fat dairy products, nuts, fruit, vegetables, and fish and seafood increased moderately over time, the average intake was below optimal levels in 2011 and were responsible for 15.8, 11.3, 9.9, 6.0, 3.6, and 2.6 million diabetes cases, respectively. Meanwhile, intakes of processed meat, red meat, and sugar-sweetened beverage showed increasing trends over time and were responsible for 2.8, 1.8, and 0.5 million diabetes cases, respectively, in 2011. CONCLUSIONS A high BMI and low intake of whole grains but high intake of refined grains are the most important individual risk factors related to Chinese diabetes burden; low physical activity and high blood pressure also significantly contributed.

Fast food price, diet behavior, and cardiometabolic health: Differential associations by neighborhood SES and neighborhood fast food restaurant availability in the CARDIA study.

Little research has addressed whether neighborhood context influences associations between fast food price, diet, and cardiometabolic health. We investigated these associations using 25 years of Coronary Artery Risk Development in Young Adults (CARDIA) study data (n=4,469, observations=21,134). We found a negative association between fast food price and consumption, with stronger inverse associations in more (vs. less) deprived neighborhoods [3rd tertile: β=-0.68 (95% CI: (-0.85, -0.51); 1st tertile: β=-0.22 (95% CI: -0.42, -0.02); p-interaction-0.002], and a similar association for BMI [3rd tertile: β=-1.34 (95% CI: -1.54, -1.14); 1st tertile: β=-0.45 (95% CI: -0.66, -0.25); p-interaction<0.001], but not insulin resistance [3rd tertile: β=-0.07 (95% CI: -0.24, 0.09); 1st tertile: β=0.09 (95% CI: -0.08, 0.26); p-interaction=0.40]. We observed no modification of fast food price by fast food availability. Future research on obesity disparities should consider potential differences in the association between fast food prices and health outcomes across neighborhood socioeconomic levels.

Recent urbanization in China is correlated with a Westernized microbiome encoding increased virulence and antibiotic resistance genes

BackgroundUrbanization is associated with an increased risk for a number of diseases, including obesity, diabetes, and cancer, which all also show associations with the microbiome. While microbial community composition has been shown to vary across continents and in traditional versus Westernized societies, few studies have examined urban-rural differences in neighboring communities within a single country undergoing rapid urbanization. In this study, we compared the gut microbiome, plasma metabolome, dietary habits, and health biomarkers of rural and urban people from a single Chinese province.ResultsWe identified significant differences in the microbiota and microbiota-related plasma metabolites in rural versus recently urban subjects from the Hunan province of China. Microbes with higher relative abundance in Chinese urban samples have been associated with disease in other studies and were substantially more prevalent in the Human Microbiome Project cohort of American subjects. Furthermore, using whole metagenome sequencing, we found that urbanization was associated with a loss of microbial diversity and changes in the relative abundances of Viruses, Archaea, and Bacteria. Gene diversity, however, increased with urbanization, along with the proportion of reads associated with antibiotic resistance and virulence, which were strongly correlated with the presence of Escherichia and Shigella.ConclusionsOur data suggest that urbanization has produced convergent evolution of the gut microbial composition in American and urban Chinese populations, resulting in similar compositional patterns of abundant microbes through similar lifestyles on different continents, including a loss of potentially beneficial bacteria and an increase in potentially harmful genes via increased relative abundance of Escherichia and Shigella.

Management of Vascular Risk Factors in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST)

Background The Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) is a multicenter randomized trial of stenting versus endarterectomy in patients with symptomatic and asymptomatic carotid disease. This study assesses management of vascular risk factors. Methods and Results Management was provided by the patients physician, with biannual monitoring results collected by the local site. Therapeutic targets were low‐density lipoprotein, cholesterol <100 mg/dL, systolic blood pressure <140 mm Hg, fasting blood glucose <126 mg/dL, and nonsmoking status. Optimal control was defined as achieving all 4 goals concurrently. Generalized estimating equations were used to compare risk factors at baseline with those observed in scheduled follow‐up visits for up to 48 months. In the analysis cohort of 2210, significant improvements in risk‐factor control were observed across risk factors for all follow‐up visits compared with baseline. At 48 months, achievement of the low‐density lipoprotein cholesterol goal improved from 59.1% to 73.6% (P<0.001), achievement of the systolic blood pressure goal improved from 51.6% to 65.1% (P<0.001), achievement of the glucose goal improved from 74.9% to 80.7% (P=0.0101), and nonsmoking improved from 74.4% to 80.9% (P<0.0001). The percentage with optimal risk‐factor control also improved significantly, from 16.7% to 36.2% (P<0.001), but nearly 2 of 3 study participants did not achieve optimal control during the study. Conclusions Site‐based risk‐factor control improved significantly in the first 6 months and over the long term in CREST but was often suboptimal. Intensive medical management should be considered for future trials of carotid revascularization. Clinical Trial Registration URL: ClinicalTrials.gov. Unique identifier: NCT00004732.