Margo A. Sidell

Effects of Physical Activity and Sedentary Time on the Risk of Heart Failure

Background— Although the benefits of physical activity for risk of coronary heart disease are well established, less is known about its effects on heart failure (HF). The risk of prolonged sedentary behavior on HF is unknown. Methods and Results— The study cohort included 82 695 men aged ≥45 years from the California Men’s Health Study without prevalent HF who were followed up for 10 years. Physical activity, sedentary time, and behavioral covariates were obtained from questionnaires, and clinical covariates were determined from electronic medical records. Incident HF was identified through International Classification of Diseases, Ninth Revision codes recorded in electronic records. During a mean follow-up of 7.8 years (646 989 person-years), 3473 men were diagnosed with HF. Controlling for sedentary time, sociodemographics, hypertension, diabetes mellitus, unfavorable lipid levels, body mass index, smoking, and diet, the hazard ratio (95% confidence interval [CI]) of HF in the lowest physical activity category compared with those in the highest category was 1.52 (95% CI, 1.39–1.68). Those in the medium physical activity category were also at increased risk (hazard ratio, 1.17 [95% CI, 1.06–1.29]). Controlling for the same covariates and physical activity, the hazard ratio (95% CI) of HF in the highest sedentary category compared with the lowest was 1.34 (95% CI, 1.21–1.48). Medium sedentary time also conveyed risk (hazard ratio, 1.13 [95% CI, 1.04–1.24]). Results showed similar trends across white and Hispanic subgroups, body mass index categories, baseline hypertension status, and prevalent coronary heart disease. Conclusions— Both physical activity and sedentary time may be appropriate intervention targets for preventing HF.

Survival of propensity matched incident peritoneal and hemodialysis patients in a United States health care system

We sought to compare survival among incident peritoneal dialysis (PD) patients to matched hemodialysis (HD) patients who received pre-dialysis care, including permanent dialysis access placement. Patients starting PD were propensity matched to those starting HD. HD patients who used a central venous catheter during the first 90 days of dialysis were excluded. Stratified Cox proportional hazards models were used to compare patient survival using both intent-to-treat and as-treated analyses. In the intent-to-treat analysis, patients were followed from the date of first dialysis until death and censored at the earliest of the following: renal transplantation, death, renal recovery, loss to follow-up or study end. In the as-treated analysis, patients were also censored at the time of modality change. A total of 1003 matched pairs were obtained from 11,301 incident patients (10,298 HD and 1003 PD). The cumulative hazard ratio for death at one year was 2.38 (95% CI 1.68-3.40) and 2.10 (1.50-2.94) for HD relative to PD patients in the as-treated and intent-to-treat analyses, respectively. The cumulative risk of death, as estimated by the cumulative hazard ratio, favored PD for almost up to 3 years of follow-up in the as-treated analysis and nearly 2 years of follow-up in the intent-to-treat analysis with no differences thereafter. The higher adjusted rate of death observed for HD patients cannot be attributed to initial use of central venous catheters or lack of pre-dialysis care.

Associations Between Physical Activity and Cardiometabolic Risk Factors Assessed in a Southern California Health Care System, 2010–2012

Introduction Risk factors associated with many chronic diseases can be improved through regular physical activity. This study investigated whether cross-sectional associations between physical activity, assessed by the Exercise Vital Sign (EVS), and cardiometabolic risk factors can be detected in clinical settings. Methods We used electronic records from Kaiser Permanente Southern California members (N = 622,897) to examine the association of EVS category with blood pressure, fasting glucose, random glucose, and glycosylated hemoglobin. Adults aged 18 years or older with at least 3 EVS measures between April 2010 and December 2012, without comorbid conditions, and not taking antihypertension or glucose-lowering medications were included. We compared consistently inactive (EVS = 0 min/wk for every measure) with consistently active (EVS ≥150 min/wk) and irregularly active (EVS 1–149 min/wk or not meeting the consistently active or inactive criteria) patients. Separate linear regression analyses were conducted controlling for age, sex, race/ethnicity, body mass index, and smoking status. Results Consistently active women had lower systolic (−4.60 mm Hg; 95% confidence interval [CI], −4.70 to −4.44) and diastolic (−3.28 mm Hg; 95% CI, −3.40 to −3.17) blood pressure than inactive women. Active men had lower diastolic blood pressure than inactive men. Consistently active patients (women, −5.27 mg/dL [95% CI, −5.56 to −4.97]; men, −1.45 mg/dL [95% CI, −1.75 to −1.16] and irregularly active patients (women, −4.57 mg/dL [95% CI, −4.80 to −4.34]; men, −0.42 mg/dL [95% CI, −0.66 to −0.19]) had lower fasting glucose than consistently inactive patients. Consistently active and irregularly active men and women also had favorable random glucose and HbA1c compared with consistently inactive patients. Conclusion Routine clinical physical activity assessment may give health care providers additional information about their patients’ cardiometabolic risk factors.

Predictors of Peritonitis, Hospital Days, and Technique Survival for Peritoneal Dialysis Patients in a Managed Care Setting

♦ Introduction: Many clinicians perceive that peritoneal dialysis (PD) should be reserved for younger, healthier, more affluent patients. Our aim was to examine outcomes for PD patients in a managed care setting and to identify predictors of adverse outcomes. ♦ Methods: We identified all patients who initiated PD at our institution between 1 January 2001 and 31 December 2010. Predictor variables studied included age, sex, race, PD modality, cause of end-stage renal disease (ESRD), dialysis vintage, Charlson comorbidity index (CCI) score, education, and income level. Poisson models were used to determine the relative risk (RR) of peritonitis and the number of hospital days per patient-year. The log-rank test was used to compare technique survival by patient strata. ♦ Results: Among the 1378 patients who met the inclusion criteria, only female sex [RR: 0.85; 95% confidence interval (CI): 0.74 to 0.98; p = 0.02] and higher education (RR: 0.77; 95% CI: 0.60 to 0.98; p = 0.04) were associated with peritonitis. For hospital days, dialysis vintage (RR: 1.11; 95% CI: 1.04 to 1.18; p = 0.002), CCI score (RR: 1.06; 95% CI: 1.02 to 1.20; p = 0.002), and cause of ESRD (RR for glomerulonephritis: 0.59; 95% CI: 0.43 to 0.80; p = 0.0006; and RR for hypertension: 0.69; 95% CI: 0.55 to 0.88; p = 0.002) were associated with 1 extra hospital day per patient-year. The 2-year technique survival was 61% for patients who experienced at least 1 episode of peritonitis and 72% for those experiencing no peritonitis (p = 0.0001). Baseline patient age, primary cause of ESRD, and PD modality were the only other variables associated with technique survival in the study. ♦ Conclusions: Neither race nor socio-economic status predicted technique survival or hospital days in our study. Female sex and higher education were the only two variables studied that had an association with peritonitis.

Quadrivalent Human Papillomavirus Vaccine Uptake in Adolescent Boys and Maternal Utilization of Preventive Care and History of Sexually Transmitted Infections

OBJECTIVES We examined whether maternal utilization of preventive care and history of sexually transmitted infections (STIs) predicted quadrivalent human papillomavirus vaccine (HPV4) uptake among adolescent boys 1 year following the recommendation for permissive use of HPV4 for males. METHODS We linked maternal information with electronic health records of 254 489 boys aged 9 to 17 years who enrolled in Kaiser Permanente Southern California health plan from October 21, 2009, through December 21, 2010. We used multivariable Poisson regression with robust error variance to examine whether HPV4 initiation was associated with maternal uptake of influenza vaccine, Papanicolaou (Pap) screening, and history of STIs. RESULTS We identified a modest but statistically significant association between initiation of HPV4 series and maternal receipt of influenza vaccine (rate ratio [RR] = 1.16; 95% confidence interval [CI] = 1.07, 1.26) and Pap screening (RR = 1.13; 95% CI = 1.01, 1.26). Boys whose mothers had a history of genital warts were more likely to initiate HPV4 (RR = 1.47; 95% CI = 0.93, 2.34), although the association did not reach statistical significance (P = .1). CONCLUSIONS Maternal utilization of preventive care and history of genital warts may influence HPV4 uptake among adolescent boys. The important role of maternal health characteristics and health behaviors needs be considered in intervention efforts to increase vaccine uptake among boys.

Re-recruiting young adult women into a second follow-up study

Background Recruitment among young adults presents a unique set of challenges as they are difficult to reach through conventional methods. Purpose To describe our experience using both traditional and nontraditional methods in the re-recruitment of young adult women into the second follow-up study of the Trial of Activity for Adolescent Girls (TAAG). Methods 589 adolescent girls were re-recruited as 11th graders into TAAG 2. Re-recruitment efforts were conducted when they were between 22 and 23 years of age (TAAG 3). Facebook, email, postal mail, and telephone (call and text) were used. Descriptive statistics were used to summarize cohort characteristics. Discrete categorical variables were compared using Pearson chi-square or Fishers exact test, while Wilcoxon rank sum or t-tests were calculated for continuous variables. Pearsons chi square test, analysis of variance, and the Kruskal-Wallis test were also used. Logistic regression was used to calculate adjusted models. Results All 589 cohort members were located and 479 (81.3%) were re-recruited. Participants who reported living in a two parent household or with their mothers only, and who did not perceive a lot of crime in their neighborhood were more likely to consent to participate in TAAG 3 (p = 0.047 and p = 0.008, respectively). Perceived neighborhood crime remained significant in the adjusted model (OR 0.48, 95% CI 0.25–0.90, p = 0.02). Early and late consenters differed by race/ethnicity (p = 0.015), household type (p = 0.001), and socioeconomic status (p = 0.005). In the adjusted model, Black participants were more likely to consent later than White participants (OR 1.83, 95% CI 1.07–3.13, p = 0.03). Conclusions A number of recruitment strategies and outreach attempts were needed to recruit young adult women into a follow-up study. Persistent efforts may be needed to recruit participants with race/ethnic diversity and lower socioeconomic status.

Quadrivalent Human Papillomavirus Vaccine Initiation in Boys Before and Since Routine Use: Southern California, 2009–2013

OBJECTIVES We examined the trends and correlates of quadrivalent human papillomavirus vaccine (HPV4) initiation in insured boys during the periods before and after routine use recommendation. METHODS We grouped data from electronic medical records of boys aged 9 to 17 years from the Kaiser Permanente Southern California prepaid health plan into 3 open cohorts: permissive use: 2009 to 2010; anal cancer indication added: 2010 to 2011; and routine use: 2011 to 2013. We estimated adjusted risk ratios (ARRs) between demographics and vaccination initiation using Poisson regression. RESULTS HPV4 initiation increased across cohorts--1.6%, 3.4%, and 18.5%--with the greatest increase among boys aged 11 to 12 years in cohort 3. Initiation was associated with receiving influenza vaccination in the previous year in all cohorts (cohort 3: ARR = 1.48; 95% confidence interval [CI] = 1.46, 1.51) and with non-White race/ethnicity following routine recommendation (cohort 3, non-Hispanic Black: ARR = 1.18; 95% CI = 1.08, 1.30; Hispanic: ARR = 1.23; 95% CI = 1.17, 1.29; Asian/Pacific Islanders: ARR = 1.16; 95% CI = 1.11, 1.20). CONCLUSIONS Routine use recommendation increased the uptake of HPV4 in boys. System-level interventions to encourage providers to routinely recommend HPV4 vaccination may help increase HPV4 uptake in boys.

Assessing the Relationship between Parental Activation and Obesity-related Health Behaviors among a Racially/Ethnically Diverse Population of Low-income Pediatric Patients: A Cross-sectional Study (Preprint)

Background Despite a recent decline in the obesity prevalence among preschool-aged children, obesity remains disproportionately high among children from low-income racial or ethnic minority families. Promoting healthy lifestyles (eg, obesity-preventative behaviors) in primary care settings is particularly important for young children, given the frequency of preventative health visits and parent-provider interactions. Higher adoption of specific health behaviors is correlated with increased patient activation (ie, skill, confidence, and knowledge to manage their health care) among adults. However, no published study, to date, has examined the relationship between parental activation and obesity-related health behaviors among young children. Objective The goal of this study is to measure parental activation in low-income parents of preschoolers in 2 large health systems and to examine the association with diet, screen-time, and physical activity behaviors. Methods We will conduct a cross-sectional study of parents of preschool-aged patients (2-5 years) receiving primary care at multiple clinic sites within 2 large health care systems. Study participants, low-income black, Hispanic, and white parents of preschool-aged patients, are being recruited across both health systems to complete orally administered surveys. Results Recruitment began in December 2017 and is expected to end in May 2018. A total of 267 low-income parents of preschool-aged children have been enrolled across both clinic sites. We are enrolling an additional 33 parents to reach our goal sample size of 300 across both health systems. The data analysis will be completed in June 2018. Conclusions This protocol outlines the first study to fully examine parental activation and its relationship with parent-reported diet, physical activity, and screen-time behaviors among low-income preschool-aged patients. It involves recruitment across 2 geographically distinct areas and resulting from a partnership between researchers at 2 different health systems with multiple clinical sites. This study will provide new knowledge about how parental activation can potentially be incorporated as a strategy to address childhood obesity disparities in primary care settings. International Registered Report Identifier (IRRID) RR1-10.2196/9688