Qiuping Gu

Mortality Trends in Men and Women with Diabetes, 1971 to 2000

Context Whether the mortality reductions observed over recent decades in the United States have been similar among diabetic and nondiabetic persons is unknown. Contribution The 19712000 National Health and Nutrition Examination Surveys and vital statistics data reveal higher mortality in the diabetic population than in the nondiabetic population. Over this period, diabetic men experienced mortality reductions that paralleled those of nondiabetic men. However, mortality rates in women have not changed, and the mortality difference between diabetic and nondiabetic women more than doubled. Implications Mortality among diabetic women does not reflect improvements in the care of diabetes and other cardiovascular risk factors. Understanding the sex differences in diabetes outcomes should be a research priority. The Editors The decrease in cardiovascular disease (CVD) mortality rates and the accompanying increases in overall longevity are major public health successes in the United States over the past 40 years (1). These have been attributed to decreases in CVD risk factors, as well as advances in medical management and revascularization, among persons with diagnosed CVD (2, 3). Aggressive management of CVD risk factors has been shown to be particularly effective among persons with diabetes, and implementation of these findings into practice along with aggressive diabetes care should, in theory, result in increased longevity among persons with diabetes (49). The quality of diabetes care and levels of certain CVD risk factors have improved among the U.S. population with diagnosed diabetes (10, 11). Whether reductions in mortality have occurred among persons with diabetes, however, remains unclear. Although regional studies of persons with diabetes suggest that rates of all-cause mortality and cardiovascular complications have declined in recent decades (1215), the only nationally representative study to examine trends in mortality rates of adults with diabetes found no improvement between 1971 and 1992 (16). However, no national studies of mortality trends of the U.S. diabetic population have extended through the 1990s, a period of major advances in clinical diabetes management, leaving the question of whether longevity in this population has improved (4, 11, 17). Thus, we assembled data from 3 consecutive nationally representative cohorts to assess whether all-cause and CVD mortality have declined among the U.S. population with diabetes and whether the disparity in mortality rates between persons with and without diabetes has decreased. Methods Study Design and Population The National Health and Nutrition Examination Survey (NHANES) is a series of independent, nationally representative health surveys of the U.S. noninstitutionalized population conducted from 1971 to 1975 (NHANES I), 1976 to 1980 (NHANES II), and 1988 to 1994 (NHANES III) (1820). Each survey used a stratified, multistage probability design that sampled, interviewed, and examined participants to determine their health status. Sampling approaches, interview, and examination methods were standardized across surveys, and data were linked to death certificate data (21). To minimize bias from differential follow-up, we limited follow-up to 12.2 years, which was the maximum period for the survey with the shortest follow-up (NHANES III). Thus, the follow-up years for the 3 survey cohorts were 1971 to 1986, 1976 to 1992, and 1988 to 2000. Overall, 28043 persons, 27801 persons, and 39695 persons were selected for NHANES I, II, and III, respectively, and 75% (20749 persons), 73% (20322 persons), and 78% (30818 persons) were examined. We restricted our analyses to adults age 35 to 74 years who were examined at baseline. These groups included 8654 (80%), 8213 (76%), and 9399 (90%) persons from each of the 3 cohorts. After excluding persons without information on diabetes (7, 3, and 12 persons) or death (176, 5, and 6 persons), we were left with 8471, 8205, and 9381 persons in the primary analyses. Previous analyses have indicated little bias due to nonresponse (22, 23). Measurements Demographic characteristics, self-reported diabetes status, duration of disease, insulin use, and history of CVD (heart attack, heart failure, or stroke) were determined by interview. Weight and height were measured and were used to calculate body mass index (BMI). Underlying causes of death were classified according to the International Classification of Diseases, Ninth Revision, with CVD coded as 390 to 448. Statistical Analysis We completed mortality rates as the number of deaths divided by the sum of person-years and standardized by age and sex to the 2000 U.S. population. We examined changes in absolute standardized mortality rates over time by using t tests. We also used proportional hazards models to estimate the hazard rate ratios for the NHANES II and III cohorts compared with the NHANES I cohort among the diabetic and nondiabetic populations, with primary models controlling for age, sex, and race or ethnicity and additional models controlling for duration of diabetes and prevalent CVD. We also examined 2-way interactions of survey among persons with diabetes with each of the covariates mentioned above. We assessed the validity of the proportional hazards assumption by adding time-dependent variables to the model (that is, the interaction of age, sex, or race or ethnicity and the logarithm of follow-up duration). Because this assumption was not met across sex, we fit models separately by sex. Mortality rate estimation and proportional hazards regression incorporated survey weights such that results are representative of the U.S. noninstitutionalized population and account for the stratified, clustered design and the unequal probabilities of selection from oversampling and nonresponse (24). We combined data across the 3 surveys for regression analyses, using the original survey weights and design variables. We renumbered strata to appropriately represent their respective surveys, and we calculated degrees of freedom as the number of primary sampling units minus the number of strata. Because we used original survey weights (as opposed to constructing new weights for pooled analyses), these analyses make the assumption that each survey sample is drawn from a different population, as opposed to 3 surveys from a single underlying population (25). We conducted all statistical analyses by using SUDAAN, version 9.1 (RTI International, Research Triangle Park, North Carolina), which uses Taylor series linearization to estimate variances. Role of the Funding Source The U.S. Department of Health and Human Services is the funding source for NHANES and oversees the conduct and reporting of the NHANES surveys. Results Among both men and women with diabetes, the proportion of nonwhite persons roughly doubled across the survey years, the level of education increased substantially, and mean BMI increased (Table 1). In diabetic womenbut not diabetic menthe average age at diagnosis decreased statistically significantly (mean decrease, 2.9 years) across the 3 surveys, and the average age of the diabetic population decreased by 2.5 years, from 59.1 to 56.6 years. Almost all of the secular trends in race or ethnicity, education, and BMI observed in persons with diabetes also occurred in those without diabetes. Table 1. Characteristics of the U.S. Population Age 35 to 74 Years with and without Diagnosed Diabetes Between 1971 to 1986 and 1988 to 2000 in the overall nondiabetic population (both men and women), all-cause mortality rates decreased from 14.4 to 9.5 annual deaths per 1000 persons (P< 0.001) and CVD deaths decreased from 7.0 to 3.4 annual deaths per 1000 persons (P< 0.001) (Table 2). Among the overall diabetic population, the all-cause mortality rate did not statistically significantly change (30 annual deaths per 1000 persons in 1971 to 1986 vs. 25.2 annual deaths per 1000 persons in 1988 to 2000). For CVD mortality, the absolute difference in mortality among the diabetic population between 1971 to 1986 and 1988 to 2000 (18.2 vs. 11.1 annual deaths per 1000 persons) was greater than that of the nondiabetic population, but this decrease was not significant (P= 0.09). Table 2. Trends in Mortality Rates in the U.S. Population Age 35 to 74 Years, by Diabetes Status and Sex, 19712000 Findings in the overall population, however, obscured important sex-related differences, wherein mortality rates decreased among diabetic men but not among diabetic women (interaction between survey year and sex, P= 0.005 for all-cause mortality and P= 0.59 for CVD mortality) (Figure 1). All-cause mortality rates among diabetic men decreased by 43% (from 42.6 to 24.4 annual deaths per 1000 persons) between 1971 to 1986 and 1988 to 2000 (P= 0.03). In an analysis that controlled for age and race or ethnicity, the all-cause mortality rate ratio for diabetic men in 1988 to 2000 compared with 1971 to 1986 was 0.61 (95% CI, 0.43 to 0.86). Trends for the CVD mortality rate paralleled those of all-cause mortality (26.4 vs. 12.8 annual deaths per 1000 persons; P= 0.06 for difference) (Table 2 and Figure 2). In an analysis that controlled for age, sex, and race or ethnicity, the CVD mortality rate ratio for diabetic men in 1988 to 2000 compared with 1971 to 1986 was 0.62 (CI, 0.39 to 1.01) (Table 2 and Figure 2). Additional adjustment for diabetes duration, BMI, and prevalent CVD had no appreciable effect on the mortality rate ratios (data not shown). Figure 1. Age-adjusted all-cause mortality rates among the U.S. population age 35 to 74 years with and without diabetes, by cohort and sex. Figure 2. Age-adjusted cardiovascular disease mortality rates among the U.S. population age 35 to 74 years with and without diabetes, by cohort and sex. The absolute difference in all-cause mortality rates between men with and without diabetes was 23.6 annual deaths per 1000 persons (42.6 vs. 19.0 deaths) in 1971 to 1986 compared with 12.

Trends in Antihypertensive Medication Use and Blood Pressure Control Among United States Adults With Hypertension The National Health and Nutrition Examination Survey, 2001 to 2010

Background— The monitoring of national trends in hypertension treatment and control can provide important insight into the effectiveness of primary prevention efforts for cardiovascular disease. The objective of this study was to examine recent trends in antihypertensive medication use and its impact on blood pressure control among US adults with hypertension. Methods and Results— A total of 9320 hypertensive people aged ≥18 years from the National Health and Nutrition Examination Survey 2001 to 2010 were included in this study. The prevalence of antihypertensive medication use increased from 63.5% in 2001 to 2002 to 77.3% in 2009 to 2010 (Ptrend<0.01). Most notably, there was a large increase in the use of multiple antihypertensive agents (from 36.8% to 47.7%, Ptrend<0.01). Overall, the use of thiazide diuretics, &bgr;-blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers increased by 23%, 57%, 31%, and 100%, respectively. In comparison with monotherapy, single-pill combinations and multiple-pill combinations were associated with 55% and 26% increased likelihoods of blood pressure control, respectively. By the 2009 to 2010 time period, 47% of all hypertensive people and 60% of treated hypertensive people had blood pressure controlled. However, higher treated but uncontrolled hypertension rates continued to persist among older Americans, non-Hispanic blacks, diabetic people, and those with chronic kidney disease. Also, Mexican Americans with hypertension were still less likely to take antihypertensive medication than non-Hispanic whites with hypertension. Conclusions— Antihypertensive medication use and blood pressure control among US adults with hypertension significantly increased over the past 10 years. Combination therapy regimens can facilitate achievement of blood pressure goals.Background— The monitoring of national trends in hypertension treatment and control can provide important insight into the effectiveness of primary prevention efforts for cardiovascular disease. The objective of this study was to examine recent trends in antihypertensive medication use and its impact on blood pressure control among US adults with hypertension. Methods and Results— A total of 9320 hypertensive people aged ≥18 years from the National Health and Nutrition Examination Survey 2001 to 2010 were included in this study. The prevalence of antihypertensive medication use increased from 63.5% in 2001 to 2002 to 77.3% in 2009 to 2010 ( P trend<0.01). Most notably, there was a large increase in the use of multiple antihypertensive agents (from 36.8% to 47.7%, P trend<0.01). Overall, the use of thiazide diuretics, β-blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers increased by 23%, 57%, 31%, and 100%, respectively. In comparison with monotherapy, single-pill combinations and multiple-pill combinations were associated with 55% and 26% increased likelihoods of blood pressure control, respectively. By the 2009 to 2010 time period, 47% of all hypertensive people and 60% of treated hypertensive people had blood pressure controlled. However, higher treated but uncontrolled hypertension rates continued to persist among older Americans, non-Hispanic blacks, diabetic people, and those with chronic kidney disease. Also, Mexican Americans with hypertension were still less likely to take antihypertensive medication than non-Hispanic whites with hypertension. Conclusions— Antihypertensive medication use and blood pressure control among US adults with hypertension significantly increased over the past 10 years. Combination therapy regimens can facilitate achievement of blood pressure goals. # Clinical Perspective {#article-title-35}

Prevalence of peripheral arterial disease and risk factors in persons aged 60 and older: data from the National Health and Nutrition Examination Survey 1999-2004.

OBJECTIVES: Peripheral arterial disease (PAD) is associated with significant cardiovascular morbidity and mortality. The study objectives were to examine the prevalence of PAD and associated risk factors.

Gender Differences in Hypertension Treatment, Drug Utilization Patterns, and Blood Pressure Control Among US Adults With Hypertension: Data From the National Health and Nutrition Examination Survey 1999–2004

BACKGROUND National guidelines recommend the same approach for treating hypertensive men and women. It is not known, however, whether current US antihypertensive medication utilization patterns and the resulting degrees of blood pressure (BP) control are similar or different among hypertensive women and men. METHODS The study was a cross-sectional, nationally representative survey of the noninstitutionalized civilian US population. Persons aged > or =18 years from the National Health and Nutrition Examination Survey (NHANES) 1999-2004 were classified as hypertensive based on a BP > or =140/90 mm Hg, currently taking antihypertensive medication, or having been diagnosed by a physician. RESULTS Among hypertensives, the prevalence of antihypertensive medication use was significantly higher among women than men (61.4% vs. 56.8%), especially among middle-aged persons (40-49 years, 53.1% vs. 42.7%) and among non-Hispanic blacks (65.5% vs. 54.6%). Also, treated women were more likely than men to use diuretics (31.6% vs. 22.3%) and angiotensin receptor blockers (11.3% vs. 8.7%). Among treated hypertensives, the proportion taking three or more antihypertensive drugs was lower among women than men, especially among older persons (60-69 years: 12.3% vs. 19.8%, 70-79 years: 18.6% vs. 21.2%, and > or =80 years: 18.8% vs. 22.8%). Only 44.8% of treated women achieved BP control vs. 51.1% of treated men. CONCLUSIONS Hypertensive women are significantly more likely to be treated than men, but less likely to have achieved BP control. Additional efforts may be needed to achieve therapeutic goals for the US hypertensive population, especially for hypertensive women.

High blood pressure and cardiovascular disease mortality risk among U.S. adults: the third National Health and Nutrition Examination Survey mortality follow-up study.

PURPOSE We sought to examine whether prehypertension is associated with increased cardiovascular disease (CVD) mortality risk and whether the association of blood pressure with CVD outcome is modified by social demographics or hypertension treatment and control. METHODS Data from the Third National Health and Nutrition Examination Survey and mortality follow-up through 2000 were used to estimate the relative risk of death from CVD associated with hypertension and prehypertension, after adjusting for confounding and modifying factors. RESULTS Compared with normotension, the relative risks of CVD mortality were 1.23 (95% confidence interval [95% CI] 0.85-1.79, p=0.26) for prehypertension, 1.64 (95% CI 1.11-2.41, p=0.01) for hypertension, 1.74 (95% CI 1.28-2.49, p=0.007) for uncontrolled hypertension, and 1.15 (95% CI 0.79-1.80, p=0.53) for controlled hypertension. Hypertensive adults <65 years and non-Hispanic blacks had a 3.86-fold and a 4.65-fold increased CVD mortality risk respectively. Age, gender, and race/ethnicity stratified analyses showed no associations between prehypertension and CVD mortality. However, blood pressure at a high range of prehypertension (130-139/84-89 mmHg) was associated with increased risk of CVD mortality (hazard ratio 1.41, p<0.05) relative to blood pressure less than 120/80 mmHg. CONCLUSIONS This study supports a strong, significant, and independent association of elevated blood pressure with CVD mortality risk. Hypertension continued to greatly increase CVD morality risk, particularly among persons <65 years and non-Hispanic blacks. Treatment and control of hypertension eliminated the excess CVD mortality risk observed among the hypertension population.

Antihypertensive Medication Use Among US Adults With Hypertension

BACKGROUND High blood pressure can be controlled through existing antihypertensive drug therapy. This study examined trends in prescribed antihypertensive medication use among US adults with hypertension and compared drug utilization patterns with recommendations of the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. METHODS AND RESULTS Persons aged > or =18 years from the National Health and Nutrition Examination Surveys were identified as hypertensive on the basis of either a blood pressure > or =140/90 mm Hg or self-reported current treatment for hypertension with a prescription medication. In 1999-2002, 62.9% of US hypertensive adults took a prescription antihypertensive medication compared with 57.3% during 1988-1994 (P<0.01). Men had the greatest increase in antihypertensive medication use (47.5%, 1988-1994 versus 57.9%, 1999-2002 [P<0.001]). In both surveys, antihypertensive medication use increased with age, was lower among men than among women, and was lower among Mexican Americans than among non-Hispanic whites and blacks. Multiple antihypertensive drug use increased from 29.1% to 35.8% (P<0.001). Polytherapy with a calcium channel blocker, beta-blocker, or angiotensin-converting enzyme inhibitor significantly increased by 30%, 42%, and 68%, respectively, whereas monotherapy with a diuretic or beta-blocker significantly decreased. For hypertensives with diabetes, congestive heart failure, or a prior heart attack, the utilization patterns closely followed the Sixth Joint National Committee guideline recommendations. CONCLUSIONS Antihypertensive medication use and multiple antihypertensive medication use among US hypertensive adults increased over the past 10 years, but disparities by sociodemographic factors continue to exist.

Trends in Blood Pressure Among Adults With Hypertension: United States, 2003 to 2012

The aim of this study is to describe trends in the awareness, treatment, and control of hypertension; mean blood pressure; and the classification of blood pressure among US adults 2003 to 2012. Using data from the National Health and Nutrition Examination Survey 2003 to 2012, a total of 9255 adult participants aged ≥18 years were identified as having hypertension, defined as measured blood pressure ≥140/90 mm Hg or taking prescription medication for hypertension. Awareness and treatment among hypertensive adults were ascertained via an interviewer administered questionnaire. Controlled hypertension among hypertensive adults was defined as systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg. Blood pressure was categorized as optimal blood pressure, prehypertension, and stage I and stage II hypertension. Between 2003 and 2012, the percentage of adults with controlled hypertension increased (P-trend <0.01). Hypertensive adults with optimal blood pressure and with prehypertension increased from 13% to 19% and 27% to 33%, respectively (P-trend <0.01 for both groups). Among hypertensive adults who were taking antihypertensive medication, uncontrolled hypertension decreased from 38% to 30% (P-trend <0.01). Similarly, a decrease in mean systolic blood pressure was observed (P-trend <0.01); however, mean diastolic blood pressure remained unchanged. The trend in the control of blood pressure has improved among hypertensive adults resulting in a higher percentage with blood pressure at the optimal or prehypertension level and a lower percentage in stage I and stage II hypertension. Overall, mean systolic blood pressure decreased as did the prevalence of uncontrolled hypertension among the treated hypertensive population.

Symptomatic Hand Osteoarthritis in the United States: Prevalence and Functional Impairment Estimates from the Third U.s. National Health and Nutrition Examination Survey, 1991–1994

Dillon CF, Hirsch R, Rasch EK, Gu Q: Symptomatic hand osteoarthritis in the United States: prevalence and functional impairment estimates from the third U.S. National Health and Nutrition Examination Survey, 1991–1994. Am J Phys Med Rehabil 2007;86:12–21. Objective:To estimate the United States prevalence of symptomatic hand osteoarthritis using American College of Rheumatology (ACR) physical examination criteria. Design:The Third National Health and Nutrition Examination Survey (NHANES III), a nationally representative cross-sectional health examination survey, performed upper-extremity physical examinations on a sample of United States adults age 60+ yrs. Data for demographics, pain history, analgesic use, and activity limitations were obtained by interview. Results:Among United States adults, 58% had Heberden’s nodes, 29.9% had Bouchard’s nodes, and 18.2% had first carpal–metacarpal deformities. Women had significantly more first carpal–metacarpal deformities (24.3%) than men (10.3%). Symptomatic osteoarthritis prevalence at these sites was 5.4, 4.7, and 1.9%, respectively. Overall, symptomatic hand osteoarthritis prevalence by ACR criteria was 8% (95% CI 6.5–9.5%), or 2.9 million persons. Symptomatic hand osteoarthritis significantly increased with age and was decreased among non-Hispanic blacks, but there were no gender differences. Symptomatic hand osteoarthritis was associated with self-reported difficulty lifting 10 lbs (OR 2.31; 95% CI 1.23–4.33), dressing (OR 3.77; 95% CI 1.99–7.13), and eating (OR 3.44; 95% CI 1.76–6.73). Frequent monthly use was significantly increased for analgesics, especially acetaminophen, but not nonsteroidal antiinflammatory drugs. Conclusion:Symptomatic hand osteoarthritis affects 1 in 12 older United States adults. NHANES III data provide a population-based assessment of the impact and associated functional impairments of symptomatic hand osteoarthritis.

Association of Hypertension Treatment and Control With All-Cause and Cardiovascular Disease Mortality Among US Adults With Hypertension

BACKGROUND Clinical trials have provided convincing evidence that blood pressure (BP) lowering treatment reduces the risk of cardiovascular disease (CVD) and total mortality. The objective of this study was to examine the association of hypertension treatment, control, and BP indexes with all-cause and cardiovascular mortality among US adults with hypertension. METHODS Persons aged > or =18 years from the Third National Health and Nutrition Examination Survey (NHANES III) were identified as hypertensives based on a BP > or =140/90 mm Hg or current treatment for hypertension. Vital status in 2006 was ascertained by passive follow-up using the National Death Index. Cox regression models were used to assess correlates of survival. RESULTS At baseline, 52% of hypertensive adults reported currently taking prescription medicine for high BP and 38% of treated persons had BP controlled. Compared to treated controlled hypertensives, treated uncontrolled hypertensives had a 1.57-fold (95% confidence interval (CI) 1.28-1.91) and 1.74-fold (95% CI 1.36-2.22) risk of all-cause and cardiovascular mortality; untreated hypertensives had a 1.34-fold (95% CI 1.12-1.62) and 1.37-fold (95% CI 1.04-1.81) risk of all-cause and cardiovascular mortality, respectively. The association persisted after further excluding persons with pre-existing hypertension comorbidities. Mortality risk was linearly increased with systolic BP (SBP), pulse pressure (PP), and mean arterial pressure (MBP), whereas diastolic BP (DBP) was not a significant predictor of cardiovascular mortality overall. No significant associations were observed between drug classes and mortality risk. CONCLUSIONS This study indicates that uncontrolled and untreated hypertension was associated with increased risk of total and cardiovascular mortality among the general hypertensive population.

Skeletal muscle relaxant use in the United States: data from the Third National Health and Nutrition Examination Survey (NHANES III).

Study Design. Population-based cross-sectional prevalence survey. Objectives. To define muscle relaxant use patterns in the United States. Summary of Background Data: Despite a long history of use for back pain and musculoskeletal disorders, national prevalence patterns of prescription muscle relaxant use have not been defined. Methods. NHANES III (1988–1994) is an in-person health examination survey of the U.S. civilian population, based on a complex, multistage probability sample design. Results. An estimated 2 million American adults reported muscle relaxant use (1-month period prevalence 1.0%; 95% confidence interval 0.8–1.3%). While virtually all (94%) used individual muscle relaxants rather than fixed combination muscle relaxant analgesics, two thirds took an additional prescription analgesic. Men and women had similar usage. Median user age was 42 years, but 16% of users were older than 60 years. Eighty-five percent of users took muscle relaxants for back pain or muscle disorders. Two thirds of muscle relaxant users had histories of recent back pain; however, only 4% of all those with a recent history of back pain reported any muscle relaxant use. Mean length of use was 2.1 years (95% confidence interval 1.6–2.6), with 44.5% taking medication longer than a year (95% confidence interval 35.7–53.3). Muscle relaxant use in the elderly, among older persons with ambulatory impairments, and in chronic obstructive pulmonary disease appeared undiminished compared with general population use. Conclusions. Although typically recommended for short-term treatment of back pain, muscle relaxants are often used chronically and are prescribed to subpopulations potentially at risk for adverse effects.