Robert Merritt

Trends in Cardiovascular Health Metrics and Associations With All-Cause and CVD Mortality Among US Adults

CONTEXT Recent recommendations from the American Heart Association aim to improve cardiovascular health by encouraging the general population to meet 7 cardiovascular health metrics: not smoking; being physically active; having normal blood pressure, blood glucose and total cholesterol levels, and weight; and eating a healthy diet. OBJECTIVE To examine time trends in cardiovascular health metrics and to estimate joint associations and population-attributable fractions of these metrics in relation to all-cause and cardiovascular disease (CVD) mortality risk. DESIGN, SETTING, AND PARTICIPANTS Study of a nationally representative sample of 44,959 US adults (≥20 years), using data from the National Health and Nutrition Examination Survey (NHANES) 1988-1994, 1999-2004, and 2005-2010 and the NHANES III Linked Mortality File (through 2006). MAIN OUTCOME MEASURES All-cause, CVD, and ischemic heart disease (IHD) mortality. RESULTS Few participants met all 7 cardiovascular health metrics (2.0% [95% CI, 1.5%-2.5%] in 1988-1994, 1.2% [95% CI, 0.8%-1.9%] in 2005-2010). Among NHANES III participants, 2673 all-cause, 1085 CVD, and 576 IHD deaths occurred (median follow-up, 14.5 years). Among participants who met 1 or fewer cardiovascular health metrics, age- and sex-standardized absolute risks were 14.8 (95% CI, 13.2-16.5) deaths per 1000 person-years for all-cause mortality, 6.5 (95% CI, 5.5-7.6) for CVD mortality, and 3.7 (95% CI, 2.8-4.5) for IHD mortality. Among those who met 6 or more metrics, corresponding risks were 5.4 (95% CI, 3.6-7.3) for all-cause mortality, 1.5 (95% CI, 0.5-2.5) for CVD mortality, and 1.1 (95% CI, 0.7-2.0) for IHD mortality. Adjusted hazard ratios were 0.49 (95% CI, 0.33-0.74) for all-cause mortality, 0.24 (95% CI, 0.13-0.47) for CVD mortality, and 0.30 (95% CI, 0.13-0.68) for IHD mortality, comparing participants who met 6 or more vs 1 or fewer cardiovascular health metrics. Adjusted population-attributable fractions were 59% (95% CI, 33%-76%) for all-cause mortality, 64% (95% CI, 28%-84%) for CVD mortality, and 63% (95% CI, 5%-89%) for IHD mortality. CONCLUSION Meeting a greater number of cardiovascular health metrics was associated with a lower risk of total and CVD mortality, but the prevalence of meeting all 7 cardiovascular health metrics was low in the study population.

Added Sugar Intake and Cardiovascular Diseases Mortality Among US Adults

IMPORTANCE Epidemiologic studies have suggested that higher intake of added sugar is associated with cardiovascular disease (CVD) risk factors. Few prospective studies have examined the association of added sugar intake with CVD mortality. OBJECTIVE To examine time trends of added sugar consumption as percentage of daily calories in the United States and investigate the association of this consumption with CVD mortality. DESIGN, SETTING, AND PARTICIPANTS National Health and Nutrition Examination Survey (NHANES, 1988-1994 [III], 1999-2004, and 2005-2010 [n = 31,147]) for the time trend analysis and NHANES III Linked Mortality cohort (1988-2006 [n = 11 733]), a prospective cohort of a nationally representative sample of US adults for the association study. MAIN OUTCOMES AND MEASURES Cardiovascular disease mortality. RESULTS Among US adults, the adjusted mean percentage of daily calories from added sugar increased from 15.7% (95% CI, 15.0%-16.4%) in 1988-1994 to 16.8% (16.0%-17.7%; P = .02) in 1999-2004 and decreased to 14.9% (14.2%-15.5%; P < .001) in 2005-2010. Most adults consumed 10% or more of calories from added sugar (71.4%) and approximately 10% consumed 25% or more in 2005-2010. During a median follow-up period of 14.6 years, we documented 831 CVD deaths during 163,039 person-years. Age-, sex-, and race/ethnicity-adjusted hazard ratios (HRs) of CVD mortality across quintiles of the percentage of daily calories consumed from added sugar were 1.00 (reference), 1.09 (95% CI, 1.05-1.13), 1.23 (1.12-1.34), 1.49 (1.24-1.78), and 2.43 (1.63-3.62; P < .001), respectively. After additional adjustment for sociodemographic, behavioral, and clinical characteristics, HRs were 1.00 (reference), 1.07 (1.02-1.12), 1.18 (1.06-1.31), 1.38 (1.11-1.70), and 2.03 (1.26-3.27; P = .004), respectively. Adjusted HRs were 1.30 (95% CI, 1.09-1.55) and 2.75 (1.40-5.42; P = .004), respectively, comparing participants who consumed 10.0% to 24.9% or 25.0% or more calories from added sugar with those who consumed less than 10.0% of calories from added sugar. These findings were largely consistent across age group, sex, race/ethnicity (except among non-Hispanic blacks), educational attainment, physical activity, health eating index, and body mass index. CONCLUSIONS AND RELEVANCE Most US adults consume more added sugar than is recommended for a healthy diet. We observed a significant relationship between added sugar consumption and increased risk for CVD mortality.

Physical activity trends among 26 states, 1986-1990

Data to monitor physical activity from large, representative samples are rare. Therefore, we conducted standardized telephone surveys for 26 states participating in the Behavioral Risk Factor Surveillance System from 1986 through 1990. More than 34,800 adults aged 18 and older responded annually. We scored leisure time physical activity data into four patterns: 1) physically inactive, 2) irregularly active, 3) regularly active, not intensive, and 4) regularly active, intensive. Over time, roughly 6 in 10 persons were physically inactive or irregularly active. While almost 4 in 10 persons were regularly active, less than 1 in 10 were regularly active, intensive. There were statistically significant decreases (-2.3%) in physically inactive persons and significant increases (+2.1%) in persons classified as regularly active, intensive. The irregularly active pattern did not change, while only men of all ages and men less than age 30 increased the regularly active, not intensive pattern (+1.7% and +3.8, respectively). Improvements across the activity patterns varied by demographic group: women and older adults made the most beneficial changes, while races other than white and the least educated groups had unfavorable changes. Despite many improvements, most persons still did little or no physical activity, signaling the need for enhanced intervention efforts.

Sodium Intake and Blood Pressure Among US Children and Adolescents

OBJECTIVE: To assess the association between usual dietary sodium intake and blood pressure among US children and adolescents, overall and by weight status. METHODS: Children and adolescents aged 8 to 18 years (n = 6235) who participated in NHANES 2003–2008 comprised the sample. Subjects’ usual sodium intake was estimated by using multiple 24-hour dietary recalls. Linear or logistic regression was used to examine association between sodium intake and blood pressure or risk for pre-high blood pressure and high blood pressure (pre-HBP/HPB). RESULTS: Study subjects consumed an average of 3387 mg/day of sodium, and 37% were overweight/obese. Each 1000 mg per day sodium intake was associated with an increased SD score of 0.097 (95% confidence interval [CI] 0.006–0.188, ∼1.0 mm Hg) in systolic blood pressure (SBP) among all subjects and 0.141 (95% CI: –0.010 to 0.298, ∼1.5 mm Hg) increase among overweight/obese subjects. Mean adjusted SBP increased progressively with sodium intake quartile, from 106.2 mm Hg (95% CI: 105.1–107.3) to 108.8 mm Hg (95% CI: 107.5–110.1) overall (P = .010) and from 109.0 mm Hg (95% CI: 107.2–110.8) to 112.8 mm Hg (95% CI: 110.7–114.9; P = .037) among those overweight/obese. Adjusted odds ratios comparing risk for pre-HBP/HPB among subjects in the highest versus lowest sodium intake quartile were 2.0 (95% CI: 0.95–4.1, P = .062) overall and 3.5 (95% CI: 1.3–9.2, P = .013) among those overweight/obese. Sodium intake and weight status appeared to have synergistic effects on risk for pre-HBP/HPB (relative excess risk for interaction = 0.29 (95% CI: 0.01–0.90, P < .05). CONCLUSIONS: Sodium intake is positively associated with SBP and risk for pre-HBP/HPB among US children and adolescents, and this association may be stronger among those who are overweight/obese.

Associations Between Sleep Disorders, Sleep Duration, Quality of Sleep, and Hypertension: Results From the National Health and Nutrition Examination Survey, 2005 to 2008

J Clin Hypertens (Greenwich). 2011;13:739–743. ©2011 Wiley Periodicals, Inc.

Association between usual sodium and potassium intake and blood pressure and hypertension among U.S. adults: NHANES 2005-2010.

Objectives Studies indicate high sodium and low potassium intake can increase blood pressure suggesting the ratio of sodium-to-potassium may be informative. Yet, limited studies examine the association of the sodium-to-potassium ratio with blood pressure and hypertension. Methods We analyzed data on 10,563 participants aged ≥20 years in the 2005–2010 National Health and Nutrition Examination Survey who were neither taking anti-hypertensive medication nor on a low sodium diet. We used measurement error models to estimate usual intakes, multivariable linear regression to assess their associations with blood pressure, and logistic regression to assess their associations with hypertension. Results The average usual intakes of sodium, potassium and sodium-to-potassium ratio were 3,569 mg/d, 2,745 mg/d, and 1.41, respectively. All three measures were significantly associated with systolic blood pressure, with an increase of 1.04 mmHg (95% CI, 0.27–1.82) and a decrease of 1.24 mmHg (95% CI, 0.31–2.70) per 1,000 mg/d increase in sodium or potassium intake, respectively, and an increase of 1.05 mmHg (95% CI, 0.12–1.98) per 0.5 unit increase in sodium-to-potassium ratio. The adjusted odds ratios for hypertension were 1.40 (95% CI, 1.07–1.83), 0.72 (95% CI, 0.53–0.97) and 1.30 (95% CI, 1.05–1.61), respectively, comparing the highest and lowest quartiles of usual intake of sodium, potassium or sodium-to-potassium ratio. Conclusions Our results provide population-based evidence that concurrent higher sodium and lower potassium consumption are associated with hypertension.

State smoking prevalence estimates: a comparison of the Behavioral Risk Factor Surveillance System and current population surveys.

OBJECTIVES This study examined whether there are systematic differences between the Behavioral Risk Factor Surveillance System (BRFSS) and the Current Population Survey (CPS) for state cigarette smoking prevalence estimates. METHODS BRFSS telephone survey estimates were compared with estimates from the US Census CPS tobacco-use supplements (the CPS sample frame includes persons in households without telephones). Weighted overall and sex- and race-specific BRFSS and CPS state estimates of adults smoking were analyzed for 1985, 1989, and 1992/1993. RESULTS Overall estimates of smoking prevalence from the BRFSS were slightly lower than estimates from CPS (median difference: -2.0 percentage points in 1985, -0.7 in 1989, and -1.9 in 1992/1993; P < .05 for all comparisons), but there was variation among states. Differences between BRFSS and CPS estimates were larger among men than among women and larger among Blacks than among Hispanics or Whites; for most states, these differences were not significant. CONCLUSIONS The BRFSS generally provides state estimates of smoking prevalence similar to those obtained from CPS, and these are appropriate for ongoing state surveillance of smoking prevalence.

Sodium and Sugar in Complementary Infant and Toddler Foods Sold in the United States

OBJECTIVES: To evaluate the sodium and sugar content of US commercial infant and toddler foods. METHODS: We used a 2012 nutrient database of 1074 US infant and toddler foods and drinks developed from a commercial database, manufacturer Web sites, and major grocery stores. Products were categorized on the basis of their main ingredients and the US Food and Drug Administration’s reference amounts customarily consumed per eating occasion (RACC). Sodium and sugar contents and presence of added sugars were determined. RESULTS: All but 2 of the 657 infant vegetables, dinners, fruits, dry cereals, and ready-to-serve mixed grains and fruits were low sodium (≤140 mg/RACC). The majority of these foods did not contain added sugars; however, 41 of 79 infant mixed grains and fruits contained ≥1 added sugar, and 35 also contained >35% calories from sugar. Seventy-two percent of 72 toddler dinners were high in sodium content (>210 mg/RACC). Toddler dinners contained an average of 2295 mg of sodium per 1000 kcal (sodium 212 mg/100 g). Savory infant/toddler snacks (n = 34) contained an average of sodium 1382 mg/1000 kcal (sodium 486 mg/100 g); 1 was high sodium. Thirty-two percent of toddler dinners and the majority of toddler cereal bars/breakfast pastries, fruit, and infant/toddler snacks, desserts, and juices contained ≥1 added sugar. CONCLUSIONS: Commercial toddler foods and infant or toddler snacks, desserts, and juice drinks are of potential concern due to sodium or sugar content. Pediatricians should advise parents to look carefully at labels when selecting commercial toddler foods and to limit salty snacks, sweet desserts, and juice drinks.

Vital Signs: Recent Trends in Stroke Death Rates - United States, 2000-2015

Introduction The prominent decline in U.S. stroke death rates observed for more than 4 decades has slowed in recent years. CDC examined trends and patterns in recent stroke death rates among U.S. adults aged ≥35 years by age, sex, race/ethnicity, state, and census region. Methods Trends in the rates of stroke as the underlying cause of death during 2000–2015 were analyzed using data from the National Vital Statistics System. Joinpoint software was used to identify trends in stroke death rates, and the excess number of stroke deaths resulting from unfavorable changes in trends was estimated. Results Among adults aged ≥35 years, age-standardized stroke death rates declined 38%, from 118.4 per 100,000 persons in 2000 to 73.3 per 100,000 persons in 2015. The annual percent change (APC) in stroke death rates changed from 2000 to 2015, from a 3.4% decrease per year during 2000–2003, to a 6.6% decrease per year during 2003–2006, a 3.1% decrease per year during 2006–2013, and a 2.5% (nonsignificant) increase per year during 2013–2015. The last trend segment indicated a reversal from a decrease to a statistically significant increase among Hispanics (APC = 5.8%) and among persons in the South Census Region (APC = 4.2%). Declines in stroke death rates failed to continue in 38 states, and during 2013–2015, an estimated 32,593 excess stroke deaths might not have occurred if the previous rate of decline could have been sustained. Conclusions and Implications for Public Health Practice Prior declines in stroke death rates have not continued in recent years, and substantial variations exist in timing and magnitude of change by demographic and geographic characteristics. These findings suggest the importance of strategically identifying opportunities for prevention and intervening in vulnerable populations, especially because effective and underused interventions to prevent stroke incidence and death are known to exist.

Sodium consumption among hypertensive adults advised to reduce their intake: national health and nutrition examination survey, 1999-2004.

J Clin Hypertens (Greenwich). 2012; 14:447–454. ©2012 Wiley Periodicals, Inc.